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  • Focus Charting (DAR)

    Transféré par

    Raisa Robelle Quicho
    841 vues1 page
    - The patient was experiencing pain at their IV site on the wrist, with edema and skin discoloration noted around the site. Their temperature was elevated at 101.3 degrees. - The IV infusion was stopped, antibiotics were administered, and the patient was elevated. Blood cultures, CBC and chest x-ray were ordered. Pain medication was also given. - By the end of the shift the patient's temperature had decreased, edema had resolved, and pain level was much improved at 1/10. Lab results were pending but the patient's condition seemed to be stabilizing.

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    - The patient was experiencing pain at their IV site on the wrist, with edema and skin discoloration noted around the site. Their temperature was elevated at 101.3 degrees. - The IV infusion was stopped, antibiotics were administered, and the patient was elevated. Blood cultures, CBC and chest x-ray were ordered. Pain medication was also given. - By the end of the shift the patient's temperature had decreased, edema had resolved, and pain level was much improved at 1/10. Lab results were pending but the patient's condition seemed to be stabilizing.

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOCX, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    841 vues1 page

    Focus Charting (DAR)

    Transféré par

    Raisa Robelle Quicho
    - The patient was experiencing pain at their IV site on the wrist, with edema and skin discoloration noted around the site. Their temperature was elevated at 101.3 degrees. - The IV infusion was stopped, antibiotics were administered, and the patient was elevated. Blood cultures, CBC and chest x-ray were ordered. Pain medication was also given. - By the end of the shift the patient's temperature had decreased, edema had resolved, and pain level was much improved at 1/10. Lab results were pending but the patient's condition seemed to be stabilizing.

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOCX, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 1

    DA1A AC1ICN kLSCNSL

    (What are the facts? What do


    you see]assess)

    L8 runnlng aL 123 ml/hr vla 8
    wrlsL lv L denles paln Lo lv
    slLe Skln cool Lo Louch edema
    noLed 10 cm surroundlng slLe
    skln blanched




    aLlenLs LemperaLure aL 1303
    was 1013 (oral) 1he resL of hls
    vlLals were sLable and he was ln
    no acuLe dlsLress



    L sLaLes shes nauseaLed
    vomlLed 100ml clear fluld aL
    2233

    lnclslon slLe ln fronL of lefL ear
    exLendlng down and around Lhe
    ear and lnLo neckapproxlmaLely
    6 lnches ln lengLhwlLhouL
    dresslng !acksonraLL draln ln
    lefL neck below ear secured ln
    place wlLh suLure

    aLlenL reporLed dlzzlness afLer
    Lrylng Lo geL CC8 Lo use Lhe
    baLhroom





    aLlenL reporLs paln as 7/10 on
    0 Lo 10 scale

    (What d|d you do about |t]your
    |ntervent|on)

    L8 lnfuslon sLopped hyslclan
    noLlfled PCLu CenLamycln unLll
    paLenL lv can be sLarLed (whaL
    would happen lf you ran genL
    lnLo Lhls lv?) LxLremeLy
    elevaLed on plllow (ConsulL wlLh
    physlclan wheLher Lo use
    cold/warm compresses) u/C lv

    Called ur SmlLh and he
    ordered blood culLures x2 a C8C
    and a porLable chesL xray AfLer
    blood culLures were drawn
    paLlenL was glven 1ylenol aL
    1400

    Clven Compazlne 1mg lv aL
    2300


    Assess slLe and empLled draln
    1aughL paLlenL SS of lnfecLlon






    AsslsLed paLlenL back ln bed
    and wlLh use of bedpan 1aughL
    paLlenL how Lo dangle legs and
    geL CC8 slowly Also LaughL
    coughlng and deep breaLhlng
    exerclses Lurnlng ln bed and
    use of anLlembollsm sLocklngs

    Clven morphlne 1mg lv aL
    2333

    (Lva|uate)


    hyslclan noLlfled orders
    recelved new lv sLarLed good
    blood reLurn edema resolved
    eLc paln scores how Lhe
    paLlenL responded




    8y 1300 paLlenLs LemperaLure
    was 998 (oral) Lab and xray
    resulLs are pendlng Wlll
    conLlnue Lo monlLor closely



    L reporLs no furLher nausea
    aL 2333 no furLher vomlLlng


    no swelllng or bleedlng blulsh
    dlscoloraLlon below lefL ear
    noLed ! dralned 20mL bloody
    dralnage aLlenL sLaLes
    undersLandlng of Leachlng



    aLlenL volded 200mL ln
    bedpan uld cough and deep
    breaLhlng approprlaLely Lungs
    clear bllaLerally uslng
    anLlembollsm sLocklngs



    aLlenL reporLs paln as 1/10 aL
    2333

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