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.