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  • Date and Time Focus: D - Received Patient On Bed

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    Graphaiene Neika Wacas
    258 views2 pages
    The document describes a patient encounter on 10/4/2020 at 7am. The patient presented with an ineffective breathing pattern and was pale with decreased breath sounds in the right lung. Vital signs were normal except for tachycardia. The nurse monitored vitals every 4 hours, assessed the patient's respiratory status, demonstrated breathing and coughing techniques, and encouraged rest, hydration, and breathing exercises to promote wellness. At the end of the encounter, the patient reported easier breathing but remained tachypneic.

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    Original Title

    FDAR INEFFECTIVE

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    The document describes a patient encounter on 10/4/2020 at 7am. The patient presented with an ineffective breathing pattern and was pale with decreased breath sounds in the right lung. Vital signs were normal except for tachycardia. The nurse monitored vitals every 4 hours, assessed the patient's respiratory status, demonstrated breathing and coughing techniques, and encouraged rest, hydration, and breathing exercises to promote wellness. At the end of the encounter, the patient reported easier breathing but remained tachypneic.

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    © All Rights Reserved
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    258 views2 pages

    Date and Time Focus: D - Received Patient On Bed

    Uploaded by

    Graphaiene Neika Wacas
    The document describes a patient encounter on 10/4/2020 at 7am. The patient presented with an ineffective breathing pattern and was pale with decreased breath sounds in the right lung. Vital signs were normal except for tachycardia. The nurse monitored vitals every 4 hours, assessed the patient's respiratory status, demonstrated breathing and coughing techniques, and encouraged rest, hydration, and breathing exercises to promote wellness. At the end of the encounter, the patient reported easier breathing but remained tachypneic.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    DATE AND TIME FOCUS

    10/4/2020 Ineffective breathing pattern D---Received patient on bed,


    7am alert afebrile, with IV fluids to
    follow was D5NM 1 L, with
    occasional cough; normal vital
    signs within normal limits
    except for tachycardia. Pale
    conjunctivae, lips and oral
    mucosa, and right lung field
    with decreased tactile fremitus.
    Presence of dull and decreased
    breath sound.
    A--Monitored vital signs every 4
    hours; Established rapport;
    Monitored respiration and
    breath sound; Assessed
    respiratory status; Noted chest
    movement; Evaluated clients
    cough and or gag reflex and
    swallowing ability
    Assisted patient on comfortable
    position; thought patient
    appropriate deep breathing and
    coughing techniques; Promoted
    wellness; Demonstrated client in
    performing specific airway
    clearance; Administered
    medication as ordered;
    Encourage hydration at least 8
    glasses of water; Encourage the
    patient to have adequate rest
    period; Encourage deep
    breathing exercise and coughing
    exercise; Advise client to avoid
    cold places; Encourage position
    of comfort

    R---Patient verbalize ease of


    breathing; still tachypneic.

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