focus data charting

8/17/2019 focus data charting

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High Risk for infection r/t knowledge deficit: illness,

information misinterpretation

Subjective: "Na-admit ta adda kanu infection ditoy

reproductive na."

Objective: not using of personal protective equipment

Planning

Sort !erm oal: #ill able to participate in learning process

$ong !erm oal: %emonstrate lifestyle canges

&ssessment

'. &ssess client(s kno#ledge about te disease )simplifye*planation on client+

,. %etermine clients learning style )i.e. visual aids+ )to

facilitate learning or recall+

. *plain te disease process )s/s0 causes+ )increase

kno#ledge and reduce an*iety+

1. %iscuss te uses of medications

2. Provide calm 3 quiet environment )to promote rela*ation+

4. 5nitiated te ff.: use of PP )protect and/or avoid0 minimi6e

e*posure to oter patogens+

:increase intake of nutritious foods )promote #ellness

:increase intake of food ric in vit 7 )to boost immunity+

:e*ercise and ave adequate rest periods )to regain strengt+

Risk for Deficient fluid volume r/t excessive lossess

through normal route

Subjective: "Nagsarsar#a ak ken nagburis ak0 nabanog ti

riknak."

Objective: fatigue0 #eakness0 sunken eye balls0 skin non

resilient

5nterventions

stablis rapport )gain pts( trust+

8onitor and record v/s )obtain baseline data+

&ssessed for skin resiliency )note for any signs of deydration+8ade self available by staying at bedside )provide timely

support+

Positioned on bed comfortably

9i*ed linens and keep clotes clean and dry )to provide comfort

3 keep pt #arm+

ncourage te ff.

:increase fluid intake up to $ per day )prevent deydration 3

electrolyte imbalance+

:eat nutritious foods )to regain strengt+

:bed rest

:verbali6e feelings and concerns

&dminister medications prescribed )suc as probiotics0 to

promote gro#t of normal flora+

Ineffective Breathing pattern r/t decreased lung

expansion (accumulation of air/liuid!

-dyspnea

-tacypnea

-respiratory dept canges

-use of accessory muscles

-impaired development of te cest

-cyanosis

-abnormal blood gas analysis

oal: effective breating pattern

Outcomes: so#ed normal breating pattern / effective #/

normal blood gas analysis free cyanosis and signs of ypo*iasymptoms

Nursing interventions

5dentify te etiology or trigger factor - evaluation of respiratory

function )rapid breating0 cyanosis0 canges in v/s+

&uscultation of breat sounds

Note te position of te tracea and cest dev(p0 revie#

fremitus

8aintain a comfortable position0 usually O; elevated

ive O, via nasal cannula/mask


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Rest and 'leep

%> @estlessness0 appears #eak0 letargic

&> &ssessed current ealt status? assisted to position

comfort? reiterated importance of ouring adequate rest

periods? minimi6ed controllable noise for comfortable sleep?

facilitated on deep breating e*ercises and rela*ation

tecniques conducive to sleep0 listening of music

@> &ble to ave adequate rest and sleep at least 2 ours #/n

te sift

utrition: im)alance less than )od" reuirements

>receiving statement

%> "%amdama ak nga mangan"0 lack of interest in foods0 eats

,2D of food served

&> &ssessed current ealt status0 evaluated total daily food

intake? instructed on small frequent feeding diet? reiterated

importance of #ell balanced and encourage to eat nutritious

foods for ealt promotion? made self available for any possible

concerns

@> &ble to consume E2D of food served

Deficient Diversional *ctivit"

%> %isinterest on moving or doing e*ercises0 inattentiveness0

avoids eye contact

&> Noted impact of disability/illness in lifestyle to provide

comparative baseline for assessments and interventions?

made self available for any possible concerns? reiterated

importance of participating in activities like morning e*ercises

to prevent from muscle fatigue and immobility? provide a

clean and comfortable environment to promote comfort and

increase desire to participate? encouraged to verbali6e

feelings and concerns to lessen burden? encouraged ondiversional activities suc as reading maga6ines0 listening to

music and encouraged on deep breating e*ercises to

promote rela*ation.

@> &ble to participate actively on any given activities.

Infection control

%> 9i*ator on rigt leg0 s#elling on te rigt foot

&> Observed aseptic tecnique during interventions0 reiterated

te importance of keeping te fi*ator clean and dry0 encouraged

te ff.: proper and #asing before and after andling tings0

intake of Bit 7 ric foods suc as lemon0 oranges0 and oter

citrus foods to boost immune system0 and protein ric foods

suc as eggs and meat to promote #ound ealing0 advised to

report unto#ard signs suc as foul smell and yello#is

discarges

@> numerated #ays of keeping fi*ator clean and dry0 no signsof complication or infection

%atigue

%> "&gkakapsut ak? kasla a#an pigpigsak"0 appears #eak0

needs minimal assistance in doings &%$(s

&> &ssessed environmental factors contributing to fatigue0

assisted #it self care needs0 planned interventions to allo#

adequate rest periods0 promoted overall ealt measures

suc as adequate fluid intake? instructed to limit activities tat

requires e*cessive use of energy? encouraged intake of

nutritious foods0 ig sugar foods and beverages0 verbali6e

feelings and concerns0 regular ligt e*ercise as tolerated

@> 5mproved sense of energy after rendering interventions

Risk for fluid volume deficit (H"povolemia!

S/s: acute #eigt loss0 decreased skin turgor0 oliguria0

concentrated urine0 ortostatic PN0 fatigue0 tacycardia0

ypertermia0 polidipsia0 delayed caplliary refill0 decreased

7BP0 cold0 pale and clammy skin0 anore*ic0 nauseous0 muscle

cramps0 dry mucosa membranes

&> 8onitor v/s0 skin turgor0 capilliary refill0 #eigt0 and ourly 5

and O0 ceck for diarrea0 vomiting and e*cessive urination

)polyuria+ - may cause furter fluid loss? ceck AAA for

concentration0


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@r of ,C

7yanosis

Ortopnea

%iaporesis

Planning: sort term: after tree ours of nursing interventions

te pt #ill demonstrate appropriate coping beaviors and

metods to improve breating pattern.

$ong term: after ' to , days of nursing interventions te pt

#ould be able to apply tecniques tat #ould improve breating

pattern and be free from signs and symptoms af respiratorydistress

Nursing interventions:

establised rapport? monitor and record v/s

&ssessed breat sounds0 rr0 dept0 and rytm

levate ead of te pt

Provide rela*ing environment

&dminister supplemental O, as ordered

&ssist client in te use of rela*ation tecnique

&dminister prescribed medications as ordered: ma*imi6e

respiratory effort #/ good posture and effective use of accessory

muscle.

Risk for infection related to incision sites

%: 5ncision site in front of left ear e*tending do#n and around

te ear and into neck'1 cm in lengt--#itout dressing.

Hackson-Pratt drain in left neck belo# ear secured in place

#it suture.

&: &ssess site and emptied drain. !augt patient S3S of

infection.

@: No s#elling or bleeding? bruising belo# left ear noted. HPdrained ,Fm$ bloody drainage. States understanding of

teacing.

Dela"ed surgical recover"

%: 7/O di66iness after trying to get OO; to use te batroom.

&: &ssisted patient back in bed and #it use of bedpan by

7N&. !augt o# to dangle legs and get OO; slo#ly. !augt

couging and deep breating e*ercises0 turning in bed0 and

use of anti-embolism stockings.

@: Boided ,FFm$ in bedpan. %id coug and deep breating

appropriately. $ungs clear bilaterally. &nti-embolism stockings

on.

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