Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 817 views

    Nurses' Notes and Treatment Record: Date/Time Focus Progress Notes (D-Data A-Action R-Response)

    Uploaded by

    Jamie Lee
    John Rey, an 18-year-old male, was admitted to the male medical ward on August 15, 2021 for moderate dehydration due to continuous vomiting and diarrhea. Upon admission, his vital signs were abnormal and lab results showed electrolyte imbalances. He was given IV fluids, medications, and introduced to a low-salt diet. By noon, his vital signs and pain level improved as his fluid and electrolyte balance was restored as evidenced by normal urine output and skin turgor. His condition responded well to the treatment received.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Nurses' Notes and Treatment Record: Date/Time Focus Progress Notes (D-Data A-Action R-Response)

    Uploaded by

    Jamie Lee
    817 views2 pages
    John Rey, an 18-year-old male, was admitted to the male medical ward on August 15, 2021 for moderate dehydration due to continuous vomiting and diarrhea. Upon admission, his vital signs were abnormal and lab results showed electrolyte imbalances. He was given IV fluids, medications, and introduced to a low-salt diet. By noon, his vital signs and pain level improved as his fluid and electrolyte balance was restored as evidenced by normal urine output and skin turgor. His condition responded well to the treatment received.

    Original Title

    - FDAR

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    John Rey, an 18-year-old male, was admitted to the male medical ward on August 15, 2021 for moderate dehydration due to continuous vomiting and diarrhea. Upon admission, his vital signs were abnormal and lab results showed electrolyte imbalances. He was given IV fluids, medications, and introduced to a low-salt diet. By noon, his vital signs and pain level improved as his fluid and electrolyte balance was restored as evidenced by normal urine output and skin turgor. His condition responded well to the treatment received.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    817 views2 pages

    Nurses' Notes and Treatment Record: Date/Time Focus Progress Notes (D-Data A-Action R-Response)

    Uploaded by

    Jamie Lee
    John Rey, an 18-year-old male, was admitted to the male medical ward on August 15, 2021 for moderate dehydration due to continuous vomiting and diarrhea. Upon admission, his vital signs were abnormal and lab results showed electrolyte imbalances. He was given IV fluids, medications, and introduced to a low-salt diet. By noon, his vital signs and pain level improved as his fluid and electrolyte balance was restored as evidenced by normal urine output and skin turgor. His condition responded well to the treatment received.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    NURSES' NOTES AND

    TREATMENT RECORD

    Name of Patient:John Rey Ward/Room: Male Medical Ward 1


    Address:Mansilingan, Bacolod City
    Age:18 y/o Sex:Male Admission Date: August 15, 2021

    Date/Time Focus Progress Notes


    (D-Data A-Action R-Response)
    Deficient volume related to D:
    8/15/21 moderate dehydration as evidenced
    by continuous vomiting and ● Received awake and responsive on bed.
    7AM diarrhea. ● Complained of continuous vomiting, loose bowel
    movement, and fever
    ● Noted that the patient is weak and pale due to
    continuous vomiting and defecating.
    V/S follows:

    T-37.9 C,
    RR-21 cpm, Pain Scale: 7/10
    PR-78 bpm,
    Lab Results folows:
    BP-110/7
    CBC done with WBC 13x 1000mm2

    Urinalysis Result:

    0-2/hpf plus cells and 5-10/hpf rbc squamous epithelial cells


    rare

    Sodium: 121mEq/L, Potassium: 2.9 mEq/L, Chloride Blood:


    88 mEq/L.

    -Stools exam shows numerous bacteria

    Vital Signs at noon:

    T-37.1 C, RR-21 cpm, PR-83 bpm, BP-120/70--FJLSO

    12 noon A:
    Vital Signs ● - Monitored vital signs Q4 hours
    at noon: ● -Perform/Assist IV insertion
    ● -Encouraged to increase fluid intake for electrolyte
    T-37.1 C, balance
    RR-21 cpm, ● -Increased the fluid intake of the patient .
    PR-83 bpm, ● -Patient was introduced to a low salt, low fat diet--
    BP-120/70 FJLSO
    Medication given as follows;

    Cotrimoxazole 800 mg 1 capsule BID PO


    Omeprazole 20 mg 1 cap OD PO
    Metoclopramide 10mg q 8 hrs PO for 2 days then PRN
    Paracetamol 500 mg I tab PO PRN for fever --FJLSO

    R:

    Pain Scale: 4/10


    -The pain of the patient was reduced due to the increase
    of volume in the body and with the medication given.

    - The patient experienced adequate fluid and electrolyte


    balance as evidence by urine output more than
    30ml/hour, normal vital signs and good skin turgor.--
    FJLSO

    FJLSO
    Florianne Jamie Lee S. Oraa
    SN-USLS

    You might also like