Reynaldo Pama

M
Surname First Name M.I. y/o Sex Civil Status Admission No. Attending Physician
Age

Diagnosis
Room/Ward
NURSES NOTES
Date Focus Data, Action, Response
9/07/20 Chronic Reported difficulty of breathing, fatigue and feverish feeling. Temperature at
Obstructive 37.6’, Respiratory Rate increased at 30 rr/min with spO2 at 93%
Tachypnea noted
Pulmonary
Disease
A: Vital signs checked at 8am
Monitored Vital signs for baseline data
Administered oxygen inhalation @2L/min
Monitored oxygen concentration
Regulated Iv flow at 80cc/hr
Measured intake and output
Patient placed in high fowlers position

Client teaching:
Instructed patient to have high caloric, high protein and low carb diet
Advised for bed rest
encouraged increased fluid intake

R: Respiratory Rate: 20
Difficulty of breathing relieved
No signs of IV dislodged
No signs of hypoxia