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Gender: Female
Date of birth:
Cultural Group:
Primary Language:
Religion: Catholic
Occupation: Accountant
2nd: Physician
3rd: Hospitalization
Description of Patient:
Patient is in moderate
Dec. 8-10
NOC
12D- patient is in moderate high back rest position, with edema on the face particularly on the
right side, eyes closed but awake, with edematous body with wounds on the neck and chest
complaints of pain
A- reassessed patients status checked ivf site, due meds given,provided comfort and needs,
6R- pt awake and was sitting on bed, not dyspnic, afebrile with bp of 130/70 coherent
AM
8D- lying on bed awake with patent ivf, edema noted all over body and on right side of face,
wounds noted on neck and chest, appears weak , responsive and oriented
A-assessment done checked and recorded v/s, regulated ivf to prescribed rate, raise side rails,
provided comfort, encourage relaxation exercises and rest. needs attended, kept monitored.
2R-pt on bed awake, no complaints of pain, edema noted all over body and right side of face,
wound noted on neck and chest, appears weak, afebrile, not in respi distress
PM
4D- awake conversant, edema noted all over body and right side of the face, unable to tilt head,
not dyspnic, with complaints of pain, dry wound noted on neck , chest and shoulders
A-assessed condition v/s taken, instructed pt not to void until ultra sound is carried out. needs
5:30D- received pt from ultrasound dept. still c complains of pain c patent ivf and infusing well,
10R- awake c complaints of pain, open wounds, still with edematous body noted, still unable to
tilt head with complaints of nausea c not episodes of vomitting as claimed by pt.