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Student Nurse
Room No.
Patient
Chief Category Complaint/ Diagnosis
6AM
WORKPLAN 7AM 8AM
9AM
10AM
11AM
12NN
1PM
2PM
Date: 01-12-07 Remarks
de Leon, 446 Elaine S.
Consolacion Felipe, 87 yrs. old, female
Difficulty of III Breathing, S/P MRM, Breast CA Stage III, HTN, DM type II, UTI, Pleural Effusion
- receive endorsemen t
Assessment:
-Monitor O2
S> “I could hardly breath, my chest is like tightening.”, as verbalized by client.
-assess patient’s condition
-raised siderails
-prepare medication *Norisec *Ciprobay -monitor client’s vital signs -position client to high back rest -assist in nebulization -encouraged and instruct patient for use of relaxation technique such as deep breathing exercises, pursed lip breathing.
O> receive patient in bed conscious, coherent, afebrile, appears restless. Self focusing, (+)facial grimace, (+)wheezes, pursed lip breathing, with O2 @ 2LPM. Use of accessory muscle, nasal flaring, with vital signs of: BP:120/70, temp:36.1, PR:94bpm, RR:24bpm
-assess for client’s condition.
A> Impaired Gas Exchange r/t Alveolar Capillary Membrane Changes Endorseme nt: -IV removed by SI but no order for reinsertion -RBS Q6 6am-not done client
-instruct client to open mouth while nebulizing so that the medication would go directly to her lungs
-supervise in feeding -assist in nebulization for every 15 mins. -administer medication -administer Medrol 16mg as ordered. -position client to high back rest -encourage use of relaxation technique -ensure client’s comfort.
-change bed linens
-allow for rest periods
-prepare medicati on
-assist and supervise in feeding.
-assist in nebulizat ion
-offer massage
-prepare for RBS
-assess for respirato ry distress
-allow for rest period
-encourage increase in fluid intake
-reassess client’s condition -ensure comfort -allow for rest periods
-monitor client’s vital signs
-reassess client understand ing of relaxation technique and ask to demonstrat e proper relaxation technique -obtain RBS -administer medication -obtain I&O -plot V/S
-provide clean & calm environmen t -Provide morning care -plot V/S
-Charting of SOAPIE
Post Conferen ce
Post conferen ce
After 6 hours of Nursing Intervention, verbalized, “I feel much better, but still a little hard to breath but much better now.” Client appears less restless ad irritable, wheezes are decreased, less use of accessory muscle, client’s vital signs are BP: 110/70, Temp:36.4, PR:86bpm, RR:21bpm
Student Nurse
Room No.
Patient
de Leon, Elaine S.
446
Consolacion Felipe, 87 yrs. old, female
Chief Category Complaint/ Diagnosis Difficulty of III Breathing, S/P MRM, Breast CA Stage III, HTN, DM type II, UTI, Pleural Effusion
6AM - receive endorsemen t -assess patient’s condition -Monitor O2 -regulate IV
Endorseme nt: RBS Q612nn O2 @2LPM DM Diet D5NM x 16hr
WORKPLAN 7AM 8AM -prepare medication
-give due meds
-monitor vital signs
-regulate IV fluid
-regulate IV fluid -position client to position of comfort -raised siderails -assist in nebulizatio n. -ensure client’s comfort.
-plot V/S -provdie clean and calm environm ent
9AM
10AM
11AM
12NN
1PM
2PM
-encourage use of relaxation technique such as deep breathing exercises
-assess patient’ s comfort
-prepare meds
-RBS monitor ing
-Obtain I&O
-Post conferen ce
- regulate IV fluid
-give pain reliever as -encourag ordered e use of relaxation technique such as deep breathing exercises and pursed lip breathing -provide morning care -provide comfort measures -change bed linens
-encour age use of diversio nal activitie s such as watchin g TV. -allow for rest periods
-prepare for RBS -regulate IV -allow fro rest periods -monitor vital signs BP:100/ 70 T:36.5 P:62bpm R:20bpm
-charting - assist client in feeding -admini ster meds
-endorse -reassess ment for client’s conditio n
Date: 01-11-07 Remarks
Room No.
Patient
Chief Category Complaint/ Diagnosis
6AM
WORKPLAN 7AM 8AM
9AM
10AM
11AM
12NN
1PM
2PM
Date: 01-12-07 Remarks
de Leon, 446 Elaine S.
Consolacion Felipe, 87 yrs. old, female
Difficulty of III Breathing, S/P MRM, Breast CA Stage III, HTN, DM type II, UTI, Pleural Effusion
- receive endorsemen t
Assessment:
-Monitor O2
S> “I could hardly breath, my chest is like tightening.”, as verbalized by client.
-assess patient’s condition
-raised siderails
-prepare medication *Norisec *Ciprobay -monitor client’s vital signs -position client to high back rest -assist in nebulization -encouraged and instruct patient for use of relaxation technique such as deep breathing exercises, pursed lip breathing.
O> receive patient in bed conscious, coherent, afebrile, appears restless. Self focusing, (+)facial grimace, (+)wheezes, pursed lip breathing, with O2 @ 2LPM. Use of accessory muscle, nasal flaring, with vital signs of: BP:120/70, temp:36.1, PR:94bpm, RR:24bpm
-assess for client’s condition.
A> Impaired Gas Exchange r/t Alveolar Capillary Membrane Changes Endorseme nt: -IV removed by SI but no order for reinsertion -RBS Q6 6am-not done client
-instruct client to open mouth while nebulizing so that the medication would go directly to her lungs
-supervise in feeding -assist in nebulization for every 15 mins. -administer medication -administer Medrol 16mg as ordered. -position client to high back rest -encourage use of relaxation technique -ensure client’s comfort.
-change bed linens
-allow for rest periods
-prepare medicati on
-assist and supervise in feeding.
-assist in nebulizat ion
-offer massage
-prepare for RBS
-assess for respirato ry distress
-allow for rest period
-encourage increase in fluid intake
-reassess client’s condition -ensure comfort -allow for rest periods
-monitor client’s vital signs
-reassess client understand ing of relaxation technique and ask to demonstrat e proper relaxation technique -obtain RBS -administer medication -obtain I&O -plot V/S
-provide clean & calm environmen t -Provide morning care -plot V/S
-Charting of SOAPIE
Post Conferen ce
Post conferen ce
After 6 hours of Nursing Intervention, verbalized, “I feel much better, but still a little hard to breath but much better now.” Client appears less restless ad irritable, wheezes are decreased, less use of accessory muscle, client’s vital signs are BP: 110/70, Temp:36.4, PR:86bpm, RR:21bpm
Student Nurse
Room No.
Patient
de Leon, Elaine S.
446
Consolacion Felipe, 87 yrs. old, female
Chief Category Complaint/ Diagnosis Difficulty of III Breathing, S/P MRM, Breast CA Stage III, HTN, DM type II, UTI, Pleural Effusion
6AM - receive endorsemen t -assess patient’s condition -Monitor O2 -regulate IV
Endorseme nt: RBS Q612nn O2 @2LPM DM Diet D5NM x 16hr
WORKPLAN 7AM 8AM -prepare medication
-give due meds
-monitor vital signs
-regulate IV fluid
-regulate IV fluid -position client to position of comfort -raised siderails -assist in nebulizatio n. -ensure client’s comfort.
-plot V/S -provdie clean and calm environm ent
9AM
10AM
11AM
12NN
1PM
2PM
-encourage use of relaxation technique such as deep breathing exercises
-assess patient’ s comfort
-prepare meds
-RBS monitor ing
-Obtain I&O
-Post conferen ce
- regulate IV fluid
-give pain reliever as -encourag ordered e use of relaxation technique such as deep breathing exercises and pursed lip breathing -provide morning care -provide comfort measures -change bed linens
-encour age use of diversio nal activitie s such as watchin g TV. -allow for rest periods
-prepare for RBS -regulate IV -allow fro rest periods -monitor vital signs BP:100/ 70 T:36.5 P:62bpm R:20bpm
-charting - assist client in feeding -admini ster meds
-endorse -reassess ment for client’s conditio n
Date: 01-11-07 Remarks
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