DATE TIME SHIFT FOCUS D-ata A-ction R-esponse

5/4/12 0900 6-2 Nausea related to disease D: Pt. states she's nauseated. Vomited 100ml
process clear fluid
0915 A: Given __________ IV .
0945 R: Pt. reports no further nausea . No further
vomiting.
1000 6-2 Fluid Volume Deficit D: weightloss of 3 lbs in 1 day, intake of 550ml
related to nausea and in 24 hours; urine output of 800ml/24h;emesis
vomitting 240ml x3
1010 A: Maintained IV fluids; encouraged small
frequent fluid intake (400ml over 2-3 hours);
placed the client in upright position; requested
and administered antiemetic drug as prescribed
by physician.
1300 R: Pt. reports no further nausea . No further
vomiting.
1400 Fluid Volume Excess D: “Maglisud ko ug ginhawa” as verbalized by
related to congestive client; S3 heart sounds,restlessness/
heart failure anxiety,jugular vein distention noted;
1410 A:positioned bed to semi-fowlers position;
administered O2 as ordered;limit fluid intake to
800ml / day;administered diuretics as ordered
2200 R: ct reports of ease in breathing, decrease
anxiety noted
FLUID/HYDRATION PROBLEMS