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Nurses Notes 11

A patient presented with a persistent cough for 3 months, and chills and night sweats for the last 3 days. They were coughing up blood. Vital signs showed an elevated temperature, rapid heart rate and breathing rate, and low oxygen levels. The nurse administered medications as ordered, taught breathing exercises, and explained the disease, medications, and dietary management to the patient and family members. The patient's cough was relieved and vital signs improved by the end of the shift.

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308 views1 page

Nurses Notes 11

A patient presented with a persistent cough for 3 months, and chills and night sweats for the last 3 days. They were coughing up blood. Vital signs showed an elevated temperature, rapid heart rate and breathing rate, and low oxygen levels. The nurse administered medications as ordered, taught breathing exercises, and explained the disease, medications, and dietary management to the patient and family members. The patient's cough was relieved and vital signs improved by the end of the shift.

Uploaded by

janna mae patriarca
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NURSES NOTES

DATE/ TIME DAR


SHIFT
11-16-2020 7:30 am D >Received awake in supine position with IVF # 1 PNSS 1L @ 30
gtts/min. she reported of a persistent cough for the last 3 months and
in the last 3 days she’s been experiencing chills and night sweats and
today she noticed she was coughing up blood. Facial grimacing and
guarding behaviour noted.
8:00 am >c vital signs of Temp : 101.2 F , HR : 92 bpm, RR: 24 bpm , BP:
146/78 mmHg, Spo2: 90%
8:30 am A> IVF regulated to desired rate.
> Vital signs were monitored and recorded.
>medications were administered as per doctor’s order. The right of
medication administration were followed.
> explain about dietary management to the patient.
> Knowledge given about disease condition.
>steam inhalation given to the patient.
> breathing exercise taught to the patient with demonstration.
>uses of medication explained to the patient and family members.
>explain the dietary management and disease condition to the patient
and family members.
2:30 pm R> endorsed to NOD with latest v/s of Temp : 97 F , HR : 86 bpm, RR:
18 bpm , BP: 120/80 mmHg, Spo2: 97%
>ongoing IVF # 1 of PNSS IL with 30 gtts/min level left 20ml.
>reported cough was relieved.

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