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Fdar (3 Days)

John Kanaman, a 42-year-old male patient, was admitted to the ER feeling dizzy and weak with compromised breathing. Over the next few days, nurses monitored his vital signs, administered medications, collaborated with respiratory therapists, and assisted with breathing exercises, though he continued to rely on an Ambu bag for breathing. On the third day, his respiratory rate improved to 24 breaths per minute without the Ambu bag, showing increased ability to clear his airway.

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499 views2 pages

Fdar (3 Days)

John Kanaman, a 42-year-old male patient, was admitted to the ER feeling dizzy and weak with compromised breathing. Over the next few days, nurses monitored his vital signs, administered medications, collaborated with respiratory therapists, and assisted with breathing exercises, though he continued to rely on an Ambu bag for breathing. On the third day, his respiratory rate improved to 24 breaths per minute without the Ambu bag, showing increased ability to clear his airway.

Uploaded by

gia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NURSES PROGRESS NOTES

Patient’s Name: John Kanaman Age: 42 Sex: M Bed # 15 Hosp. # 2021-123456789

DATA/ TIME FOCUS D= Data A= Action R= Response


11/16/21 Ineffective Airway D- Received in the ER awake, felt dizzy and very weak.
8:01 am Clearance - Vital signs were as follows:
BP= 90/50mmHg
HR= 112 bpm
RR= Ambu bag (AB)
Temp= 36.4°C
Oxygen saturation of 92%
- Airway was compromised and RT placed an
endotracheal tube.
- Stridor were heard bilateral upon auscultation.

A- Vital signs were monitored.


- Laboratory results were monitored.
- Breath sounds were auscultated.
- Positioned in semi-Fowler’s or high Fowler’s position.
- Assisted with turning and deep breathing or coughing
exercises.
- Environmental pollution from sources such as dust,
smoke, and feather pillows were kept in minimum.
- Provided with oxygen therapy as prescribed.
- Administered medications as prescribed.
- Collaborated with a respiratory therapist for
consultation. G.Moreno

GIA M. MORENO

HNU-CHS-NSG
4:00 pm R- Patient was still not able to maintain airway patency
and improve airway clearance as evidenced by
respiratory rate with the of use of an Ambu Bag.

11/17/21 Ineffective Airway D- Vital signs were as follows:


8:01 am Clearance BP= 110/60 mmHg
HR= 75 bpm
RR= Ambu bag (AB)
Temp= 37°C
Oxygen saturation of 99%

A- Vital signs were monitored.


- Laboratory results were monitored.
- Breath sounds were auscultated.
- Positioned in semi-Fowler’s or high Fowler’s position.
- Assisted with turning and deep breathing or coughing
exercises.
- Environmental pollution from sources such as dust,
smoke, and feather pillows were kept in minimum.
- Provided with oxygen therapy as prescribed
- Administered medications as prescribed
- Collaborated with a respiratory therapist for
consultation.
G.Moreno

GIA M. MORENO
HNU-CHS-NSG

4:00 pm R- Patient was still not able to maintain airway patency


and improve airway clearance as evidenced by
respiratory rate with the of use of an Ambu Bag.

11//18/21 Ineffective Airway D- Vital signs were as follows:


8:01 am Clearance BP= 100/60 mmHg
HR= 87 bpm
RR= 24 cpm
Temp= 37.3°C

A- Vital signs were monitored.


- Laboratory results were monitored.
- Breath sounds were auscultated.
- Positioned in semi-Fowler’s or high Fowler’s position.
- Assisted with turning and deep breathing or coughing
exercises.
- Environmental pollution from sources such as dust,
smoke, and feather pillows were kept in minimum.
- Provided with oxygen therapy as prescribed.
- Administered medications as prescribed.
- Collaborated with a respiratory therapist for
consultation.
G.Moreno

GIA M. MORENO
HNU-CHS-NSG

4:00 pm R- Patient was able to improve airway patency and


airway clearance as evidenced by presence of respiratory
rate of 23 cpm without the use of an Ambu Bag.

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