ACTUAL SOAPIERs

Published on December 2016 | Categories: Documents | Downloads: 34 | Comments: 0 | Views: 171
of 8
Download PDF   Embed   Report

Comments

Content

ACTUAL SOAPIERs January 4,2010 S > O > Ø Received on bed, conscious and coherent with an ongoing IVF of D5NR 1L x 120 cc/hr @ 280 cc level, patent and intact infusing well on left metacarpal with no signs of infiltrations; with intact indwelling foley catheter connected to urine bag at 1000 cc level draining a amber colored urine; dry and intact dressing on his right hip; no complaint of dizziness and headache; anicteric sclera; moist buccal mucosa; no difficulty of breathing; no signs of chest retractions; capillary refill time of less than 3 seconds; with good skin turgor; afebrile. V/S taken as follows: T: 36.2 C, PR: 85 bpm, RR: 19 cpm, BP: A > P > I> 140/70mmHg Risk for infection related to inadequate primary defenses (broken skin) After 4 hours of nursing interventions, the patient will be able to identify interventions to prevent or reduce risk for infection. > Establihed rapport > > > > > > > > > > > > Monitored and recorded v/s Assessed general condition Placed to semi fowlers position Provided health teaching such as to follow exercise program Identified necessary changes in lifestyle and assisted client to incorporate disease management to ADL’s Stressed proper handwashing techniques by all caregivers clients Provided regular catheter care Encouraged diet as tolerated, especially foods rich in protein and Vitamin C for faster wound healing and tissue repair Emphasized importance of taking antibiotics Regulated IVF as indicated Due meds given Needs attended between

E>

Goal met as evidenced by the patient is able to identify interventions to prevent or reduce risk for infection.

January 5, 2010
S> O> Ø Received on bed, conscious and coherent with an ongoing IVF of D5NSS 1L x 120 cc/hr @ 890 cc level, patent and intact infusing well on left metacarpal with no signs of infiltrations; with intact indwelling foley catheter connected to urine bag at 900 cc level draining a amber colored urine; dry and intact dressing on his right hip; no complaint of dizziness and headache; anicteric sclera; moist buccal mucosa; no difficulty of breathing; no signs of chest retractions; capillary refill time of less than 3 seconds; with good skin turgor; afebrile. V/S taken as follows: T: 36.4 C, PR: 79 bpm, A> P> I> RR: 21 cpm, BP: 140/70 mmHg Impaired skin integrity related to mechanical factors ( compression screw hip fixation) After 4 hours of nursing interventions, the patient will be able to display timely healing of surgical incision without complications. > Establihed rapport > > > > > > > > > > > > > > E> Monitored and recorded v/s Assessed general condition Placed to semi fowlers position Changed position every 2 hours Provided health teaching such as to follow exercise program Identified necessary changes in lifestyle and assisted client to incorporate disease management to ADL’s Stressed proper handwashing techniques by all caregivers between clients Provided regular catheter care Encouraged diet as tolerated, especially foods rich in protein and Vitamin C for faster wound healing and tissue repair Kept the incision area clean and dry Reviewed measures to prevent spread infection Regulated IVF as indicated Due meds given Needs attended

Goal met as evidenced by the patient is able to display timely healing of surgical incision without complications.

January 6, 2011 S> Ø O > Received on bed, conscious and coherent with an ongoing IVF #6 of D5NR 1L x 120 cc/hr @ 60 cc level, infusing well on left metacarpal vein with no signs of infiltrations; with indwelling foley catheter connected to urine bag with 600 cc amber colored urine, with dry and intact dressing on his right hip, with antiembolic stockings, with capillary refill time of 2 seconds, with pink palpebral conjunctiva, with initial vital signs of T: 36.9oC, PR: 86 bpm, RR: 22 A > P > I> cpm, BP: 150/80mmHg Impaired physical mobility related to musculoskeletal impairment After 4 hours of nursing interventions, the patient will be able to verbalize understanding therapeutic regimen > > > > > > > > > > > > > > E> Establihed rapport Monitored and recorded vital signs Assessed patient’s general condition Assessed surgical site Provided PM care Regulated and monitored IVF as ordered Provided safety measures such as raising side rails Provided comfort measures such as keeping bed wrinkle free Instructed to increase oral fluid intake Instructed to position in a semi-fowler position Instructed to perform coughing and breathing exercises Kept back dry Meds given Needs attended

Goal met, the patient verbalized understanding of therapeutic regimen

January 07, 2011

January 08, 2011 S > O > Ø Received on bed, conscious and coherent with an ongoing IVF #7 0.9 NaCl 1L x 30-31 gtts/min @ 60 cc level, infusing well on left metacarpal vein with no signs of infiltrations; with indwelling foley catheter connected to urine bag with 1200 cc amber colored urine, with dry and intact dressing on his right hip, with antiembolic stockings, skin is warm to touch, with initial vital signs of T: 38.7 C, A > P > I> PR: 91 bpm, RR: 25 cpm, BP: 120/80mmHg Hyperthermia After 4 hours of nursing interventions, the patient’s temperature will achieve and maintain within normal range. > Monitored and recorded vital signs > > > > > > > > > > > > > > E> Assessed patient’s general condition Assessed surgical site Provided AM care Regulated and monitored IVF as ordered Provided tepid sponge bath q15 minutes Provided safety measures such as raising side rails Provided comfort measures such as keeping bed wrinkle free Instructed to increase oral fluid intake Instructed to position in a semi-fowler position Instructed to perform coughing and breathing exercises Kept back dry Meds given Needs attended Above intravenous fluid consumed; hooked, 0.9 NaCl @ 5 PM and

regulated @ 31 gtts/min Goal met as evidenced by the patient’s temperature achieved and maintained within normal range.

Bibliography Orthopedic Nursing Manual Second Edition by Artemio M. Buitre Jr., R.N. S “I still have difficulty doing my usual routine” > O > Received patient undergoing session with physical therapist, conscious and coherent, with pain scale of 4/10, with intact and dry dressing at the surgical site, with capillary refill time of 2 seconds, with pink palpebral conjunctiva, (+) dizziness, (-) DOB, (-) headache, with good skin turgor, complaint of weakness, A > P > I> with initial vital signs of T: 36.5oC, P: 88 bpm, R-22 cpm, BP- 120/80 mmHg Activity intolerance related post surgical procedure After 4 hours of nursing interventions, the patient will be able to identify techniques to enhance activity tolerance > Monitored and recorded vital signs > > > > > > > > > > > > E> Assessed patient’s general condition Assessed surgical site PM care rendered Regulated and monitored IVF as ordered Noted client report of difficulty accomplishing task Assisted client in performing his ADL’s such as helping him go to the comfort room and move out of his bed Provided safety measures such as raising side rails and instructing SO to stay with him Provided comfort measures such as stretching bed linens and keeping it wrinkle free Encouraged to increase oral fluid intake Provided health teachings to eat protein rich foods for bone and muscle repair Kept back dry Meds given

> Needs attended Goal met as evidenced by the patient identified techniques to enhance activity tolerance.

Lippincott’s Review Series Pathophysiology Second Edition by Catherine Paradiso

http://www.imaginis.com/osteoporosis/osteo_affectswhom2.asp http://www.medicinenet.com/fracture/article.htm http://www.fnri.dost.gov.ph/index.php?option=content&task=view&id=749 http://en.wikipedia.org/wiki/Bone_fracture http://www.iofbonehealth.org/facts-and-statistics.html http://www.wrongdiagnosis.com/f/fractures/stats-country.htm http://www.sciencedaily.com/releases/2009/02/090218114320.htm http://www.medical-look.com/human_anatomy/systems/Skeletal_System.html

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close