FOCUS D - DATA A- ACTION R- RESPONSE

FEVER Temp – 38, skin warm to touch, flushed skin,

dry lips, irritable

Continuous TSB, increase fluid intake, expose skin, avoid

warm binding clothes and blanket, antipyretic medication as

ordered, comfort measures, cold compress applied to

forehead

Afebrile, temp – 37.5

Infiltration Swollen IV site, not flowing, cold to touch,

tenderness, pain at the site

Observed for signs of infiltration or phlebitis; Informed

nurse about patient’s status; Explained procedure to

patient/watcher. Assisted in removing IV device aseptically;

secured necessary materials. Assisted in reinsertion of IV

device aseptically. Placed patient in comfortable position.

Monitored for unusualities.

Seen patient comfortable; IV site free from

infiltration/infection and infusing well at ___.

Ineffective breathing pattern

Airway clearance altered

Risk for infection

Anxiety

Intubated, increase RR, cyanosis, nasal

flaring, retractions, restlessness,

apprehensions, wheezing, crackles,

productive cough, poor oral intake

Oxygen therapy, check placement and patency of ET,

suction secretions, comfortable positions, high backrest,

decrease stress/ calm environment, nebulize as ordered,

gentle chest/ back clapping after nebulization, adequate

hydration, observe iv site for infiltration, maintain NPO,

record I & O, provide rest and comfort, skin care, change

positions frequently.

No signs of complication; stable V/S, no

infections; normal temp., seen relaxed and at

ease, still intubated, still with productive

cough

For discharge

Discharge teaching

a. With may go home as ordered by

Dr._____; V/S stable.

b. With DAMA as ordered by Dr._____

Assessed patient’s condition, Allowed patient / watcher to

verbalize feelings and concerns regarding status, Informed

about discharge process, clearance given (NP) and

facilitated, followed up laboratory / diagnostic test results,

health teaching done, instructed home medications and care,

encouraged to come back for follow up on _____ , 10 am at

room 10.

(NP) nonPhilhealth

a. Patient went home accompanied/ carried/

cuddled by mother/father in good condition.

b. Patient still in; awaiting clearance.

c. Patient still in; to secure all lab results/ xray

result and awaiting clearance.

Laboratory / diagnostic work-

up

With order of ________ by Dr. ______. Assessed patient’s condition, vital signs taken and recorded.

Informed watcher about work-up; explained procedure and

its importance. Encouraged expression of feelings and

concern. Lab/ Xray requested as ordered. Monitored for

unusualities. Followed up request.

a. Lab/ xray result in, referred to Dr. _____.

b. Still for lab / Xray once with available

funds.

c. Still for follow-up lab/ xray result.

Pain Discomfort

With pain scale of _____; guarding position,

crying, irritable, poor appetite.

Explored probable cause of pain; encouraged to verbalize

feelings; determined factors that aggravate pain; encouraged

to perform relaxation techniques; informed the nurse

regarding status; provided comfort measures; promoted

calm and restful environment; administered pain medication

a. seen asleep and without further complaints.

b. still with pain with pain scale of ____.

Your name/ Myra P. Oka, RN/ ______

SN UZ/ CI UZ/ NOD