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  • 5th Rotation Case - Nurses Notes

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    Angelica Bernales
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    1) A 1-year-old patient was brought to the hospital by their mother for excessive coughing, phlegm, and difficulty breathing for the past 3 days. 2) Upon examination, the nurse noted the patient had rolling eyes, cyanotic lips for 30 seconds, crackles in both lungs, and a congested nose. 3) The nurse provided treatments like positioning the patient, administering medications, using a nebulizer, and educating the guardian on increasing fluids to help clear the patient's airways.

    Original Description:

    Ineffective airway clearance; related to increased production of secretions.

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    1) A 1-year-old patient was brought to the hospital by their mother for excessive coughing, phlegm, and difficulty breathing for the past 3 days. 2) Upon examination, the nurse noted the patient had rolling eyes, cyanotic lips for 30 seconds, crackles in both lungs, and a congested nose. 3) The nurse provided treatments like positioning the patient, administering medications, using a nebulizer, and educating the guardian on increasing fluids to help clear the patient's airways.

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    © All Rights Reserved
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    3 views2 pages

    5th Rotation Case - Nurses Notes

    Uploaded by

    Angelica Bernales
    1) A 1-year-old patient was brought to the hospital by their mother for excessive coughing, phlegm, and difficulty breathing for the past 3 days. 2) Upon examination, the nurse noted the patient had rolling eyes, cyanotic lips for 30 seconds, crackles in both lungs, and a congested nose. 3) The nurse provided treatments like positioning the patient, administering medications, using a nebulizer, and educating the guardian on increasing fluids to help clear the patient's airways.

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    © All Rights Reserved
    Flag for inappropriate content
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    DAVAO DEL SUR PROVINCIAL HOSPITAL

    “PHILHEALTH ACCREDITED”
    Lapu-Lapu Street, Digos City

    Name:__AMARI____________________________________________ Age:_1 y/o__ Ward:_Pediatric_

    Address:___TIENDA, APLAYA, DIGOS CITY_________________________ Case No.:_______________

    NURSES NOTES

    Date & Time Focus DAR

    10/11/2021 Ineffective airway clearance; D:


    7-3 related to increased production - At 7:20am; 1y/o pt. arrived at the hospital
    of secretions. - Patients mother stated “Nisulirap mana iyaha mata ma’am ganiha
    sa balay”. “tulo kaadlaw na iyaha ubo
    maam, nay plema.” “Usahay kay galisod sya ginhawa kay
    nagsugod na ug barado iyaha ilong”.
    - With rolling eyeball upward; cyanotic lips for 30 sec.
    - No fever, no loss of consciousness, and no vomiting noted.
    - Breath sounds; crackles/rales both lungs noted.
    A:
    - Assisted the toddler to a comfortable position eg. elevate the
    head of the bed.
    - Kept the environment clean such as dust
    - Administered medication as prescribed by the physician
    - Provided supplemental humidification like nebulizer
    - Maintained routine safety precautions (side rails up)
    - Educated the toddler’s guardian to increase fluid intake
    R:
    - Goal not met
    - Patients show no signs of improvement, still have a phlegm and
    congested nose.

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