Denisse Gabrielle D.

Eclarinal BSN 4-B5 01/10/21

Rabies
Date/Hour Focus Progress Notes
01/ 10/ 21 Partial Paralysis D:
 Inability to move
3:00 pm purposefully within
the physical
environment,
including bed
mobility, transfers,
and ambulation
 Inability to perform
action as instructed
 Limited ROM
A:

 Check for functional

level of mobility.
 Establish measures to
prevent skin
breakdown and
thrombophlebitis from
prolonged immobility:
- Clean, dry, and
moisturize skin as
necessary.
- Use anti embolic
stockings or
sequential
compression devices
if appropriate.
- Use pressure-relieving
devices as indicated
(gel mattress).
 Execute passive or
active assistive ROM
exercises to all
extremities.
 Encourage a diet high
in fiber and liquid
intake of 2000 to 3000
ml per day unless
contraindicated.
 R:

Patient is free from

complications of immobility,
as evidenced by intact skin,
absence of thrombophlebitis,
normal bowel pattern, and
clear breath sounds.

Date/ Hour Focus Progress Notes

1/ 10/ 21 Difficulty swallowing D:

 Coughing and
6:00 pm choking during eating
and drinking.
 Drooling

A:
 Position patient
upright at a 90-degree
angle with the head
flexed forward at a
45-degree angle.
 Ensure patient is
awake, alert, and able
to follow sequenced
directions before
attempting to feed.
 Observe for signs of
aspiration and
pneumonia.
Auscultate lung
sounds after feeding.
Note new crackles or
wheezing, and note
elevated temperature.
Notify physician as
needed.
 Advance slowly,
giving small amounts;
whenever possible,
alternate servings of
liquids and solids.
 Reassure the patient to
 chew completely, eat
gently, and swallow
frequently, especially
if extra saliva is
produced. Give the
patient with direction
or reinforcement until
he or she has
swallowed each
mouthful.
R:
 Patient will be able to
swallow his food and
prevent aspiration.

Date/Hour Focus Progress notes

01/ 02/ 21 Insomnia D:
 Irritability
 Problems with
12:00 pm concentration and
memory
 Verbal reports of
difficulty falling
asleep
A:

 Introduce relaxing
activities such as
warm bath, calm
music, reading a book,
and relaxation
exercises before
bedtime.
 Suggest an
environment
conducive to rest or
sleep.
 Render bedtime
nursing care such as
back rub and other
relaxation techniques.
 Educate patient about
their sleep
requirements
R:

Patient obtains optimal

amounts of sleep as
evidenced by rested
appearance, verbalization of
feeling rested, and
improvement in sleep pattern