Alvarez Marcelo 59 M M 0001 Dr.

Malta
M.I Civil Admission Attending
Surname First Name Age Sex
Status No. Physician
Incomplete Spinal Cord Injury ICU-A
Diagnosis/Impression Room/Ward

NURSES NOTES

Date Focus Data-Action-Response

04/20/2 Altered body D- Client is on bed, eye opening response is spontaneous,
1
temperature obeys commands but does not have response to verbal
r/t illness/trauma stimuli. Watcher informed of redness, swelling with
AEB raise of Serosanguinous discharges, client’s skin is warm to
Body temperature touch and is chilling GCS 11 (E4V1M6); T: 38C, P: 69 bpm,
R: 28 cpm, BP: 110/60 mmHg
Risk for infection A- Independent: Advised client to maintain bedrest, monitor
r/t invasive Vital signs Including input and output every hour and record
procedure/ significant changes in client’s status, adjust and monitor
insufficient Environmental factors such as room temperature,
Knowledge Demonstrate and encourage deep breathing exercises,
To avoid exposure Educate significant other of importance of maintaining the
To pathogens Cleanliness of operative site to prevent infections.
Dependent: Administer medications as prescribed.
R- Client and significant other demonstrates positive
Attitude towards the treatment process, client continues to
Obey commands of nurse and health care professional in
The course of treatment.