Fdar Cabg 3nesurgical
Fdar Cabg 3nesurgical
Fdar Cabg 3nesurgical
CASE SCENARIO:
Submitted to
Clinical Instructor
Submitted by
NURSE’S NOTES 1
DATE/ TIME FOCUS DATA, ACTION, and RESPONSE
09/30/2020 Acute pain related to D:“Pwede unya na nang mga
5:00 pm Surgical Incision pangutana? sakit jud kaayo akong
dughan tungod kay gi opera ko” as
verbalized by the patient.
-Facial grimacing and guarding is
observed.
-Patient was easily irritated and
snapped when asked about his pain
scale.
-Increase in Blood pressure and
respiratory rate.
-Shortness of breath is observed.
A:Administered pain-relieving
medication specifically Aspirin as per
doctor’s order.
-Monitored patient’s vital signs which
can be affected due to pain.
-Provided patient teaching regarding
pain control measures such as deep
breathing, music and relaxation
therapy and positive thinking.
R:Patient was able to report diminished
pain and stated that from a pain rating
scale of 7 out of 10 it has now reduced
to 5 out of 1.
-Vital signs are within normal range
-Patient is feeling more relaxed and no
longer shows facial grimacing and
guarding behavior.
NURSE’S NOTES 2
DATE/ TIME FOCUS DATA, ACTION, and RESPONSE
09/30/2020 Decreased cardiac D: “ luya man kaayo akong ginabati,
5:00 pm output related to tapos
alteration in heart Murag lisod bitaw iginhawa”
rate -variations in the blood pressure and
heart rate were noted.
-abnormal heart sounds and cyanosis
were observed.
A: Administered Losartan 25 mg OD for
high blood pressure and Trimetazidine 35
mg BID for Patient’s angina.
-Monitored blood pressure, heart rhythm,
rate and sound every 4 hours.
-Provided patient teaching on how to
prevent and control high blood pressure
such as compliance to medications and
having a potassium-rich food diet.
-Encouraged patient to rest.
R: Blood pressure was within normal range
-Patient verbalized that he was well
rested and demonstrated increased
tolerance to activities with no discomfort
observed.
NURSE’S NOTES 3
DATE/ TIME FOCUS DATA, ACTION, and RESPONSE
09/30/2020 Anxiety related to D: “Gaka-balaka jud ko og maayo pako
5:00 pm situational crises as aning akong sakit labi nag tiguwang
evidenced by nako... gadugang rajud kos problema
helplessness
sakoang pamilya” as verbalized by the
patient.
-the patient looks weak and helpless. A
-provided reassurance and comfort
measures.
-Maintained calmness during approach
to the client.
-Remained with the client at all times
when levels of anxiety are high (severe
or panic); reassure client of his or her
safety and security.
-Moved the client to a quiet area with
minimal stimuli
-Encouraged the client’s
participation in relaxation exercises
such as deep breathing, progressive
muscle relaxation, guided imagery
or meditation.
R: -patient was able to discuss his
feelings of dread, anxiety and fear.
-Patient was able to verbalized his
understanding in relaxation exercises.
-Patient was able to respond to
relaxation techniques with a decreased
anxiety level.