NCM 109 – Care of the Mother, Child at Risk or with Problems (Acute and Chronic)

(High Risk OB – LEVEL II NURSING STUDENTS)

NURSES’ PROGRESS NOTES

DATE TIME FOCUS NURSES’ PROGRESS NOTES

02-23-2023 8:30 AM Ineffective airway D: Received client on stretcher in supine position,
clearance r/t conscious, and calm. With chest tube attached to a CT
excessive mucus bottle, maintained on clamp CT @ 300 mL PNSS. With
oxygen via venturi mask @ 6 lpm. Upon chest auscultation,
crackles can be heard, client exhibits dyspnea, tachypnea,
ineffective cough, and hypoxemia. Vital signs as follows:
Temperature – 37.8 °c; HR – 123 bpm; RR – 60; O2 – 98%
A: - Monitored vital signs
- Assessed the rate, rhythm, and chest movement
- Assessed cough effectiveness and productivity
- Auscultated breath sounds
- Monitored client’s input and output and oxygen
level
- Assisted with changing and fixing of chest tube
- Assisted in cleaning and fixing the client’s space
- Encouraged s/o to assist client on a side-lying
position
- Educated s/o regarding condition of the client
- Raised side rails of bed
11:30 AM - Administered IVF PNLRS x 42 cc/hr @ 200 cc lvl
R: - No presence of cyanosis
- S/o verbalizes understanding of client’s situation
- RR – 44 cpm

NAME of Px:_____________________________ Birthday: _________ Age: 3 Sex: ____ Civil Status: __

Diagnosis:__________________________________Ward: _____________ Hospital No : ______________