1. FATHER SATURNINO URIOS UNIVERSITY
San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Nursing Program
April Tom O. Cuenca Group 2 – N31
Cellular Aberrations Clinical Focus Rotation December 3, 2021
Patient’s Name: Mrs. Gray
Sex: Female
Age: 78 years old
CASE OF MRS. GRAY
Date and
Time
Focus Progress Notes
12/05/21
8:00 AM
9:30 AM
Deficient
Knowledge
D: Received patient lying in bed on moderated high-back rest
without an IVF. Patient is confused, somewhat bewildered, and
vaguely remembers the term palliative treatment when discussing
her situation with her provider
and doesn't know what it means.
Vital signs are as follows:
BP = 130/90 mmHg
PR = 76 bpm,
RR = 24 cpm,
T = 37.4°C, and
O2 Sat = 93%.
A:
1. Ascertain level of knowledge, including anticipatory needs and
the ability to learn. Assess motivation and willingness of patient to
learn.
2. Allow the patient to open up about previous experience and
health teaching.
3. Assess barriers to learning (e.g., perceived change in lifestyle,
financial concerns, cultural patterns, lack of acceptance by peers or
coworkers).
4. Render physical comfort for the patient.
5. Grant a calm and peaceful environment without interruption.
Provide an atmosphere of respect, openness, trust, and
collaboration.
6. Include the patient in creating the teaching plan, beginning with
establishing objectives and goals for learning at the beginning of the
session.
7. Provide clear, thorough, and understandable explanations and
demonstrations. Give information with the use of media. Use visual
aids like diagrams, pictures, videotapes, audiotapes, and interactive
Internet websites.
8. When presenting a material, start with the basics or familiar,
simple, and concrete information to less familiar, complex ones.
9. Focus teaching sessions on a single concept or idea. Pace the
instruction and keep sessions short.
10. Encourage questions and identify the patient’s understanding
through common medical terminology or through the teach-back
technique. Then, provide immediate feedback.
R: The patient was able to participate in the learning process and
verbalize understanding of condition, disease process, and
treatment as evidenced by the understanding of palliative treatment
and its relevance
-------------------------------------------------- A.T.O, CUENCA, FSUU, SN
2. FATHER SATURNINO URIOS UNIVERSITY
San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Nursing Program
1:00 PM
2:00 PM
Medication
Administration
D: The doctor ordered Prednisolone 10mg 1 tablet p.o. PC lunch to
the patient.
A:
1. Allowed the patient to eat a meal for lunch before taking the
medication
2. Observed the 10 rights of medication administration before
preparing and administering the medication to the patient
3. Administered the medication (Prednisolone) to the patient as
ordered by the doctor.
4. Encouraged patient to perform deep breathing exercises.
5. Started oxygen 2 LPM to the patient via nasal cannula.
6. Documented the administration of the prescribed medication to
the patient and the nursing care rendered.
R: The patient was able to participate in the conducted treatment
procedures and take the medication prescribed by the doctor.
-------------------------------------------------- A.T.O, CUENCA, FSUU, SN
