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    Fdar Gammy

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    Andrea Sibayan Soriano
    Mr. MS, a 59-year-old male, was admitted to the hospital with complaints of acute chest pain, shortness of breath, and anxiety. Upon initial examination, he reported severe chest pain radiating to his left arm and was diaphoretic and pale. His oxygen saturation was 92% with crackles in his lungs. Throughout the day, nurses monitored his vital signs, administered medications, ensured safety and comfort, and encouraged rest and deep breathing. His anxiety was treated and he was relieved from distress. He remained under observation for continuity of care.

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    Fdar Gammy

    Uploaded by

    Andrea Sibayan Soriano
    1K views2 pages
    Mr. MS, a 59-year-old male, was admitted to the hospital with complaints of acute chest pain, shortness of breath, and anxiety. Upon initial examination, he reported severe chest pain radiating to his left arm and was diaphoretic and pale. His oxygen saturation was 92% with crackles in his lungs. Throughout the day, nurses monitored his vital signs, administered medications, ensured safety and comfort, and encouraged rest and deep breathing. His anxiety was treated and he was relieved from distress. He remained under observation for continuity of care.

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    FDAR GAMMY

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    Mr. MS, a 59-year-old male, was admitted to the hospital with complaints of acute chest pain, shortness of breath, and anxiety. Upon initial examination, he reported severe chest pain radiating to his left arm and was diaphoretic and pale. His oxygen saturation was 92% with crackles in his lungs. Throughout the day, nurses monitored his vital signs, administered medications, ensured safety and comfort, and encouraged rest and deep breathing. His anxiety was treated and he was relieved from distress. He remained under observation for continuity of care.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views2 pages

    Fdar Gammy

    Uploaded by

    Andrea Sibayan Soriano
    Mr. MS, a 59-year-old male, was admitted to the hospital with complaints of acute chest pain, shortness of breath, and anxiety. Upon initial examination, he reported severe chest pain radiating to his left arm and was diaphoretic and pale. His oxygen saturation was 92% with crackles in his lungs. Throughout the day, nurses monitored his vital signs, administered medications, ensured safety and comfort, and encouraged rest and deep breathing. His anxiety was treated and he was relieved from distress. He remained under observation for continuity of care.

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    PATIENT NAME: Mr.

    MS AGE: 59 years old HOSPITAL ROOM:

    PHYSICIAN: SEX: Male WARD/ROOM

    DATE/ TIME FOCUS D- DATA A- ACTION R- RESPONSE NURSE


    SIGNATURE
    2/18/20 D- received patient on stretcher, conscious and
    10 am Acute pain responsive; reports "pain under my left chest
    that radiates to my left arm"; rates the pain as
    an scale of 8 on a scale of 1 to 10; diaphoretic
    and pale
    A- Monitored Vital signs taken and recorded
    - Raised side rails to ensure safety
    - IVF regulated accordingly
    - Bedside care done
    - Advised to rest
    - Deep breathing exercise encouraged
    - Medications given prior to the Doctor’s Order
    R- Endorse for continuity of care and
    monitoring
    12pm Shortness of D- received patient on bed, conscious, and
    breath responsive; has an O2 saturation of 92%;
    patient reports "slight shortness of breath”; (+)
    crackles at the bases
    A- Vital signs taken and recorded
    -IVF regulated accordingly

    -Auscultated chest and back to determine


    adventitious sound

    -Bedside care done

    -Needs attended

    -Medication given

    -Safety and comfort ensured

    -Placed in semi fowler’s position


    -Deep breathing exercise encouraged

    -Promote adequate fluid intake

    -Maintain adequate rest

    R- for continuity of care


    2/18/20 Anxiety D- patient received on bed, conscious and
    5pm alert; feels anxious and constantly verbalizing
    fear of death
    A- Monitored Vital signs taken and recorded
    - Raised side rails to ensure safety
    - IVF regulated accordingly
    - Bedside care done and maintain quiet area
    - Advised to rest
    - Limit visitors
    - Deep breathing exercise encouraged
    - Educate the patient that anxiety disorders are
    treatable
    - Medications given prior to the Doctor’s Order
    R- Patient was relieved from anxiety
    - For continuity of care

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