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Focus Charting

Mary Jane Tulabot documented her nursing care of a patient over the course of one day. In the afternoon, she treated the patient's hypotension by elevating their legs and monitoring their blood pressure as it increased. Later, she changed the patient's wound dressing and ensured the incision site showed no signs of infection. She also taught the patient how to change their own dressing. Over the course of the evening, she addressed the patient's decreased appetite, gave dietary recommendations, and treated their constipation with increased fluids and fiber while monitoring their bowel movements.

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Jane Umali Tulabot
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10K views2 pages

Focus Charting

Mary Jane Tulabot documented her nursing care of a patient over the course of one day. In the afternoon, she treated the patient's hypotension by elevating their legs and monitoring their blood pressure as it increased. Later, she changed the patient's wound dressing and ensured the incision site showed no signs of infection. She also taught the patient how to change their own dressing. Over the course of the evening, she addressed the patient's decreased appetite, gave dietary recommendations, and treated their constipation with increased fluids and fiber while monitoring their bowel movements.

Uploaded by

Jane Umali Tulabot
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

FOCUS CHARTING Mary Jane U.

Tulabot
BSN 4y3-29D

8/20/10  HYPOTENSION D : Blood pressure of 90/60 and dizziness


4:00pm A:
 Elevate the legs of the person by placing
pillow below the feet or if in a hospital
setting place the client in trendelenburg
position.
 Provide well ventilation
 Promote client’s safety
 Promote client’s comfort
R: Patient verbalized loss of dizzines
Patient BP from 90/60 to 110/90
S: Mary Jane Tulabot (student RN)

8/20/10  Risk for infection related to D: Incision located at the lower left abdominal
5:00pm surgical incision quadrant with dressing unchange
A: wound dressing done
R: No swelling or bleeding
S: Mary Jane Tulabot ( student RN)
5:30pm
 HEALTH TEACHING: Dressing R: Patient is demonstrate he is able to change
change his own dressing using aseptic technique
S: Mary Jane Tulabot (student RN)

6:00pm  Decrease in apetite D: weakness


A: encourage the patient ti eat fruits to
replenish his body with vitamins
R: the patient is able to eat well
S: Mary Jane Tulabot (student RN)

6:30pm  Constipation D: difficulty in defacation


A:
 Encourage the patient to increase fluid
intake
 Encourage the patient to eat foods high
in fiber
R: The patient verbalize normal bowel
movement
S: Mary Jane Tulabot (student RN)
FOCUS CHARTING Mary Jane U. Tulabot
BSN 4y3-29D

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