Fdar Proper 523s1u

The patient’s past and present history are needed. 1. These must explain why the patient sought care, the nature of the complaints, the duration of the complaints and whether the patient was involved in a traumatic event. The documentation should explain if the patient has exhibited the same or similar complaints previously, whether there is a family history of illness or injury and if there are contraindications to care. received patient on bed Conscious and coherent received patient on bed asleep FOCUS: Pain DATA:

>Facial grimace >General Weakness >Restlessness “Sakit akong kilid kung muobo ug sakit kung magsulti” “Nabudlayan ko mag ginhawa kung kis-a gain gasakit akon dughan mag ubo.” Verbalized chest pain felt rated as 6 in a scale of 0-10 10 (0 for no pain and 10 as to excruciating pain) gradually decreasing after coughing lasting 2 to 3 minutes, aggravated by return of coughing and prolonged conversation Facial grimace and muscle guarding as claimed Burning pain on the IV site rated as 3 in the scale of 0-10, aggravated by moving, alleviated by immobilization. Grade 1, non-pitting edema noted at IV site. “Masakit ang dibdib ko”, as verbalized by the patient. -Patient raises hand (as if to protect his left chest area), an example of guarding behavior -Facial mask of pain - grimaced face noted -guarding behavior observed Diaphoresis noted Fatigue Actions:

Encouraged use of relaxation techniques, i.e., guided imagery, visualization, deep-breathing exercises. Provided diversional activities. a. proper positioning b. breathing exercise c. massage d. heat and cold application. Provided diversional activities appropriate for age and condition such listening to radio, watching TV, reading Encouraged relaxation techniques, such as deep breathing, touch therapy. Response: FOCUS: Airway DATA: pale in

appearance

>Restlessness with nasal flaring > With rales on both lung fields > warm, flushed skin >minimal colorless nasal secretions >tachypnea AEB RR=53bpm >DOB >tachycardia >irritability >chest indrawing >cough >cyanosis >noisy breathing >pallor >changes in RR and rhythm >risk for infection >orthopnea >tachypnea

- frequent unproductive coughing episodes noted - appears weak - crackles heard over lung fields “I have cough but I can’t expectorate the phlegm” “Maglisod ko ginhawa ug mag-ubo ko panagsa” Adviced to dispose used tissues in sputum receptacle. “Nabudlayan ko mag ginhawa kung kis-a gani gasakit akon dughan mag ubo.” “Nahihirapan akong huminga” as verbalized by the patient "ubo pa, cge ubo pa, e gawas jud ang plema sa imong tutunlan pra dli mu bara sa imong pag hinga.", as verbalized by his sister. Crackles heard over the right lung and pleural friction rub on the left lung Dullness heard upon percussion of the posterior left lung Asymmetrical chest expansion with left chest slightly higher upon inspiration Decreased tactile fremitus at lower lobe of the left lung. Persistent productive cough noted and expectorates to a copious, yellow to greenish, blood streaked sputum approximately 2-3 cc per expectoration Nasal flaring and use of accessory muscles upon breathing Yellowish secretions  restless  wheezing  crackles  ineffective cough  moderate high back rest “Nahihirapan ako huminga at inuubo po ako na may kasamang dugo ”as verbalized by the patient ” “Hinahapo ako” “ galisod ug ginhawa akong anak “ as verbalized by the mother “sige ug ubo-ubo akong anak pero walay gagawas nga phlema, muhilak dayon siya “ as verbalized by the mother fatigue facial grimace crying no secretions are being expectorated dry and harsh cough  Cough ineffective  Difficulty in vocalizing  Wide-eyed  Wheezes  Cyanosis  •Use of accessory muscle  •Dyspnea SpO2-82% Patient was able to tolerate the position and no complaints of difficulty of breathing and aspiration were noted. Patient was able to return demonstrate deep breathing and coughing exercises The mother and father were able to understand the significance of the intervention and the mother verbalized, “ Ay oo..Nagawa ko na yan kanina para mas lumabas yung plema niya.” Actions:

Instructed to use abdominal muscles for more forceful cough Instructed/Demonstrated to use of quad and huff techniques Adviced to keep back dry and loosen clothing Adviced the mother to turn the infant to side-lying position when coughing is initiated. Instructed the SO to provide adequate rest periods for the child

Instructed patient to avoid bronchial irritants such as aerosols and extremes of temperature Reiterated importance of compliance to therapeutic and drug regimen Encouraged patient to increase fluid intake as tolerated Instructd and assisted patient in using pillow to splint chest during coughing episodes. Provided warm compress Adviced to keep patient’s back dry, Pat dry and change shirt as needed. Instructed family , significant others and visitors to limit prolonged conversation or discussion with patient. Instructed patient to cover mouth when coughing.

Instructed and demonstrated proper hand washing. Encouraged patient to ambulate when tolerated and change position at least every 2 hours. Adviced patient to splint chest when coughing. Encouraged rest during exacerbation of cough or dyspnea. Assist patient with coughing and deep breathing exercises at least 10 times every hour while awake. Adviced SO to provide sputum receptacle and tissue by bedside. Encouraged patient to cough out sputum. Performed chest physiotherapy such as percussion and vibration. Adviced to Increase oral fluid intake at least 2oo ml per day. Assisted patient with coughing, deep breathing exercise and splinting as necessary. Adviced SO on performing T Instructed coughing exercises Instructed deep breathing exercises Instructed to take adequate rest periods Instructed to perform back clapping. Encouraged deep breathing and coughing exercises. Positioned patient appropriately specifically elevate head of bed. Positioned the client in a semi-fowler’s position. istered 02 inhalation as prescribed encouraged deep breathing exercises due meds given as prescribed Instructed the significant others of the patient do not let the patient to wear tight clothes. Instruct the significant others of the patient to increase her fluid intake. Adviced patient to perform splinting chest and effective coughing while in upright position. Response: The patient exhibits less difficulty in breathing FOCUS: Impaired social interaction DATA: “Nahuya na ko mag atubang sa mga taw okay gaubo ako permi.” “Anha ra panutana sa akong asawa.” Kamo ra sa akong asawa pagsabot.” To wife,”Ayaw sige isturyakay daghan unya kag sayop ma sulti.” Patient was irritable and uncooperative Patient does not comply with recommended therapies: has not ambulated since ission Actions: Assisted patient and family in progressive participation in care and therapies. Encouraged participation in special interest activities such as having conversations with health team, visitors and significant others. Encouraged patient and significant others to converse and interact with each other. Encouraged family or significant others to provide praise for attempted or accomplished tasks. Response: FOCUS: Fever DATA: Body temp per axillae 38.8°C Diaphoresis Flushing of skin Skin warm to touch “Nilalagnat ata ako, ang init ng pakiramdam ko” as verbalized by the patien Actions: Encouraged adequate rest periods Performed TSB Adviced to increase oral fluid intake Provided safe & quite environment Response:

FOCUS: Interrupted Family Process DATA: “Di pa kami kabalo kung kinsa diri magbayad sa ospital, ingon ng company na sila daw magbayad pero di pa mi sigurado” Actions: Response: FOCUS: Disturbed Sleeping Pattern DATA: “Galingin ulo ko kung mag bangon kag magkadto sa banyo….” “Kulang gid akon tulog kay sige-sige akon ubo kung gab-i siguro mga tatlo lang asta lima kaoras akon tulog, kis-a gani gasakit na akon dughan ka-ubo.” Actions: Adviced to Keep personal items within reach (glass, water, pitcher, eyeglasses, personal hygiene, and grooming materials) at bedside. Encouraged/Provided comfort measures such as backrub, washing of hands and face, bathing, oral hygiene, cleaning and fixing linens in preparations for sleep. Encouraged to adjust air condition, thermostat to keep room cool or to provide electric fan for patient as needed, to provide extra blanket by bedside during nighttime sleep in case patient feels cold or chilly, or to change after perspiring or diaphoretic episode. Encourage and stress the importance of participation in regular exercise program during the day, such as deep breathing and coughing exercises and other active and ive range of motion exercises as tolerated. Informed patient that foods and drinks high in caffeine such as tea, coffee, cola drinks, and chocolates may interfere with sleep. Encouraged to rest after meals. Instructed patient to have extra clothing by bedside or shirts to change when perspiring or wet. Stressed the importance of compliance to medications and treatments Response: FOCUS:impaired physical mobility DATA: “Hindi ako makalakad dahil dito sa paa ko” as verbalized by the patient. “dli na na siya ata kalakaw kron kay ni grabe na iyang sakit, dili parehas sauna na naka lakaw pa.”as verbalized by his sister. With internal fixator on the phalanges of the left foot With cast Actions: Instructed to Perform active or ive ROM exercises to all extremities every 2-4 hours. Instructed the SO to Turn and reposition the patient every 2 hrs. Adviced to establish a turning schedule. Instructed to Maintain proper body alignment at all times Encouraged active exercise with a trapeze. Adviced to do isometric exercises. adviced patient to perform self care activities slowly and increase daily as tolerated. explained the importance of following prescribed medical and physical therapy regimens Instructed to do ive range-of-motion (ROM) exercises to unaffected extremity every 2 to 4 hours Instructed to change positions at least every 2 hr (supine, sidelying). Instructed to maintain neutral position of head. Placed pillow under axilla to abduct arm. Maintaind leg in neutral position. Encouraged exercises such as quadriceps/gluteal exercise, hand grip exercise and extension of fingers and legs/feet. Instructed to maintain upright position for 45–60 min after eating Response: Focus: Altered nutrition Data: “Nagniwang gid ko ya. Halin sa 49.6 kilos sang sine lang nga Agosto 29, 45 kilos na lang akon timbang subong.” ”Indi gid manamit ang sud-an sa hospital.”

“Di ko gawa ka panimaho kung lain matyag ko….” ”Indi mayo ang panabor ko sa pagkaon kay gina ubo ako…” slightly pale conjunctiva, palm of the hands and nailbeds poor capillary refill of 3 seconds upon blanching test Actions: Adviced to remove noxious stimuli such as bedpan, urinal, and trash can. Instructed patient to perform oral care before and after meals. Advised patient to take food and drinks rich in Vitamin C such as citrus fruits or drinks an orange juice. Advised patient to take food and drinks rich Folic acid such as green leafy vegetables (iron rich foods like liver and other organ meats) Advised patient to take food and drinks rich in Protein rich foods such as meat, milk and fish Advised patient to take food and drinks rich in Vitamin B6 such as liver and organ meats Advised patient to take food and drinks rich in Carbohydrates such as rice, corn and bread Advised patient to take food and drinks rich in Vitamin A such as cheese and carrots Advised patient to take food and drinks rich in High fiber foods such as ripe papaya and green leafy vegetables Instructed patient to take medications with food. Responses: Focus: Infections Data: Instruct patient/SO to minimize ing the hands, fingers with the face, mouth or nose. Instructd patient to provide disposable tissue for expectoration. Demonstrated and encouraged good hand washing technique to patient and family and visitors. Instructed to cover mouth when coughing. Instructed patient to bring with him disposable tissue paper and dispose properly after use in sputum receptacle. Adviced to avoid crowds during cold/flu season and persons with respiratory infections. Emphasized the need of continuing antibiotic therapy for prescribed period. Actions: Responses: Focus: Knowledge deficit Data: ” Gapacheck up ko pero wala ko kabalo kung anu sakit ko kay wala ya man ginhambal sa akon…basta ginaresitahan lang ko…anong pulmonya day haw?” Actions: Responses: Focus: Data: Actions: Responses: Focus: Data: Actions: Responses: Focus: Data: Actions: Responses: