DAY2
Focus: Impaired physical mobility related loss of balance and coordination.
Data: Received lying on bed with an IVF of PNSS 1 liter x KVO @ 800cc level;
“Natutumba ako pag naglalakad” as verbalized by the patient” With an O2 at 2LPM via
NC;With intact and patent NGT; With intact and patent IFC connected and draining in a
urine bag ;With clean and dry adult diaper.
Action: Evaluated patient’s ability to perform Activities of Daily Living efficiently and
safely on a daily basis; Assessed the strength to perform ROM to all joints. Assessed
input and output record and nutritional pattern; Monitored nutritional needs as they relate
to immobility; Evaluated the need for assistive devices;
Presented a safe environment: bed rails up, bed in a down position, important items close
by; Execute passive or active assistive ROM exercises to all extremities; Promote and
facilitate early ambulation when possible. Aid with each initial change: dangling legs,
sitting in chair, ambulation; Provided medications as appropriate; Turn and position the
patient every 2 hours or as needed; Encouraged a diet high in fiber and liquid intake of
2000 to 3000 ml per day unless contraindicated. Had given explanation about progressive
activity to patient.
Response: Patient demonstrated measures to increase mobility.