Date/Shift Focus Data

11-06-2020 Impaired gas exchange Received patient lying on bed, awake.

AM shift (8am-4pm) related to altered oxygen  Dyspnea noted
supply.  Presence of hemoptysis
 Pale
 have been off and depressed
 chest x-ray result suggested cancer
 Initial vital signs are as follows:
T: 35.6 degrees Celsius
PR: 113 bpm
RR: 25 bpm
BP: 80/60 mmHg
O2 saturation: 93%
Within 8 hrs of nursing intervention the patient will be
able to alleviate the dyspnea and improve the breathing
patterns.
Interventions:
 Provided a clean and well-ventilated environment
for the patient.
 Initial vital signs taken as ordered and recorded.
 Assessed level of consciousness/cognition and ability
to protect own airway.
 Assessed respiratory rate, depth, and rhythm and
color changes of the patient.
 Auscultate lungs air movement and abnormal breath
sound.
 Monitored for the use of accessory muscle, pursed
lip breathing, changes in skin.
 Assessed if occasional cough of patient is productive
or unproductive and assess its amount, color, odor,
and secretion viscosity.
 Monitored and recorded I/O, and oxygen saturation
with the use of pulse oximeter.
 Monitored chest x-ray and laboratory results of
patient.
 Monitored for any unusualities manifested by
patient.
 Monitored O2 saturation and ABG.
 Administered IV fluids and other medications as
ordered.
 Administered supplemental oxygen via nasal
cannula as prescribed.
 Provided passive activities to patient such as
listening to music or reading a book.
 Repositioned frequently, placing patient in sitting
position and semi-fowler’s position appropriately
and comfortably.
  Encouraged and assisted with deep breathing
exercises as appropriate.
 Encouraged patient to increase fluid intake up to
3000ml/day as tolerated or as ordered by physician.
 Promoted adequate rest periods to patient.
After 8 hrs of nursing intervention the patient was able
to demonstrate improve ventilation and adequate
oxygenation of tissue by ABGs within patient’s normal
range. Endorsed patient with latest vital signs as follow:
T: 37.0 degrees Celsius; PR: 100 bpm; RR: 20 bpm; BP:
120/90 mmHg; O2 saturation:
95%----------------------------------------------------------------------
-----------KPJOSOL,FSUU/SN
Name: Zeph

Age: 23 years old Sex: Male Room number: 304 Hospital number: 100921