DATE SHIFT FOCUS TIME PROGRESS NOTES
8/11/2020 2-10 Impaired gas 2 D- Received pt on lying in bed, awake, consci
exchange responsive. The patient is afebrile and verbal
“nahadlok ko kay nag lisod kog ginhawa og sigi ko
ubo-ubo”.
A- Assess respiratory rate, depth, and effort, inclu
the use of accessory muscles, nasal flaring, and abno
breathing patterns. Monitor for alteration in BP
HR.Position patient with head of bed elevated, in a s
- Fowler’s position.to increased lung expans
Maintain an oxygen administration device as orde
attempting to maintain oxygen saturation at 90%
greater. Encouraged patient to take a deep breathe
perform controlled coughing. Have patient inhale dee
hold breath for several seconds, and cough two to t
times with mouth open while tightening the u
abdominal muscles as tolerated. Helped patient to
calm and reduce anxiety. Provided a quiet and c
environment away from irritants. Performed suc
because the patient is not capable of effectively clea
the airway.
10 R- The patient is comfortably resting and able to br
better.