Avon Grace B.

Yrag
Patient: John Michael Cailing
Dx: Mild Injury (Vehicular Accident)

Date / Clinical
Time Focus

08-12-2010  Received patient awake lying on bed with IVF line of PNSS at 550 cc
level regulated at 30 gtts/min; infusing well at right arm.
 With folley bag catheter in place attached to urobag; newly drained.
 Cooperative and coherent
 Initial vital signs taken and recorded
NPO  Instructed watchers
 Above IVF consumed and followed up with PNSS 1 L at 30 gtts/min
12:00 pm  Kept monitored for any signs of unusualities

 purse-lip breathing
Ineffective  Prolonged inspiration phases
Breathing  Use of assessory muscle
Pattern  Position client in a semi- fowler’s postion/ or at least elevate head of the
patient.
 Oxygen administration
 Provide rest
 Able to breathe effectively
 Stable vital signs: RR: 20, HR: 82, Bp: 110/70, T: 37.1 C

 Difficulty in moving
Impaired Physical  Pain / discomfort
Mobility  Decreased muscle strength
 Provide patient assistance
 Change position slowly with assistance
 Encourage to verbalization of feelings regarding limitations.
 Able to move side to side slowly with some assistance

 Slight breath odor

 Weakness
Self- care Defict:  Pain/ discomfort
Hygeine  Impaired mobility
 Done morning care, oral mouth care and bedside care
 Assist client in good hygiene
 Establish a therapeutic relationship with patient to have patient
cooperation.
 Include relatives and available caregivers in the care of patient for
assisting to his recovery.
 Health teaching done to watcher with emphasis on daily mouth care.
 Perform self- care activities within level of own ability.

 Resting on bed without complaints.

 Endorsed patient with stable vital signs
T:37.1 PR: 82 bpm RR: 19 cpm BP: 120/70 mmHg