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FOCUS CHARTING Mary Jane U.

Tulabot
BSN 4y3-29D

8/20/10  HYPOTENSION D : Blood pressure of 90/60 and dizziness


4:00pm A:
 Elevate the legs of the person by placing
pillow below the feet or if in a hospital
setting place the client in trendelenburg
position.
 Provide well ventilation
 Promote client’s safety
 Promote client’s comfort
R: Patient verbalized loss of dizzines
Patient BP from 90/60 to 110/90
S: Mary Jane Tulabot (student RN)

8/20/10  Risk for infection related to D: Incision located at the lower left abdominal
5:00pm surgical incision quadrant with dressing unchange
A: wound dressing done
R: No swelling or bleeding
S: Mary Jane Tulabot ( student RN)
5:30pm
 HEALTH TEACHING: Dressing R: Patient is demonstrate he is able to change
change his own dressing using aseptic technique
S: Mary Jane Tulabot (student RN)

6:00pm  Decrease in apetite D: weakness


A: encourage the patient ti eat fruits to
replenish his body with vitamins
R: the patient is able to eat well
S: Mary Jane Tulabot (student RN)

6:30pm  Constipation D: difficulty in defacation


A:
 Encourage the patient to increase fluid
intake
 Encourage the patient to eat foods high
in fiber
R: The patient verbalize normal bowel
movement
S: Mary Jane Tulabot (student RN)
FOCUS CHARTING Mary Jane U. Tulabot
BSN 4y3-29D