WORKPLAN Date: 01-12-07

Student Room Patient Chief Category 6AM 7AM 8AM 9AM 10AM 11AM 12NN 1PM 2PM Remarks
Nurse No. Complaint/
Diagnosis
de Leon, 446 Consolacion Difficulty of III - receive -prepare -supervise -change -allow -prepare -assist and After 6 hours
Elaine Felipe, 87 Breathing, S/P MRM, endorsemen medication in feeding bed for rest medicati supervise of Nursing
t *Norisec linens periods on in feeding.
S. yrs. old, Breast CA Stage III, *Ciprobay
Intervention,
female HTN, DM type II, -assist in Post Post verbalized, “I
-assess nebulization -assist in -offer -prepare -encourage Conferen conferen
UTI, Pleural Effusion -monitor feel much
patient’s for every 15 nebulizat massage for RBS increase in ce ce
condition
client’s vital
mins. ion fluid
better, but still
signs a little hard to
-assess -allow intake
Assessment: -Monitor -position -administer -reassess for for rest breath but
O2 client to high medication client’s respirato period -reassess much better
S> “I could hardly back rest condition ry client now.”
breath, my chest is like -raised -administer distress -monitor understand
tightening.”, as siderails -assist in Medrol -ensure client’s ing of Client appears
nebulization 16mg as comfort vital relaxation
verbalized by client. less restless ad
ordered. signs technique irritable,
-encouraged
-allow and ask to wheezes are
and instruct
-position for rest demonstrat
O> receive patient in bed patient for decreased, less
use of client to periods e proper
conscious, coherent, use of
relaxation high back relaxation
afebrile, appears restless. rest technique accessory
technique
Self focusing, (+)facial such as deep -obtain muscle,
grimace, (+)wheezes, breathing -encourage RBS client’s vital
pursed lip breathing, exercises, use of signs are BP:
with O2 @ 2LPM. Use pursed lip relaxation -administer 110/70,
breathing. technique medication
of accessory muscle, Temp:36.4,
nasal flaring, with vital -assess for PR:86bpm,
signs of: BP:120/70, client’s
-ensure -obtain RR:21bpm
temp:36.1, PR:94bpm, condition. client’s I&O
comfort.
RR:24bpm
-instruct -plot V/S
client to open -provide
A> Impaired Gas mouth while clean & -Charting
Exchange r/t Alveolar nebulizing so calm of
Capillary Membrane that the environmen SOAPIE
Changes medication t
Endorseme would go
directly to
nt: -Provide
her lungs
-IV morning
removed by care
SI but no
order for -plot V/S
reinsertion

-RBS Q6
6am-not
done client
 WORKPLAN Date: 01-11-07
Student Room Patient Chief Category 6AM 7AM 8AM 9AM 10AM 11AM 12NN 1PM 2PM Remarks
Nurse No. Complaint/
Diagnosis
de Leon, 446 Consolacion Difficulty of III - receive -prepare -give due -encourage -assess -prepare -RBS -Obtain -Post
Elaine Felipe, 87 Breathing, S/P MRM, endorsemen medication meds use of patient’ meds monitor I&O conferen
S. yrs. old, Breast CA Stage III, t relaxation s ing ce
female HTN, DM type II, -monitor -regulate technique comfort -prepare -charting
-assess
UTI, Pleural Effusion vital signs IV fluid such as for RBS - assist -endorse
patient’s
deep -encour client in -reassess ment
condition
-regulate -plot V/S breathing age use -regulate feeding for
-Monitor IV fluid exercises of IV client’s
O2 -provdie diversio -admini conditio
-position clean and - regulate nal -allow ster n
-regulate IV client to calm IV fluid activitie fro rest meds
position of environm s such periods
comfort ent -give pain as
reliever as watchin -monitor
Endorseme
-raised -encourag ordered g TV. vital
nt:
RBS Q6- siderails e use of signs
12nn relaxation -allow
O2 @2LPM -assist in technique for rest BP:100/
DM Diet nebulizatio such as periods 70
D5NM x n. deep T:36.5
16hr breathing P:62bpm
-ensure exercises R:20bpm
client’s and
comfort. pursed lip
breathing

-provide
morning
care

-provide
comfort
measures

-change
bed linens