KRISTIAN KARL B.

KIW-IS

Focus: D: Received lying on bed with an ongoing IVF of PNSS 1 liter x KVO
Impaired @ 800cc level and VS. as follows: T – 36.5 °C PR – 52 BPM RR– 20CPM
Physical BP –mmHg SP02-95% .. “ Jak unay maka garaw- garaw sir ta atoy
Mobility sugat ko.” Slowed movement noted.

A: Checked vital signs before and

immediately after activity, especially if
patient is receiving vasodilators, diuretics,
or beta-blockers. Documented
cardiopulmonary response to activity.
Noted tachycardia, dysrhythmias,
dyspnea, diaphoresis, pallor. Assessed for
other causes of fatigue (treatments, pain,
medications) and patient’s general
condition. Evaluated accelerating activity
intolerance. Provided assistance with self-
care activities as indicated. Intersperse
activity periods with rest periods.
Assisted patient with ROM exercises.
Check regularly for calf pain and
tenderness. Adjusted client’s daily
activities and reduce intensity of level.
Discontinued activities that cause
undesired psychological changes.
Instructed client in unfamiliar activities
and in alternate ways of conserve energy.
Encouraged patient to have adequate bed
rest and sleep. Provided the patient with
a calm and quiet environment. Assist the
client in ambulation. Noted presence of
factors that could contribute to fatigue.

R: The patient participated in desired

activities; meet own self-care needs.
 Focus: D: Received lying on bed with an ongoing IVF of PNSS 1 liter x KVO
Knowledge @ 800cc level and VS. as follows: T – 36.5 °C PR – 52 BPM RR– 20CPM
deficit BP –mmHg SP02-95% .’’ anya mangyari kanyak nu malpasak
maopera’’asked for additional information related to his condition.
A: Identified the learner: the patient,
family, significant other, or caregiver.
Assessed ability to learn or perform
desired health-related care.
Assessed motivation and willingness of
patient to learn.
Provided an atmosphere of respect, openness, trust, and
collaboration.
Involved patient in writing specific outcomes for the teaching
session, such as identifying what is most important to learn from
their viewpoint and lifestyle.
Helped patient in integrating information into daily life.
Provided clear, thorough, and understandable explanations and
demonstrations.
Noted progress of teaching and learning.

R: The patient verbalized understanding

of the health teachings and information’s.
 Focus: D: Received lying on bed with an ongoing IVF of PNSS 1 liter x KVO
Acute pain @ 800cc level and VS. as follows: T – 36.5 °C PR – 52 BPM RR– 20CPM
related surgical BP –mmHg SP02-95% . Reports of pain
incision Alteration in muscle tone; facial mask of pain
Distraction/guarding/protective behaviors
‘’ masakit ang sugat ko’’
A: Noted patient’s age, weight, coexisting medical or psychological
conditions, idiosyncratic sensitivity to analgesics, and intraoperative
course.
Reviewed intraoperative or recovery room record for type of
anesthesia and medications previously administered.
Evaluated pain regularly (every 2 hrs noting characteristics, location,
and intensity (0–10 scale). Emphasize patient’s responsibility for
reporting pain/ relief of pain completely.
Assessed vital signs, noting tachycardia, hypertension, and increased
respiration, even if patient denies pain.
Provided information about transitory nature of discomfort, as
appropriate.
Provided additional comfort measures: backrub, heat or cold
applications.
Encouraged use of relaxation techniques: deep-breathing exercises,
guided imagery, visualization, music.

R: The patient reported a pain relieved/controlled.