DATE:28/06/10 TIME:12:00 nn

SHIFT 7-3 S O ”Naang angotakon ta haanak nga makadigos” as verbalized by the patient • BP- 120/90 mmHg • T=36.1 C • CR=57 bpm • RR=20 bpm • O2SAT= 97% • GCS =M6V5E4 • (-) pain • O2 inhalation = 2-3 lpm • IVF=0.9%NaCl 1L @ kvo • Glycated Hemo = 6% • RBS = 200 mg/L • Pulse strength = +1 Lab results Hg = 88 g/L Ht = 0.31 g/L • Confined in bed • conscious & coherent • Emotionally irritable • looks weak • pale looking on face, lips and finger nails • (-) jaundice on sclera and mucous membrane • Capillary refill= 2 seconds • (-) edema on both upper and lower extremities • (+) amputation right third toe • (+) body odors • Messy looking hair • With bad breath Hygiene self care deficit related to body weakness After the shift, the patient will be able to attain good hygiene within the limits of her condition  Monitored vital signs  Assess patient’s ability to perform ADL’s.  Provided privacy  Side rails up  Provided bed bath  Bedside care done  Assisted patient to do oral care  Involved watchers in providing care to the patient  Patient expressed comfort.

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