Patient’s Name: Calvin Umbyuma Age: 42 year old

Diagnosis: Pulmonary Tuberculosis

Doctor in Charge: _____________________________________________

DATE / TIME F = FOCUS D = DATA A = ACTION R = RESPONSE

03/04/2021 Ineffective airway D:

clearance
● Vitals Signs: T: 100.6 F, RR: 22 cpm P: 86 bpm
0700H
● PaO2: 91%
● Greenish-yellowish secretion with blood tinge
● Dusky appearance
● Chest X-ray showed patchy shadowing in the right
upper lobe
● Complaints of shortness of breath with pleuritic chest
pain
● Painful to cough
A:
● Place client in high fowler’s position
0800H
● Teach and encourage deep breathing and coughing
exercises
● Heath teach patient about disease and the
compliance of therapeutic regimen
● Increased fluid intake
R:
● Client verbalized feeling rested and relaxed
0900H
● Able to demonstrate deep breathing and coughing
● Client drank 1 L of water
● Client verbalized understanding about disease
condition and the need with therapeutic regimen

D:
Altered Comfort: acute
pain ● Shortness of breath with pleuritic chest pain
0930H
● Painful to cough
● Has night sweats for the past 4 weeks
● Patient looks very dusky
● Coughed up blood sputum
● Vitals Signs: T: 100.6 F, RR: 22 cpm P: 86 bpm
● PaO2: 91%

A:
● Encourage and assist client to do deep breathing
1000H exercises
● Teach patient the use of non pharmacologic
 techniques such as distraction or massage
● Reposition the patient every 2 hours
● Administered medication as prescribed by the
physician:
○ Tylenol
R:
● Able to demonstrate deep breathing and exercises
1200H
● Feels relaxed and rested
● Not as painful to cough
● Vitals Signs: T: 98.6 F, RR: 21 cpm P: 86 bpm
● Pao2:95%

Ineffective breathing D:
pattern
● Shortness of breath with pleuritic chest pain
● Coughs with greenish-yellow with blood tinge
● Chest x-ray showed patchy shadowing in the right
upper lobe
● Vitals Signs: T: 100.6 F, RR: 22 cpm P: 86 bpm
● PaO2: 91%
A:
● Monitor vital signs especially respiratory rate
● Auscultate for breath sounds: note areas with
01300H
presence of adventitious sounds
● Maintained patient on moderate high back rest
● Encourage to do deep breathing techniques
● Ensure oxygen therapy
● Provide rest periods
● Take medication as prescribed the physician
○ Kanamycin and moxifloxacin

R:
1400H
● Vital signs are within normal level: T: 100.6 F, RR: 22
cpm P: 86 bpm
● Oxygen level at normal value : SpO2: 95%
● Normal breath sounds upon auscultation
● Demonstrate deep breathing exercises
● Feels relaxed and rested
Patient’s Name: Mary Barkley Age: 74 years old

Diagnosis:COVID-19, lupus

Doctor in Charge:

DATE / TIME F = FOCUS D = DATA A = ACTION R = RESPONSE

03/04/2021
Impaired gas exchange D:
● Does not want to be in a breathing tube
0700H
● Vital Signs: BP: 90/58, P: 116 bpm, R:28, T: 102
● PaO2 85%
● Chills, muscle pain, headache
● Fine crackles in her lungs bilaterally
● Restlessness
● Disoriented and believes the nursing staff is trying to
kill her
● With valve mask

A:
● Monitor vital signs for alternation of BP and HR
0900H ● Auscultate lungs for abnormal breath sounds
● Monitor ABGs
● Teach and encourage deep breathing and cough
exercises
● Reposition every 2 hours
● Encourage frequent rest periods and teach patient to
pace activity

R:
● Vital signs within normal value: BP: 110/70, P: 102
1000H R: 22, T: 99.6
● Oyxgen delivery is improved : PaO2- 90%
● Able to demonstrate deep breathing exercises
● Feels rested and energized
● Oriented to time and place

D:
● Fearful and is requesting to see her family
Anxiety
● States that she does not want to die alone
● at times seems to be talking to someone in the room
when no one is present
● Does not want a breathing tube but family wants the
1200H
nurse to do every effort done to save her
● Disoriented and believes that the nursing staff is
 trying to kill her
● Keeps pulling PCT’s mask to see who she is
A:
● Instruct to do deep breathing exercise
1300H
● Establish a working relationship with the patient
through continuity of care
● Use simple language when instructing patient about
condition and treatment
● Encouraged to verbalize expressions or clarifications
of needs, concerns, unknowns and questions.
● Provide ways for patient to communicate with
families such as call or video call
● Provide adequate rest

R:
1400H
● Able to established rapport
● Verbalized understanding of condition and treatment
● Able to verbalize concerns and expressions
● Feels rested
● Happy to be able to talk with family