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Nursing Care Report for Zeph

Zeph, a 23 year old male, was admitted to the hospital with a temperature of 35.6°C, heart rate of 113 bpm, respiratory rate of 25 cpm, and blood pressure of 80/60 mmHg. The nurse's focus was on Zeph's activity intolerance due to generalized weakness. Through 8 hours of nursing interventions including IV fluids, bedside care, encouragement to eat and move, Zeph's symptoms improved with his temperature rising to 37.5°C, heart rate lowering to 100 bpm, respiratory rate decreasing to 20 cpm, and blood pressure increasing to 120/80 mmHg.

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pius troy macapaz
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77 views2 pages

Nursing Care Report for Zeph

Zeph, a 23 year old male, was admitted to the hospital with a temperature of 35.6°C, heart rate of 113 bpm, respiratory rate of 25 cpm, and blood pressure of 80/60 mmHg. The nurse's focus was on Zeph's activity intolerance due to generalized weakness. Through 8 hours of nursing interventions including IV fluids, bedside care, encouragement to eat and move, Zeph's symptoms improved with his temperature rising to 37.5°C, heart rate lowering to 100 bpm, respiratory rate decreasing to 20 cpm, and blood pressure increasing to 120/80 mmHg.

Uploaded by

pius troy macapaz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as ODT, PDF, TXT or read online on Scribd
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Name: Zeph Age/Sex: 23 male Room No.

Hospital Number:

Date/ Shift Focus Data


09-24-2020 S-“Maglisod kog lihok ani
7-3 tungod sigeg suka”.
O- Received patient lying on
bed 02 sat regulated @2lpm,
awake, and coherent with Ivf
regulated at 20gtts. / min.
-with initial v/s taken as follows
Temp.-35.6 °C
PR-113 bpm
RR- 25 cpm
02-93%
Bp-80/60 mmHg
A-Activity Intolerance r/t
generalized weakness
P-Within 8 hours of nursing
intervention the pt will be able
demonstrate a decrease in
physiological signs of
intolerance
I-IVF tube patency: checked
IVF regulated as ordered
Initial v/s taken and recorded
-Bed side Care Done.
-Note Pt report of weakness,
fatigue pain, difficulty and
accomplished task
-Provide positive atmosphere
-Ascertain ability to stand and
move about the degree of
assistance
-Encouraged patient to change
clothes as needed
-Encouraged patient to eat
healthy foods.
Seen and examined by Dr. Apas
with orders carried out

E-After 8 hours of nursing


intervention, the patient was
able to demonstrate a decrease
in physiological signs of
intolerance
With latest v/s
Temp.-37.5 °C
PR- 100 bpm
RR- 20 cpm
O2-99%
BP-120/80 mmHg
P.Macapaz /SN 9-25-20

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