Burhan, Mahassen G.

17-2-01120
NLM ll
FDAR

506

Problem Focus Action Response

Sever Diarrhea Diarrhea related to irritable bowel dis- Assessed patient general status, per- Patient was able to report reduction in
order as evidenced by loose stools. formed bedside care, provided patient frequency of stools, returned to more
comfort, monitored normal stool
and recorded vital signs, tt & O and consistency, identified and avoided
02 saturation, assessed pain score. contributing factors such as poor hy-
Observed and documented giene, eating large amounts
stool frequency, characteristics, of meat and fibers and drinking poor
amount, and precipitating factors, quality water——————————
promoted bedrest, if indicated, RN.BURHAN.
and provided bedside commode.
Restarted oral fluid intake gradually,
discussed patient's usual diet,
provided opportunity to vent frustra-
tions related to disease process, ad-
ministered medications, as
indicated
FDAR
507

Problem Focus Action Response

Shortness of breath Airway proper positioning in semi-fowlers
Assess the amount, quality and color
of the sputum ,Monitored respiration
,heat and cold application.
Give medication as prescribed
The patient has clear and open
airways as evidence by normal
breath sounds. normal rate and
depth of respiration .
———————————————
——-RN.Burhan.
FDAR
504

Problem Focus Action Response

Fever and chills Fever Temp 38 C,Skin warm to touch , flush Afebrile, Temp:37 C degree
skin,dry lips. ————————
——RN:Burhan.
Increase fluid intake, cold compress,
paracetamol medication as ordered
Problem Focus Action Response