Nursing and Tepid Sponge Bath

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DEFINITIONS:
Focus Charting - is a method for organizing health information in the individual 's record. It is a systematic approach to documentation, using nursing terminology to describe individual 's health status and nursing action.
Focus
• a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit • a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital admission • a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy •
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➢ Approached sitting on bed, awake, responsive, coherent with ease in respiration, with O2 at 2 LPM, with an IVF of 4 PLR 1L + 8.25 meq KCl @ 66 ugtts/min infusing well at the Right arm, with the following V/S: BP= 110/70 mmHG, PR= 100 bpm, RR= 26 cpm, T= 36.8 degree Celsius/axilla. ➢ Followed by F-DAR ➢ After writing the F-DAR , at the end of the shift write again your general observation/survey of the patient condition

F: Hyperthermia
D: > increase in body temperature above normal range to T= 38 degree Celsius/axilla > flushed skin and warm to touched
A: 9:00am > Tepid sponge bath done > instructed SO to let patient wear loose clothing > instructed SO to provide blanket to patient when shiver > instructed SO to let patient drink lots of fluid > instructed SO to include in his diet foods rich in Vitamin C such as oranges > provided opportunity for patient to rest > due meds given
R: 1:00pm > patient was able to rest > patient temperature decrease to T= 37.8 degree Celsius/axilla

F1: Ineffective Breathing Pattern
D1: increase respiratory rate of 24 cpm
D2: use of accessory muscle to breath
D3: presence of nonproductive cough
F2: Hyperthermia
D1: skin warm and flush to touched
D2: increased body temperature of T= 37.7 degree celsius/axilla
F3: Fatigue

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