Joyce Kathreen Ebio Lopez BSN3C

DATA FOCUS D- DATA DATA FOCUS D- DATA

SHIFT A-ACTION SHIFT A-ACTION
TIME R-ESPONSE TIME R-ESPONSE

03-06-22 Admission D: 3-06-22 Fever D:

(7am-3p Admitted 65 y/o female (7am-3p The patient’s
m) 7am who presented with m) 8:00 temperature is 39
intractable nausea and am degrees celsius
vomiting over the past
several weeks. With A:
complaints of upper ● Room will
abdominal pain and be
diffuse headaches. She adjusted
also take medications as with
ff: protonic and proper
antiemetic. Patient has ventilatio
history of hypertensive n and
disorder, arthritis, high temperat
cholesterol, diabetes ure to
mellitus type 2,
provide
hypothyroidism and
comfort
obesity. Diagnosis as
● Monitor
follows: Gastritis,
pneumonia, and kidney patient’s
stones temperat
ure
A: frequently
● V/S are ● Administe
recorded and red
monitored medicatio
T= 39 C n as
BP = 150/100 ordered
mmHg by the
PR= 79 bpm Doctor
RR= 34 BPM
R:
R: ● Patient is
Consent signed in a relax
and
comfortab
le
position
● Temperat
ure
lowers to
37.4
degrees
celsius
Joyce Kathreen Ebio Lopez BSN3C

● Relieved
and well
rested.

8:30 am Pain D:
The patient
verbalizes pain
in the upper
abdomen which
is caused by
inflammation in
the stomach
lining.

A:
● Abdomin
al
assessme
nt was
performe
d with the
use of the
Techniqu
es,
inspectio
n.palpatio
n
percussio
n, nd
auscultati
on
● Administe
red pain
medicatio
n as
ordered
by the
Doctor.
● The pain
level was
assessed
● Warm
Sponge
Joyce Kathreen Ebio Lopez BSN3C

bath and
use of
tepid
water was
provided
● Hot
compress
was given
to relieve
the
abdomina
l pan
● Non-phar
macologi
cal
technique
s such as
music
therapy.
● gentle
maage

R:
● Pain level
was
reduced
compared
to the the
initial
finding
● The client
is in a
relax and
comfortab
le
position
Joyce Kathreen Ebio Lopez BSN3C