06-06-20 6-2

6:00 am
F- Ineffective D-Received lying on bed with IVF of D5.03 NaCl
breathing pattern 500ml X 60cc/hr inserted at left cephalic vein,
related to infusing well no redness nor swelling on IV
decreased lung insertion sit, febrile, sclera is white with pale
expansion as conjunctiva, with smooth pale lips, with good skin
evidenced by turgor and adequate capillary refill, with soft
dyspnea abdomen upon palpation, scars are noted at lower
extremities, with nasal discharge, with productive
cough and wheezing sound heard on both lung
8:00 am fields. RR: 39 bpm
A - Assessed the general condition, NPI established with
good rapport, early morning rounds done with
orders made and carried out, history taking done,
vital signs taken and recorded, auscultated lung
sounds, regulated IVF accordingly, advised to
complete nebulization materials, facilitated in
nebulization, advised to do back tapping, Instructed
the SO to elevate the patient’s head to maintain
passage of airway, performed AM care by removing
unnecessary things on the bed, tucking the linen
properly and wiping off the dirt on the patient’s arm,
performed tepid bath and teach the S/O on the
proper way to do it to lower the temperature,
instructed the patient and the S/O to increase fluid
intake and encouraged to eat nutritious foods such as
green leafy vegetables and fruits, informed
possibility and caution to aspiration, advised to
report presence of any unwanted signs and
symptoms, provided health teaching to the S/O
regarding on proper hygiene, hand washing, waste
disposal and segregation, emphasized the
importance of well ventilated and clean
1:30 pm environment, reminded to comply to treatment and
R - continue nebulization.
“Seen patient sleeping comfortably on bed”
Latest vital signs: BP: 90/70, T:36.8, RR:25, PR:78
(Name -Signature above)
BSN-SLSU