The document contains 3 entries in a nursing care plan for a patient experiencing breathing difficulties. The first entry from October 26th notes the patient's symptoms of difficulty breathing, wheezing, and low oxygen saturation. The nurse assessed the patient's vital signs, provided oxygen therapy, medications, and positioning. The patient's breathing improved. The second entry from October 27th addressed the patient's ongoing cough. The nurse assessed the cough and lung sounds, maintained oxygen therapy, and educated the patient. Lung sounds were clear. The third entry from October 28th covered discharge planning. The nurse educated the patient on medications, follow-up, and the patient demonstrated understanding of the discharge plan.
The document contains 3 entries in a nursing care plan for a patient experiencing breathing difficulties. The first entry from October 26th notes the patient's symptoms of difficulty breathing, wheezing, and low oxygen saturation. The nurse assessed the patient's vital signs, provided oxygen therapy, medications, and positioning. The patient's breathing improved. The second entry from October 27th addressed the patient's ongoing cough. The nurse assessed the cough and lung sounds, maintained oxygen therapy, and educated the patient. Lung sounds were clear. The third entry from October 28th covered discharge planning. The nurse educated the patient on medications, follow-up, and the patient demonstrated understanding of the discharge plan.
The document contains 3 entries in a nursing care plan for a patient experiencing breathing difficulties. The first entry from October 26th notes the patient's symptoms of difficulty breathing, wheezing, and low oxygen saturation. The nurse assessed the patient's vital signs, provided oxygen therapy, medications, and positioning. The patient's breathing improved. The second entry from October 27th addressed the patient's ongoing cough. The nurse assessed the cough and lung sounds, maintained oxygen therapy, and educated the patient. Lung sounds were clear. The third entry from October 28th covered discharge planning. The nurse educated the patient on medications, follow-up, and the patient demonstrated understanding of the discharge plan.
The document contains 3 entries in a nursing care plan for a patient experiencing breathing difficulties. The first entry from October 26th notes the patient's symptoms of difficulty breathing, wheezing, and low oxygen saturation. The nurse assessed the patient's vital signs, provided oxygen therapy, medications, and positioning. The patient's breathing improved. The second entry from October 27th addressed the patient's ongoing cough. The nurse assessed the cough and lung sounds, maintained oxygen therapy, and educated the patient. Lung sounds were clear. The third entry from October 28th covered discharge planning. The nurse educated the patient on medications, follow-up, and the patient demonstrated understanding of the discharge plan.
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MEJIA JEMIMAH A.
BSN3-F GROUP A
DATE AND TIME FOCUS DATA
October 26, 2020 Difficulty of Breathing “I can’t breath, and it's going on for 7:30 am hours now” as verbalized by the client, dyspnoeic, wheezing, coughing, rapid irregular heart rate, tachypnea, VS: BP: 112/62 mm Hg, RR: 22, HR; 92, irregular, temp: 36.5, Spo2: 87%.
A> Assessed vital signs of the client,
Monitored oxygen saturation, Auscultated lung fields, Positioned patient in a high fowlers, Administered oxygen therapy as ordered, Administered prescribed medications, Encouarged patient to use relaxation techniques.
R> “ I can now breath properly’ as
verbalized by the client, RR: 20 cpm MEJIA JEMIMAH A. BSN3-F GROUP A
DATE AND TIME FOCUS DATA
October 27, 2020 Cough Received awake sitting on the bed 7:30 am with ongoing oxygen therapy per nasal cannula at 2 L/minute. “ I have a cough and it's already 2 weeks but ist not going away” as verbalized by the client, productive cough, thick gelatinous sputum, dyspnea, wheezing, RR:22, temp 37.5.
A> Auscultated lungs for the presence
of adventitious breath sounds, Assessed for cough efficacy and productivity, Assessed the amount, quality, and color of the sputum, Monitored respirations, Positioned the patient in Semi fowlers, Maintained humidified oxygen as prescribed, Give medications as prescribed, Encouraged patient to increase fluid intake to 3 liters per day, Educated patient on coughing, deep breathing, and splinting techniques.
R> The patient has clear and open
airways as evidence by normal breath sounds, normal rate and depth of respiration, MEJIA JEMIMAH A. BSN3-F GROUP A
DATE AND TIME FOCUS DATA
October 28, 2020 Discharge plan Received awake sitting on the bed, ‘ I 7:30 am think might go home, because the doctor said that I should process my papes because I'm now okay and ready to go home’, normal vitals signs, no distress or pain, appear to be well.
A> Educated about the medications,
dosage, route, effect, and adverse effect, Encourage to drink medication in proper dosage and time, Demonstrated the proper use of metered-dose inhalers to the patient, Instructed patients to report to their primary healthcare provider the changes and consistent, prolonged periods of dyspnea that are unrelieved by medications, Instructed and encouraged to attend follow up check-up after 2 weeks of discharge.
R> “ Yes I will go to my follow
up check up two weeks after my discharge” as verbalized by the patient, also demonstrated the proper used of inhalers. MEJIA JEMIMAH A. BSN3-F GROUP A