DATA/ TIME FOCUS D= Data A= Action R= Response

May 17, 2021 Wound D- received patient on bed lying wake with D5LR 1L
management @20gtts/min
8:01 AM
-CBS was 268mg/dl upon admission

A-Tramadol 50 mg was given via IVTT STAT per doctors’

orders

-vital signs monitored and taken q 30 mins for 2 hours

and hourly for 8 hours or until stable

-put in NPO until further doctors order

-wound dressing done

- due medications were given

-provided comfort and safety

R-cared for

-needs attended
May 18, 2021 Hyperglycemia D-received patient on bed lying awake with PNSS 1L
@20gtts/min with antibiotic piggyback @100cc
4:01 PM
-on soft diet

A-Vital signs monitored, taken and recorded

-CBS taken 30 minutes prior to meals

- due medications given as prescribe

- encouraged early ambulation

- wound dressing done

-provided comfort and safety

R-Needs attended

May 19,2021 Pain management D- received patient on bed lying awake with PNSS 1L at
KVO rate @15gtts/min with antibiotic piggyback @100cc
12:01 AM
-CBS is still above normal

- on DAT diet

- on contract precaution

A- vital signs monitored, taken and recorded

 -wound dressing done

-due medications given as ordered

- encouraged deep breathing exercise

-patient was kept comfortable and safe

R- patient reports pain was relieved