CASE PRE. GROUP 4.docx - PATIENT’S KARDEX Name of Patient:...

PATIENT’S KARDEX
Name of Patient: Patient HB
Age:38 years old Gender: Male
Room Number:
#03
Chief Complain:
Right Sided Chest Pain, Dyspnea
Physician: Dr. Charles
Guzman
Admitting diagnosis: Bronchopneumonia
Current Assessment:
8: 30AM
Vital Signs
Temp: 38. 6c
BP: 90/60
PR: 97 bpm
RR: 32 cpm
Physical Assessment
•Patient is awake, conscious and
coherent but looks weak and
anxious.
•With 02 support via face mask at
2LPM
•Lips look pale in color. Patient
verbalized itchiness on throat and
difficulty on clearing his throat. Teeth
are clean with whitish color.
•Upon auscultation, breathe sound
that sounds like scratching a
stainless steel is heard. It is near on
the sound of the breath sound
“crackles”. Percussion was not done.
Use of accessory muscles while
coughing was noted. The patient
verbalized that he feels difficulty on
breathing.
•Pale conjunctiva was noted upon
inspection of the eyes.
•Skin appears pale, capillary refill
time is greater than 2 seconds.
Special Orders:
•Pls. admit to ROC under my
service
•Secure consent for admission
•Monitor VS q 2o & record
•Give O2 support at 2 LPM via
face mask
•Relay lab results to AP once
available
•Refer accordingly
IVF:
D
5
LRS 1L x 10
o
D
5
NM 1L x 10 o
Diet:
DAT with SAP
Medications: Laboratories/ Diagnostics:
CBC, Urinalysis, Na, K
CXR-PA, RBS, BUN,
Crea, ABG
Paracetamol 500mg/tab 1tab
q4o PRN for T o =37.8
Sinecod Forte 1 tab TID
Ventolin 1 neb now then q8
hours
Levofloxacin 500mg/tab,
1tab OD
Ceftriaxone 1g q12hours
ANST

NURSES NOTES
PATIENT’S NAME AGE GENDER C/S RM/BED# HOSPITAL#
Mr. HB 38 M S 3 0441208
**PLEASE AFFIX SIGNATURE OVER PRINTED NAME AT THE END OF THE ENTRY
DATE/SHIFT/ TIME FOCUS NOTES (DATA, ACTIONS, RESPONSE)

 04/13/2021
 8:30 AM
 9:00 AM
 10:00 AM
 10:30 AM
 11:00 AM
 11:30 AM
 1:00 PM
 1:30 PM
 2:00 PM
 3:00 PM

Ineffective airway
clearance

Hyperthermia

Activity intolerance

Received patient lying on his bed awake,
conscious and coherent but looks weak and
anxious with ongoing O2 support via face mask at
2LPM.

with V/S of Temp-38.6c, BP-90/60, PR-97 bpm,
RR-32 cpm

lips look pale in color and Pale conjunctiva was
noted upon inspection of the eyes.

capillary refill time is greater than 2 seconds

with crackles and dyspnea

Establish rapport

Auscultated breath sound

Assessed cough effectiveness and productivity

Monitored vital signs and recorded

Assessed the patient’s hydration status

Position on high back rest

Instructed deep breathing exercises, coughing and
splinting in upright position

Encouraged increase fluid intake

Suctioned the patient as indicated

Encouraged patient to rest

Administered Ventolin as prescribed

Patient have negative signs of difficulty of
breathing

Performed TSB

Advised to wear loose and comfortable clothes

Encouraged patient to increase fluid intake
