Avon Grace B. Yrag Patient: John Michael Cailing Dx: Mild Injury (Vehicular Accident)
Date / Time
Clinical Focus
08-12-2010
NPO 12:00 pm
Received patient awake lying on bed with IVF line of PNSS at 550 cc level regulated at 30 gtts/min; infusing well at right arm. With folley bag catheter in place attached to urobag; newly drained. Cooperative and coherent Initial vital signs taken and recorded Instructed watchers Above IVF consumed and followed up with PNSS 1 L at 30 gtts/min Kept monitored for any signs of unusualities purse-lip breathing Prolonged inspiration phases Use of assessory muscle Position client in a semi- fowler·s postion/ or at least elevate head of the patient. Oxygen administration Provide rest Able to breathe effectively Stable vital signs: RR: 20, HR: 82, Bp: 110/70, T: 37.1 C
Ineffective Breathing Pattern
Impaired Physical Mobility
Difficulty in moving Pain / discomfort Decreased muscle strength Provide patient assistance Change position slowly with assistance Encourage to verbalization of feelings regarding limitations. Able to move side to side slowly with some assistance
Self- care Defict: Hygeine
Slight breath odor Weakness Pain/ discomfort Impaired mobility Done morning care, oral mouth care and bedside care Assist client in good hygiene Establish a therapeutic relationship with patient to have patient cooperation. Include relatives and available caregivers in the care of patient for assisting to his recovery. Health teaching done to watcher with emphasis on daily mouth care. Perform self- care activities within level of own ability. Resting on bed without complaints. Endorsed patient with stable vital signs T:37.1 PR: 82 bpm RR: 19 cpm BP: 120/70 mmHg