Scribd Logo
Upload

Welcome to Scribd!

  • 542 views

    Elevated The Head of The Bed Assisted Change Position Every 2 Hours Encouraged Liberal Fluid Intake

    Uploaded by

    Deinielle Magdangal Romero
    Mr. Alcot, a 68-year-old male, was admitted to the hospital on July 16, 2021 with a cough and fever for four days and was diagnosed with pneumonia. Over three nursing assessments, he complained of difficulty breathing due to cough and phlegm, fever and general weakness, and chest pain when breathing. Examinations found sputum, fever, and pain and decreased breathing sounds in his right lung. His conditions were treated with oxygen, suctioning, cooling measures, positioning, breathing exercises, medications, and pain relief techniques. His symptoms improved, including decreased fever, ability to cough up phlegm, and relief from chest pain.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Elevated The Head of The Bed Assisted Change Position Every 2 Hours Encouraged Liberal Fluid Intake

    Uploaded by

    Deinielle Magdangal Romero
    542 views3 pages
    Mr. Alcot, a 68-year-old male, was admitted to the hospital on July 16, 2021 with a cough and fever for four days and was diagnosed with pneumonia. Over three nursing assessments, he complained of difficulty breathing due to cough and phlegm, fever and general weakness, and chest pain when breathing. Examinations found sputum, fever, and pain and decreased breathing sounds in his right lung. His conditions were treated with oxygen, suctioning, cooling measures, positioning, breathing exercises, medications, and pain relief techniques. His symptoms improved, including decreased fever, ability to cough up phlegm, and relief from chest pain.

    Original Title

    PNEUMONIA-Charting

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Mr. Alcot, a 68-year-old male, was admitted to the hospital on July 16, 2021 with a cough and fever for four days and was diagnosed with pneumonia. Over three nursing assessments, he complained of difficulty breathing due to cough and phlegm, fever and general weakness, and chest pain when breathing. Examinations found sputum, fever, and pain and decreased breathing sounds in his right lung. His conditions were treated with oxygen, suctioning, cooling measures, positioning, breathing exercises, medications, and pain relief techniques. His symptoms improved, including decreased fever, ability to cough up phlegm, and relief from chest pain.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    542 views3 pages

    Elevated The Head of The Bed Assisted Change Position Every 2 Hours Encouraged Liberal Fluid Intake

    Uploaded by

    Deinielle Magdangal Romero
    Mr. Alcot, a 68-year-old male, was admitted to the hospital on July 16, 2021 with a cough and fever for four days and was diagnosed with pneumonia. Over three nursing assessments, he complained of difficulty breathing due to cough and phlegm, fever and general weakness, and chest pain when breathing. Examinations found sputum, fever, and pain and decreased breathing sounds in his right lung. His conditions were treated with oxygen, suctioning, cooling measures, positioning, breathing exercises, medications, and pain relief techniques. His symptoms improved, including decreased fever, ability to cough up phlegm, and relief from chest pain.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    SOAPIE CHARTING #1

    Name: Mr. Alcot


    Age: 68-years-old
    Gender: Male
    Date Admitted: July 16, 2021 (8:00 am)
    CC: Cough and fever for four days
    Diagnosis: Pneumonia

    S: “Nahihirapan akong huminga dahil sa ubo at plema” as verbalized


    O:
     Presence of sputum noted (thick and yellow with streaks of blood)
     Pain in right chest that intensifies with inspiration
     Productive cough
     Difficulty of breathing
     Auscultation reveals bilateral diminished vesicular breath sounds
     Bronchial breath sounds, rhonchi and late inspiratory crackles (are heard) in the
    area of the right mid-anterior and right mid-lateral lung fields
     Respiratory rate taken:
    RR: 24 cpm
    A – Ineffective airway clearance related to increased sputum production as evidenced by
    productive cough with presence of thick and yellow sputum streaks of blood
    P- Within 6 to 8 hours of rendering appropriate intervention, will be able to expectorate
    phlegm
    I-
    • 8:00 am- Elevated the head of the bed
    • Assisted change position every 2 hours
    • Encouraged liberal fluid intake
    • Instructed to take warm liquids instead of cold ones
    • Encouraged and demonstrated deep breathing and huff coughing technique
    • Encouraged patient to increase intake of nutritious food like fruits and vegetables rich in
    vitamin C
    • Facilitated quiet environment and adequate rest
    • 8:00am -Performed suctioning as ordered
    • Administered oxygen therapy as ordered
    E-
    • RR: 19 cpm
    • Able to expectorate phlegm within a shift
    • Able to take rest and nap at times
    • Endorsed
    SOAPIE CHARTING #2

    Name: Mr. Alcot


    Age: 68-years-old
    Gender: Male
    Date Admitted: July 16, 2021 (8:00 am)
    CC: Cough and fever for four days
    Diagnosis: Pneumonia

    S: “Mainit at masama pakiramdam ko”- as verbalized


    O:
     Fever (temperature taken:
    102.6 F)
     Shaking
     Chills
     Malaise
     Warm to touch
    A- Hyperthermia related to infection process as evidenced by temperature of 102.6 F
    P- Within 1 hour of providing appropriate nursing intervention, the temperature will
    decrease from 102.6 F to 98.9 F
    I-
    • 8:00am - Provided tepid sponge bath
    • Provided cool circulating air using a fan.
    • Placed a cool cloth or cooling patches on the client’s forehead
    • Positioned the patient in a comfortable position and elevate the head of the patient
    • Facilitated bed rest
    • Assisted patient in changing into dry clothing.
    • 8:00am- Administered medications as prescribed
    E-
    • T: 98.9 F
    • Able to take rest and nap at times
    • Endorsed
    SOAPIE CHARTING #3

    Name: Mr. Alcot


    Age: 68-years-old
    Gender: Male
    Date Admitted: July 16, 2021 (8:00 am)
    CC: Cough and fever for four days
    Diagnosis: Pneumonia

    S: “Masakit dibdib ko dahil hindi ako makahinga”- as verbalized


    O:
     Guarding Behavior (holding his right chest using left arm)
     Pain in right chest that intensifies with inspiration
     Cough Continuously
     Apical heart rate taken:
    112 bpm
     Respiratory rate taken:
    24 cpm
    A- Acute pain related to persistent cough as evidenced by pain in right chest
    P- Within 1-4 hour of providing appropriate nursing intervention, verbalize relief/ control
    of pain
    I-
    •8:00 am- Provided comfort measures: back rubs, position changes, quite music, massage.
    Encouraged use of relaxation and/or breathing exercises.
    • Positioned the patient in a comfortable position and elevated the head of the patient
    • Offered frequent oral hygiene
    • Instructed and assisted patient in chest splinting techniques during coughing episodes
    • 8:00 am- Administered antitussives as indicated. Do not suppress a productive cough;
    moderate amounts of analgesics are used to relieve pleuritic pain.
    • Administered analgesics as prescribed. Encourage patient to take analgesics before
    discomfort becomes severe
    E-
    • RR: 20 cpm
    • Verbalized relief/ control pain within a shift
    • Able to take rest and nap at times
    • Endorsed

    You might also like