The patient was admitted to the 2-10pm shift with impaired gas exchange and difficulty breathing. They were awake and responsive with no fever. Their respiratory rate, depth, effort and oxygen saturation were monitored. The patient was positioned upright and given oxygen to increase lung expansion. Controlled coughing and deep breathing exercises were encouraged to help clear the airways. By 10pm the patient was resting comfortably and able to breathe better.
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The patient was admitted to the 2-10pm shift with impaired gas exchange and difficulty breathing. They were awake and responsive with no fever. Their respiratory rate, depth, effort and oxygen saturation were monitored. The patient was positioned upright and given oxygen to increase lung expansion. Controlled coughing and deep breathing exercises were encouraged to help clear the airways. By 10pm the patient was resting comfortably and able to breathe better.
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DATE SHIFT FOCUS TIME PROGRESS NOTES
8/11/2020 2-10 Impaired gas 2 D- Received pt on lying in bed, awake, consci
exchange responsive. The patient is afebrile and verbal “nahadlok ko kay nag lisod kog ginhawa og sigi ko ubo-ubo”. A- Assess respiratory rate, depth, and effort, inclu the use of accessory muscles, nasal flaring, and abno breathing patterns. Monitor for alteration in BP HR.Position patient with head of bed elevated, in a s - Fowler’s position.to increased lung expans Maintain an oxygen administration device as orde attempting to maintain oxygen saturation at 90% greater. Encouraged patient to take a deep breathe perform controlled coughing. Have patient inhale dee hold breath for several seconds, and cough two to t times with mouth open while tightening the u abdominal muscles as tolerated. Helped patient to calm and reduce anxiety. Provided a quiet and c environment away from irritants. Performed suc because the patient is not capable of effectively clea the airway. 10 R- The patient is comfortably resting and able to br better.