DATE FOCUS D- DATA DATE FOCUS D- DATA

SHIFT A – ACTION SHIFT A – ACTION

TIME R- RESPONSE TIME R- RESPONSE

2/28/202 3/1/202
1 1
3-11 Imbalanced D: reported inadequate 7-3 D: reported feeling of
6pm nutrition: food intake, lack of Fatigue tiredness and lack of
less than interest in food energy
body
requiremen A: Ascertain dietary A:
6:30pm t program, discussed 7:00 am -advised client to eat
eating habits and high fiber foods such as
encouraged diabetic diet vegetables and fruits
as prescribed by doctor,
observed signs of -encouraged client to
hypoglycemia have periods of rest and
R: verbalized compliance uninterrupted sleep
8pm and understanding in the
prescribed dietary plan, -discussed effective ways
no signs of hypoglycemia of conserving energy

-instructed to perform
ABC, RN deep breathing exercises
PRC 123456
R:
-verbalized
7:30 am understanding in the
2/28/202 teachings provided
1 D: complains blurred -demonstrated proper
11-7 Risk for vision breathing exercises
11pm Injury A: Assessed for the -verbalized increase in
presence of contributing energy level
11:15pm factors that increase the
risk for injury, room kept GHI, RN
well lighted, belongings PRC 246810
kept within reach.
R: patient is injury free
D:
7am DEF,RN Risk for -excessive urination
PRC 654321 3/1/202 Deficient -excessive sweating
1 Fluid
3-11 Volume
A:
-V/S monitored
-checked skin color,
8:30 am moisture, and turgor
-assessed peripheral
 pulses, capillary refill,
and mucous membranes
-I&O monitored
-weighed the client
-urged to maintain
adequate and
prescribed amount of
fluid
-administered IV fluids
as per ordered

R:
-demonstrated adequate
hydration as manifested
10:00 am by stable v/s: BP: 120/78
mmHg,temp: 37, RR: 16
bpm, and HR: 67 bpm,
palpable peripheral
pulses, good skin turgor
and capillary refill of 2
seconds

GHI, RN
PRC 246810