Scribd
Upload
548 views1 page

Nurses Notes: Signature:-Ms. Rita Date:-10/1/2020 Time: - 7am

Mrs. Radha, a 40-year-old patient, is on a ventilator in the ICU. Nurse Rita assessed the patient and found her pupils dilated and fixed with swelling in her extremities. Vitals were stable. Nurse Rita identified nursing diagnoses of self-care deficit, impaired nutrition, risk of infection from invasive procedures, and risk of bedsores. Nurse Rita provided morning care, eye/oral/perineal care, turned the patient every 2 hours, and met eating and elimination needs to address the diagnoses.

Uploaded by

Meena Koushal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
548 views1 page

Nurses Notes: Signature:-Ms. Rita Date:-10/1/2020 Time: - 7am

Mrs. Radha, a 40-year-old patient, is on a ventilator in the ICU. Nurse Rita assessed the patient and found her pupils dilated and fixed with swelling in her extremities. Vitals were stable. Nurse Rita identified nursing diagnoses of self-care deficit, impaired nutrition, risk of infection from invasive procedures, and risk of bedsores. Nurse Rita provided morning care, eye/oral/perineal care, turned the patient every 2 hours, and met eating and elimination needs to address the diagnoses.

Uploaded by

Meena Koushal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

NURSES NOTES

Assigned patient :Mrs. Radha ,40 years old

IPD No. 2453

Assigned staff : Ms. Rita

Assessment

Patient is on ventilator. Maintaining IPPV mode peep 4 ,TV -400,fiO2 -60%,nasogastric tube
insitu. Et placed at the right side of corner of mouth .central line present at right internal jugular
vein .bilateral pupils are 3mm dilated & fixed. Mild swelling present over bilateral extremities
Foley’s catheter insitu and draining clear urine. Cardiac monitor is attached and showing –HR-
76b/min,BP-110/70mmHg, RR-20/min , Spo2-98%.

Nursing diagnosis :

 Self-care deficit related to inability to perform her daily activities of living as evidenced
by kempt appearance.
 Impaired nutrition intake related to disease condition as evidenced by weight loss.
 Risk for infection related to invasive procedure.
 Risk for bedsore related to prolong bed rest

Care given :

 Morning care given.


 Eye care , Oral care & perineal care given
 Foleys care done under aseptic technique.
 Back care & changed position every 2 hourly.
 Range of motion exercise done
 Met the client eating and elimination need .
 Frequent hand washing done.

Signature:- Ms. Rita

Date:-10/1/2020

Time:- 7Am

You might also like