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Nurses Notes: Signature:-Ms. Rita Date:-10/1/2020 Time: - 7am

Mrs. Radha, a 40-year-old patient, is on a ventilator in the ICU. Nurse Rita assessed the patient and found she has a nasogastric tube, endotracheal tube, central line, dilated and fixed pupils, and mild swelling. Vitals are stable. Nurse Rita identified nursing diagnoses of self-care deficit, impaired nutrition, risk of infection from procedures, and risk of bedsores. Care provided included morning care, eye/oral/perineal care, foley care, back care and position changes every 2 hours, range of motion exercises, meeting eating and elimination needs, and frequent hand washing.

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49 views

Nurses Notes: Signature:-Ms. Rita Date:-10/1/2020 Time: - 7am

Mrs. Radha, a 40-year-old patient, is on a ventilator in the ICU. Nurse Rita assessed the patient and found she has a nasogastric tube, endotracheal tube, central line, dilated and fixed pupils, and mild swelling. Vitals are stable. Nurse Rita identified nursing diagnoses of self-care deficit, impaired nutrition, risk of infection from procedures, and risk of bedsores. Care provided included morning care, eye/oral/perineal care, foley care, back care and position changes every 2 hours, range of motion exercises, meeting eating and elimination needs, and frequent hand washing.

Uploaded by

Meena Koushal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NURSES NOTES

Assigned patient :Mrs. Radha ,40 years old

IPD No. 2453

Assigned staff : Ms. Rita

Assessment

Patient is on ventilator. Maintaining IPPV mode peep 4 ,TV -400,fiO2 -60%,nasogastric tube
insitu. Et placed at the right side of corner of mouth .central line present at right internal jugular
vein .bilateral pupils are 3mm dilated & fixed. Mild swelling present over bilateral extremities
Foley’s catheter insitu and draining clear urine. Cardiac monitor is attached and showing –HR-
76b/min,BP-110/70mmHg, RR-20/min , Spo2-98%.

Nursing diagnosis :

 Self-care deficit related to inability to perform her daily activities of living as evidenced
by kempt appearance.
 Impaired nutrition intake related to disease condition as evidenced by weight loss.
 Risk for infection related to invasive procedure.
 Risk for bedsore related to prolong bed rest

Care given :

 Morning care given.


 Eye care , Oral care & perineal care given
 Foleys care done under aseptic technique.
 Back care & changed position every 2 hourly.
 Range of motion exercise done
 Met the client eating and elimination need .
 Frequent hand washing done.

Signature:- Ms. Rita

Date:-10/1/2020

Time:- 7Am

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