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    IMPIT - HA Fdar

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    John Colem Impit
    1. The document summarizes care provided for a patient experiencing a productive cough, dyspnea, pruritus, and conditions requiring referral to another doctor. 2. For the productive cough, actions included positioning, environmental control, increased fluid intake, cough and breathing techniques, suctioning, and medication administration. 3. For dyspnea, actions included body alignment, inspiratory muscle training, diet changes, rest, use of a fan, and respiratory medications. 4. For pruritus, actions included skin assessment, encouragement of skin care routines, and application of topical medications.

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    IMPIT - HA Fdar

    Uploaded by

    John Colem Impit
    11K views4 pages
    1. The document summarizes care provided for a patient experiencing a productive cough, dyspnea, pruritus, and conditions requiring referral to another doctor. 2. For the productive cough, actions included positioning, environmental control, increased fluid intake, cough and breathing techniques, suctioning, and medication administration. 3. For dyspnea, actions included body alignment, inspiratory muscle training, diet changes, rest, use of a fan, and respiratory medications. 4. For pruritus, actions included skin assessment, encouragement of skin care routines, and application of topical medications.

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    FDAR

    Original Title

    IMPIT_HA fdar

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    1. The document summarizes care provided for a patient experiencing a productive cough, dyspnea, pruritus, and conditions requiring referral to another doctor. 2. For the productive cough, actions included positioning, environmental control, increased fluid intake, cough and breathing techniques, suctioning, and medication administration. 3. For dyspnea, actions included body alignment, inspiratory muscle training, diet changes, rest, use of a fan, and respiratory medications. 4. For pruritus, actions included skin assessment, encouragement of skin care routines, and application of topical medications.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    11K views4 pages

    IMPIT - HA Fdar

    Uploaded by

    John Colem Impit
    1. The document summarizes care provided for a patient experiencing a productive cough, dyspnea, pruritus, and conditions requiring referral to another doctor. 2. For the productive cough, actions included positioning, environmental control, increased fluid intake, cough and breathing techniques, suctioning, and medication administration. 3. For dyspnea, actions included body alignment, inspiratory muscle training, diet changes, rest, use of a fan, and respiratory medications. 4. For pruritus, actions included skin assessment, encouragement of skin care routines, and application of topical medications.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    of 4

    FDAR

    NCM 101
    Output 4

    A. Productive Cough

    FOCUS DATA
    Ineffective Airway
    S
    1. Patient verbalized chest pain
    O
    1. Observed a yellow mucus
    2. The patient is having difficulty in
    breathing

    ( 9;00 am) ACTION

    1. Positioned the patients head midline


    with flexion on appropriate for
    age/condition.

    2. Keeped environmental pollution to a


    minimum such as dust, smoke, and
    feather pillows, according to the individual
    situation.

    3. Increased the fluid intake to 3000 mL


    per day within cardiac tolerance. Provide
    warm or tepid liquids. Recommend the
    intake of fluids between, instead of
    during, meals.

    4. Demonstrated effective coughing and


    deep-breathing techniques

    5. Suctioned the secretions as needed.

    6. Administer medications as prescribed:


    mucolytics or expectorants.

    (6;00 pm) RESPONSE


    1. Demonstrated behaviors that improved
    airway clearance, e.g., cough effectively
    and expectorate secretions.

    B. Dyspnea

    FOCUS DATA
    Unable to breath deeply
    S
    1. Patient verbalized tightness in his chest
    O
    1. Patient only states 2-3 words then
    stopped to breath
    2. Patient’s breathing is fast and irregular

    (8;00) ACTION

    1. Placed the patient with proper body


    alignment for maximum breathing pattern.
    2. Evaluated the appropriateness of
    inspiratory muscle training.
    3. Encouraged small frequent meals.
    4. Encouraged frequent rest periods and
    teach patient to pace activity.
    5. Availed a fan in the room.
    6. Provided respiratory medications and
    oxygen, per doctor’s orders.

    (9;00 pm) RESPONSE


    1. Observed improvement in breathing
    pattern and patient can demonstrate two
    breathing techniques

    C. Pruritus

    FOCUS DATA
    Rashes
    S
    1. Patient verbalized itching in some parts
    of the body
    O
    1. Visible dry and flaky skin
    2. Visible skin redness

    (8;00) ACTION

    1. Assess skin, noting color, moisture,


    texture, temperature; note erythema,
    edema, tenderness.
    2. Encourage the patient to adopt skin
    care routines to decrease skin irritation:
    3. Bathe or shower using lukewarm water
    and mild soap or nonsoap cleansers.
    4.After bathing, allow the skin to air dry or
    gently pat the skin dry. Avoid rubbing or
    brisk drying.
    5.Apply topical lubricants immediately
    after bathing.
    6.Apply topical steroid creams or
    ointments

    (6;00) RESPONSE
    1. Patient maintained optimal skin
    integrity within limits of the disease, as
    evidenced by intact skin.

    D. For referral to another doctor (co-management)


    FOCUS DATA

    O
    1. Another doctor ordered data of the
    patient for clinical purposes

    ACTION

    1. Informed the patient about the referral


    2. Patients consent has been secured
    3. Data has been organized and ready
    RESPONSE
    1. Patient successfully referred to another
    doctor

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