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    Nurses Notes

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    Mabelle Soriano

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    © All Rights Reserved
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    Nurses Notes

    Uploaded by

    Mabelle Soriano
    38 views2 pages

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    38 views2 pages

    Nurses Notes

    Uploaded by

    Mabelle Soriano

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    © All Rights Reserved
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    PATIENT: LUNA, ANTONNIO ROOM: 226, BED-2

    AGE: 65 SEX: MALE

    DATE NURSES’ NOTES


    11/26/20 F>
    7:00 am Ineffective airway clearance related to increase sputum production as
    evidenced by mucus secretion from tracheostomy tube.
    D>
    Received patient awake, afebrile, with an episode of non-productive cough.
    Pale, cold, clammy skin. Reports headache with pain rating of 6/10.
    Complaint of difficulty of breathing and chest pain with pain rating of 10/10
    radiating to shoulder. With mid intercoastal muscle retraction as inspected.
    With the latest vital signs of T-37.2; PR-110; RR-26; BP 150/100 SPO2- 85%.--------MS
    A>
    Monitored vital signs. Monitored oxygen saturation continuously, using pulse
    oximeter. Assessed patient’s respiratory depth. Assess the patient’s ability to
    cough out secretions. Placed the patient into semi fowler’s position. Teach
    patient with proper deep breathing exercise. Administered medications as
    prescribed. Considered verbalization of feelings. Reiterated the significance of
    medication to the patient.------------------------------------------------------------------------MS

    F>
    Acute pain related to the positive pressure in the pleural space as evidenced
    by patient verbalizes pain with rating of 10/10.------------------------------------------MS
    D>
    Received patient lying on bed, awake, and in distress. Afebrile. Reports
    headache with pain rating of 6/10. Patient complains of chest pain radiating
    from his shoulder with pain rating of 10/10. Patient displays difficulty of
    breathing. With mid intercoastal muscle retraction as inspected. Upon
    auscultation, crackles heart on the lower right lobe of patient’s lung. With the
    latest vital signs of T-37.2; PR-110; RR-26; BP 150/100 SPO2- 85%---------------------MS
    A>
    Monitored vital signs. Auscultated breathing sound. Inspect breathing pattern.
    Assessed location, characteristics, onset, duration, frequency, quality and
    severity of pain. Observed for nonverbal indicators of pain: moaning, guarding,
    crying, facial grimace. Accepted the patient’s description of pain. Positioned
    the patient in a semi fowler. Taught the patient deep breathing exercise.
    Reiterate the importance of medication.--------------------------------------------------MS

    F> Ineffective peripheral tissue perfusion related to hypoxemia as evidenced


    by pale, cold clammy skin secondary to pneumothorax------------------------------MS

    D> Received patient awake, afebrile, with an episode of non-productive


    cough. Pale, cold, clammy skin. Complaint of difficulty of breathing and chest
    pain with pain rating of 10/10 radiating to shoulder. With mid intercoastal
    muscle retraction as inspected. With the latest vital signs of T-37.2; PR-110; RR-
    26; BP 150/100 SPO2- 85%--------------------------------------------------------------------------MS
    A>
    Monitored vitals signs. Auscultated breathing sound. Inspected breathing
    pattern. Checked SPo2 of the patient. Recorded BP readings for orthostatic
    changes (drop of 20 mm Hg systolic BP or 10 mm Hg diastolic BP with position
    changes). Assessed for signs of decreased tissue perfusion. Maintained oxygen
    therapy as ordered.----------------------------------------------------------------------------------MS

    R>
    Currently not in pain. Still coughing. Difficulty of breathing relieved.
    Theoretically, With vital sign of RR 22cpm, T 37.8.0 ⸰C, PR 100 bpm, BP 140/90.

    SORIANO, MABELLE S.
    Staff Nurse SLU HSH
    12/04/20

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