DATE/TIME F (FOCUS) D – A – R (DATA, ACTION, RESPONSE)

11/22/21 Ineffective D: Clubbing of fingernails, Persistent productive

0700HRS Airway cough, Harrison’s sulcus, Bilateral lower lobe
Clearance crepitations,
related to Temp 38.9 °C, Spo2 – 89% , RR- 35cpm , PR-
mucus 130bpm
production
secondary to
A:
bronchiectasis
1. Demonstrated proper ways of coughing and
breathing such as taking a deep breath,
holding it for 2 seconds, and coughing two or
three times in succession.
2. Positioned the patient upright
3. Administered aminophyline Drip 1 amp, to
incorporate at D5W 500cc to run for
20mcgtts/min
4. Start with Piperacillin/Tazobactam 2 g / 0.25 g
is administred by intravenous infusion (over
30 minutes). ANST (-)
R: The patient demonstrated effectively
measures to facilitate expectoration of mucus
secretions such as breathing deep and holding it
for 2 seconds and was able to cough two times in
succession. Vitals signs are as follows:
RR: 20cpm
PR: 100bpm
SpO2: 90%