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Charting Exam

Nurse Ana received Mr. Franco, who had a cerebrovascular accident, and assessed hemiplegia on his right side, dysphagia, and redness on his sacral area. Dr. Smith ordered various treatments including physical rehabilitation, monitoring of vitals, insertion of an NGT, and medications. Later, Mr. Franco complained of dizziness and high blood pressure, so additional medications were ordered. Nurse Ana facilitated various treatments and tests throughout her shift.

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245 views

Charting Exam

Nurse Ana received Mr. Franco, who had a cerebrovascular accident, and assessed hemiplegia on his right side, dysphagia, and redness on his sacral area. Dr. Smith ordered various treatments including physical rehabilitation, monitoring of vitals, insertion of an NGT, and medications. Later, Mr. Franco complained of dizziness and high blood pressure, so additional medications were ordered. Nurse Ana facilitated various treatments and tests throughout her shift.

Uploaded by

leanne_567
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Formulate a SOAPIE charting and FDAR charting based on the given situation Mr.

Franco 56yo has been in the Notre Dame hospital for 2days. He was diagnosed with Cerebrovascular Accident at left middle cerebral territory under the service of Dr. Smith. Nurse Ana the incoming nurse received an IVF of D5W 500cc @10cc/hr at the level of 200cc at 7am, with oxygen inhalation @3L/min via nasal cannula, with Foley catheter attached to urine bag. The following were assessment findings of Nurse Ana: hemiplegic right, dysphagia and redness on the sacral area. He verbalized in a slurred speechwalang lakas ang kamay at paa ko.Hindi na ako makakabalik pa sa trabaho. 11/6/2007 at 8am Dr. Smith visited him with the following orders: >on CBR without BRP. >for physical rehabilitation. >monitor BP and CR hourly. >for repeat ECG now. >insert NGT now then start OF 2500 Kcal to be given in 4equally divided feedings. >still for CT scan please facilitate. >IVF to follow: D5W 500cc@25cc/hr >Mannitol 200cc now as IV bolus then give 100cc every 6hrs. >start Felodipine 5mg 1tab OD/NGT @12:30pm At 10:30am, Mr. Franco complained of dizziness, blurring of vision, nausea, BP 190/100mmHg. Nurse Ana referred it immediately to the attending physician thru telephone with the following orders: >give Captopril 50mg/tab 1 tab sublingual now (10:35AM) then tab every 6hrs PRN for BP of 150/90mmHg and above. Dr. Smith inserted NGT at 1135am and Nurse Ana gave the initial feeding at 12NN. At 2:00 pm he was sent for CT scan via stretcher and sent back to ward at 2:45pm. Nurse Ana endorsed the following to her reliever: >physical rehab started, ECG done, feeding started, CT scan done, Mannitol started, Felodipine given.

Mr. Basco, 34yo has been CMSH for 2days. He was diagnosed with Acute Gastroenteritis t/c amoebiasis under the service of Dr. Ching Nurse Danna the incoming nurse received an IVF of D5LR 1L @130cc/hr at the level of 900cc at 7am, with Foley catheter attached to urine bag. The following were assessment findings of NurseDanna: BM 4x greenish in color, mucoid to watery in consistency approximately 75cc each episode, sunken eye, dry skin, slightly febrile T-37.9 C and could not tolerate any food or fluid intake, scanty urine output less than 30cc/hr. 11/06/2007 at 8am Dr. Ching visited him with the following orders: >on CBR without BRP. >NPO x 4hrs then may have small frequent feeding. >for repeat SE stat >for serum K and Na determination now >monitor BP and CR hourly. >for repeat ECG now. >IVF to follow: PLR 1L @40gtts/min >Give Plasil 1amp IVTT now then q 6hrs prn for vomiting and nausea. >start Ranitidine 5omg IVTT q 8hrs. At 8:00am, Nurse Danna administered Ranitidine. At 10:30am, Mr. Basco complained of nausea and blurring of vision. With cold clammy skin and vital signs revealed BP 70/50mmHg, CR 112 b/min. Nurse Danna referred it immediately to the attending physician thru telephone with the following orders: >FD 500cc of present IVF then regulate @ 60gtts/ min. >monitor CR and BP q 30mins. >monitor hydration status q hour. Nurse Ana endorsed the following to her reliever SE, serum K and Na determination and repeat ECG done. With stable VS and (-)BM and vomiting for 3hrs.

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