F > Decreased Activity Tolerance related to Left Knee Amputation (ORTHO WARD)

D > Received awake lying in bed with an ongoing IVF of D5LRS 1L x 16 hours @ the right hand
and PNSS 1L to run KVO at the left hand. “Nahihirapan padin akong huminga.” as verbalized by
the patient. Confined in bed. Weakness on lower extremities noted. Dependent to significant other
in doing activities of daily life.

A > Assessed current health status. Assessed for muscle weakness and pain. Assess the patient’s
level of activity tolerance and difficulties in mobility. Assisted in performing active range of
motion exercises. Assisted the patient in his morning care. Ensured patient’s comfort for rest by
elevating the head of the bed. Encouraged significant other to offer emotional support to address
dysphoric mood by communicating with the client. Instructed significant other to re-position the
client from side to side. Educate on the proper use of assistive device like crutches prior to
admission. Encourage significant other to call for assistance if needed.

R > Still needs assistance in doing activities of daily living.

F > Impaired Bed Mobility related to Close Fracture (ORTHO WARD)

D > Received awake lying on bed in a semi-fowler’s position with an ongoing IVF of D5W 1L to
run for 8 hours at the left hand. “Mayat met, di nak lang unay makagaraw.” as verbalized by the
patient. Conversant. Weakness on lower extremities. Decreased muscle tone. Decreased range of
motion. Dependent to significant other on doing activities of daily life. Pain on lower extremities.
A > Assessed range of motion. Assessed current condition that contributes to impaired bed
mobility. Assessed for muscle strength and pain. Assisted in doing activities of daily life.
Provided safety by raising the side rails and elevating the foot using a pillow. Assisting the client
in re-positioning self every 2 hours. Encourage adequate intake of fluids and nutritious foods such
as lean meat and leafy vegetables. Encourage to keep trying doing activities of daily life
independently.
R > Still needs assistance in doing activities of daily living.
> Endorsed for further care and management.

F > Acute Pain related to Hepatic Tumor T/C Abscess R/O Carcinoma (SURG WARD)
D > Received asleep lying on bed with an ongoing IVF of PNSS 1L x 24 hours @ right hand and
TNA 763kcal x 24 hours @ left hand. “Masakit itong likod ko.” as verbalized by the patient.
Rated pain as 6 out of 10. Facial grimacing noted. Needs partial assistance in doing activities of
daily life. Irritability noted. Guarding behavior is observed. With vital signs as follows: BP:
120/70; PR: 73bpm; RR: 20cpm; T: 36.7 C; SpO2: 96%.
A > Assessed for current health status and breathing status. Assessed pain through a pain scale
method. Assessed severity of pain by observing behavioral pattern. Assessed pain location.
Monitors and recorded vital signs. Provided comfort measures by re-positioning to relieve pain.
Provided safety measures by raising the side rails and by frequently checking. Assisted on doing
activities of daily life. Provided non-pharmaceutical pain management such as back rubbing.
Encourage to promote relaxation exercises such as deep breathing. Instructed client to increase
fluid intake. Instructed client to report untoward signs and symptoms.
R > Reported pain is slightly relieved. Pain rated 2 out of 10.
> Endorsed for further care and management.

F > Activity Intolerance (SURG WARD)

D > Received patient awake lying on bed with an ongoing IVF of PNSS 1L x 24 hours @ right
hand and B fluids x 24 hours @ left hand. “Masakit siket ko kenni daytoy puson ko no magna ak.”
as verbalized by the patient. Weakness noted. Pain on the back and abdomen. Needs partial
assistance in doing activities of daily life. Guarding behavior observed. Grimacing noted.
Irritability noted. With vital signs as follows: BP: 120/90; PR: 76 bpm; RR: 21 cpm; T: 36.6 C;
SpO2: 96%.
A > Assessed current health status and well being. Monitored and recorded vital signs. Prepared
and administered medication. Seen from time to time to ensure safety. Provided comfort
measures such as re-positioning. Assisted in ambulation. Instructed to ask for assistance in doing
activities of daily life. Encouraged to increase physical activity as tolerated. Encouraged
verbalization of feelings and concerns and to report any untoward signs and symptoms observed.
R > Still needs assistance in doing activities of daily life. Receptive to care.
> Endorsed for further care and management.