Scribd Logo
Upload

Welcome to Scribd!

  • 3K views

    2012 Pedia Dar Charting

    Uploaded by

    deology
    1) A 5 month old infant was admitted to the hospital for the second day with a diagnosis of bronchopneumonia. 2) On examination, the infant had a temperature of 37.4°C, respiratory rate of 59 breaths per minute, grunting while sleeping, thick yellow secretions in the nose, and crackles heard in the lungs. 3) Nursing interventions included elevating the infant's upper body, cleaning the nose, maintaining oxygen, assisting with nebulizer treatment, back massages, encouraging increased breastfeeding in an upright position. After treatment, the respiratory rate was 51 breaths per minute with coarse crackles still heard in the lungs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd

    2012 Pedia Dar Charting

    Uploaded by

    deology
    3K views2 pages
    1) A 5 month old infant was admitted to the hospital for the second day with a diagnosis of bronchopneumonia. 2) On examination, the infant had a temperature of 37.4°C, respiratory rate of 59 breaths per minute, grunting while sleeping, thick yellow secretions in the nose, and crackles heard in the lungs. 3) Nursing interventions included elevating the infant's upper body, cleaning the nose, maintaining oxygen, assisting with nebulizer treatment, back massages, encouraging increased breastfeeding in an upright position. After treatment, the respiratory rate was 51 breaths per minute with coarse crackles still heard in the lungs.

    Original Description:

    CHARTING SOAP

    Original Title

    2012 pedia dar charting.docx

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1) A 5 month old infant was admitted to the hospital for the second day with a diagnosis of bronchopneumonia. 2) On examination, the infant had a temperature of 37.4°C, respiratory rate of 59 breaths per minute, grunting while sleeping, thick yellow secretions in the nose, and crackles heard in the lungs. 3) Nursing interventions included elevating the infant's upper body, cleaning the nose, maintaining oxygen, assisting with nebulizer treatment, back massages, encouraging increased breastfeeding in an upright position. After treatment, the respiratory rate was 51 breaths per minute with coarse crackles still heard in the lungs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    3K views2 pages

    2012 Pedia Dar Charting

    Uploaded by

    deology
    1) A 5 month old infant was admitted to the hospital for the second day with a diagnosis of bronchopneumonia. 2) On examination, the infant had a temperature of 37.4°C, respiratory rate of 59 breaths per minute, grunting while sleeping, thick yellow secretions in the nose, and crackles heard in the lungs. 3) Nursing interventions included elevating the infant's upper body, cleaning the nose, maintaining oxygen, assisting with nebulizer treatment, back massages, encouraging increased breastfeeding in an upright position. After treatment, the respiratory rate was 51 breaths per minute with coarse crackles still heard in the lungs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    SAMPLE SOAP CHARTING FOR PEDIA ABNORMAL - Assumption: bronchopneumonia, 5 month old, 2nd day hospitalization Date Time

    Focus 10/18/12 9:30am Ineffective airway clearance related to tracheobronchial secretions and ineffective cough Notes D> Maingay pa rin paghinga niya, mother claims; T = 37.4C, axillary; RR = 59/min, regular, deep ; coughs approximately 4-5x in an hour; grunting noted while asleep; with O2 inhalation at 0.5-1 LPM via nasal cannula; thick yellowish secretions noted at nasal passages; no nasal flaring; bilateral chest expansion; subcostal retractions noted; crackles auscultated at bilateral parasternal areas; Chest X-ray result reveal pneumonia (10-18-2012). A> elevated upper body with 1 pillow while changing positions every 1-2 hours, cleansed nasal passages as necessary, maintained O2 inhalation, assisted in nebulization of salbutamol 1 nebule, back massages done, encouraged mother to increase frequency of breastfeeding, instructed mother to feed child in upright position, Reassess respiration status after nebulizations R> RR =51/ min, regular, deep; moved bowel 2x within shift with streaks of mucoid secretions, coarse crackles still noted over bilateral sternal areas, still with episodes of cough.

    10:30am

    You might also like