Beruflich Dokumente
Kultur Dokumente
• Patient R.A. appears tired & weak but not that critically ill
person. He is thin for his age of 20 y/o. He stayed on bed, either
in supine or semi-fowler’s position. He often looks drowsy and
sleepy and whenever he feels something painful, he shows facial
grimace and sigh. He is oriented to time, place and person;
coherent and answer questions appropriately.
Vital Signs
• Patient R.A.’s vital signs monitored Q4H except for post blood
transfusion which is monitored Q15min. for the first hour, Q30min.
for the next hour and then QH. As of August 17, 2010 during the
6am-2pm shift, his temperature was at 37.4ºC taken @ right axilla,
afebrile and within the normal range during the entire shift. His
pulse at 92bpm palpated @ left radial pulse. He breathes
spontaneously to room air @ 23cpm, within normal rate, depth and
rhythm and his blood pressure of 100/60 mmHg.
Integumentary
• Patient’s skin is brownish, warm to touch and with pale lips
noted. Patient has good skin turgor, assessed in left forearm. No
presence of skin lesions, incisions and bruised noted. Patient
doesn’t experience itchiness in the skin.
Cardiovascular System
• Patient has ongoing mainline IVF bottle #2 D5LR 1L regulated @ 15
gtts/min with remaining amount of 650cc infusing well @ left
metacarpal vein & side drip bottle #2 PNSS 1pint interrupted.
Respiratory
• Patient breathes spontaneously to room air within normal range. He
has a respiratory rate of 23cpm and has a clear breathe sound
heard in both lung fields upon auscultation. Patient R.A. had a
chest x-ray done without significant findings noted.
Chest
• Chest size is equal and symmetrical. No mass noted upon palpation.
Abdomen
• Flat abdomen and no abdominal distention upon palpation.
Gastrointestinal Tract
• Prior to admission, patient has good appetite and had no history
of constipation, incontinence and sometimes he had episodes of
diarrhea.
Musculoskeletal