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  - is a method for organizing health information in the
individual's record. It is a systematic approach to documentation, using
nursing terminology to describe individual's health status and nursing
action.



‡ a key word or diagnostic category from a nursing diagnosis or
collaborative problem on the plan of care (action plan),
i.e. skin integrity, coping, activity tolerance, self care deficit
‡ a current individual concern or behavior,
i.e. nausea, chest pain, pre-op teaching, hospital admission
‡ a sign or symptom of (possible) importance to the nursing and/or
medical diagnosis or treatment plan,
i.e. fever, constipation, hypertension, incontinence, lethargy
‡ an acute change in an individual's condition,
i.e. respiratory distress, seizure, fever, discomfort
‡ a significant event in an individual's care,
i.e. begin treatment regimen (oxygen), change in diet, catheterization
‡ a key word or phrase indicating compliance with a standard of care or
agency policy,
i.e. self medication teaching plan, transition
  

  

| ›ubjective and/or objective information

supporting the stated focus or describing
observations at the time of significant events.
  Nursing interventions performed,
planned to be performed, and/or protocols
and procedures initiated.
 Description of individual's response
to medical and/or nursing care. ›tatement
that the Action Plan of Care outcomes have
been attained or are progressing toward
attainment.
 
 Comfort (or, Relief of pain)
|- Complaining of continuous, sharp pain in
mid-abdominal incisional area. Crying. "I need
something for pain now!" ›tates pain is 9 on a
scale of 10.
 - Medicated with Demerol 75mg IM in LUOQ
of left buttock. Repositioned on right side with
pillow to abdomen to help splint wound.
 - Patient stated pain was "much better" 30
minutes later and rated it 3 on a scale of 10.---N.
Nurse
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p :!
D > increase in body temperature above normal range to T= 38
degree Celsius/axilla
> flushed skin and warm to touched
A 9 00am
> Tepid sponge bath done
> instructed ›O to let patient wear loose clothing
> instructed ›O to provide blanket to patient when shiver
> instructed ›O to let patient drink lots of fluid
> instructed ›O to include in his diet foods rich in Vitamin C
such as oranges
> provided opportunity for patient to rest
> due meds given
R 1 00pm
> patient was able to rest
> patient temperature decrease to T= 37.8 degree
Celsius/axilla
p1 ""  6
D1 increase respiratory rate of 24 cpm
D2 use of accessory muscle to breath
D3 presence of nonproductive cough
p2 :!
D1 skin warm and flush to touched
D2 increased body temperature of T= 37.7 degree celsius/axilla
p3


D1 less movement noted with the verbalization of ³kapoy man ako lawas,
kulangan ko ug katulog´
A 9 00am
 monitored v/s and charted
 regulated IVp and charted
 morning care done
 assessed patient needs and performed handwashing before handling the
patient
 advised ›O to always stay on patient bedside
 promote proper ventilation and a therapeutic environment
 elevated the head of the bed (moderate high back rest)
 provided comfort measures and provide opportunity for patient to rest
 due meds given
9 30am
 tepid sponge bath done
 instructed ›O to provide blanket and let patient wear loose clothing
p4 Discharge Plan (12 00nn)
D1 discharged order given by Dr.Name/Time
M ± advised ›O to give the ff. meds at the right time, dose, frequency and route
E ± encouraged to maintain cleanliness of the house and surroundings
T ± advised to go to follow-up consultations on the prescribed date
H ± encouraged to do chest tapping to facilitate mobilization of secretion
O - observed for signs of super infections such as fever, black fury tongue and
foul odor discharges
D ± encouraged to eat fresh vegetables and fish
› ± advised to continue praying to God and hear mass on ›unday

2 00pm ± out of the room per wheelchair with improved condition

Discharge plan for patient who undergo ›urgery
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