F> General Survey

D> Received patient lying on bed, oriented to time, place and person with ongoing IVF
of 0.9 NaCl 1L at 850cc regulated at KVO infusing on the R hand, PNSS 1L at KVO at
full level with side drip of Omeprazole 40 mg at 90cc PNSS x 5 regulated at 20 gtts/min
with Kabiven 100 Kcal at 250cc level regulated at 60 gtts/min as side drip; VS as
follows: BP: 90/60 mmHg, PR: 64bpm, RR: 26 bpm, Temp: 35.4 C; The patient urinated
once.
F> Ineffective Breathing Pattern
D> Patient observed to be tachypneic with a RR of 26 bpm
A> Provided AM care, Assisted with self care needs, Positioned the patient on semi
fowler position, Provided group care, Instructed the patient to perform deep breathing
exercise.
R> The patient was relieved from difficulty of breathing but his/her RR is till 26 bpm.

F> General Survey

D> Received patient sitting on bed, Oriented to time, place and person with ongoing IVF
of 0.9 NaCl 1L at 400cc level regulated at 30-31 gtts/min infusing on the L hand with a
blood transfusion I u of PRBC infusing as a side drip, with pale palpebral conjunctiva,
cold clammy skin, appears red and pale; VS as follows: BP: 10/70 mmHg, PR: 104
bpm, RR: 14 bpm, Temp: 36.4C
F> Easy Fatigability
D>Patient have palpebral conjunctiva, cold clammy skin, appears red and pale, slowed
movements and complains of easy fatigability.
A> Provided AM care, Assisted with self care needs, Assisted in ambulation, Provided
group care, Encouraged client to have adequate rest periods and limit strenuous
activities, Instructed the patient to perform deep breathing exercise and proper diet.
R> Patients performed activities within personal limitation and decreased complains of
easy fatigability.