Bed4t Receiving Notes D> Recedved on bed i A cemni- fowler position , is es with axygeon aneapy at Bllinin via willy WET closed HP, with Patent Weplock ot Baht ands, with foley catheter atladhed 4p uvebag , with Ake following vital signs. 7. 76-9 rn 23 pe: 67. 14 dctbeny “Wo fico ao oe, Frigga bel “| Iateney as as PAYS e 1<6/e Impaired Waeiing < as > ne b- Seen wrih nasogastic Aube Cased MP Place Semi-fowkys positon , we wo mult cw voi upper and lower ov R- Assessed overs affecting the emdition, poritroned on High) BALK fear , “easseded o—teot ect any tg apeeoremn—ze pier tv feeding , Gredkea toe guging Sounds, NET gatertt, poimioned on Wigh yak vegt for 1 Nour after ceeding , towitored ial signs R- Brendarged feeding ADterated , seen arm tertable and reloved envied in moderle (righ back vertReceiving Notes O- Received on bed Th a sermi-frv bec position, asleep with euygen tierapy of St]iviin vio fad mask , with m going PIRS TL ot Te aMshwin ot (eft hand Witt Omeprarle dip Pug Foc PNSS regulated WA infussn pump" af defly with mmoimng wel of 22 ce-, with vital agus ot follows: T: 49-y : Gq boa bp: Moy, 0>~ 99 \mpaired pry stial Mobily p- om Find Th bed uith Viniked romge of wohm ; needs desictaee ih performing achiitie, of daily tving f- Bssesced foton atferting awe cmdition , supported affedted body part Laing pillows, ensured tte peg k vide rail ore alwoys wp far safety , AUNsisted Igy oF motion epertiser emceuragedt wing swt then le. Woner : R- Seen comfurdatle ome s4il weeds ous Stopey dovitowd tH a confer doh ped #10 i~~ Receiving Notes p- Received on bed in 4 Sewn Fowlers poshor, awake , Coherent tv bine, place and parson, WW enygen invalahin ab 2L)Jimin via yesal commuta with potent hep bout of fight bot, vith +he flowing vital agi 5 tissu be ey Req PPE yy Qovaaq Disturbed Sleeping pottern b- “wala jud key tuley J kay saba keayy abme lyped “as yorvani ted by Hy pabent > fssessed falton affecting tnt Umdihn, provided Frequent rest yenwds , pesttowed rection Cm fortayay Wepr linens cteaw oud cliy, ofelsted with SetR- cor weds, fait (dd Anigg ug br Jnfety R- Sen law tw bed , Ole a seat SAvESEpraekA a ped #9Hea & B es Receiving Notes D- Received on bed in qsemi-fowler Position, asleep , wrth cxygen thempy at aL{min via nasal cannula with patent peplouk at ngitt hard, with She following vital igi: Te we Pi da Rite pe: M>, Ov linpained Comfort b- Sinagliged ley fot boy tugraw kacyst ay verbatizped by the patent fr- pivided health edutahon cn the importance ot adequate tat perod ; kept side rol up for sorfe ty | fred planket fo lesen “epooure oF pody parks | kepr Niners cleat and dry p- Seen Jahient wail-rested ame sleepa Le Uy wah od F~ RISK: for’ Aspiration i : fea D- Seen With nasog asin. tube, Wared! hp in pigee in Moderak. high back, nat ho muscle fone: dni ffecthg ni in igh bak vest pry ye eat Sounds, d feed d Vyonm R- “ piendented feedmg, Phra poked ! Seen ComPorinby and relaxed on: bed mn made ats hgh ae rest, 1 OME Nelle bib, BOE of ook a thd ne pc Ail; #1 capanero —w | cam F Receiving notes iv D- Received on bra. in emi rowieris pasion «nan “dyspneic, | ‘Qriake, oriented fon poet“peon, wn epoch ar ‘ight bond In loce wiih ne foyening “nal sions LAGAURO fe onan ee ee mmpoied xin nego OF = importa si ‘non left 199 D- nol son-heghinge win flaky skin on left 19 und) - povided A+ nsseseg factors opechiog impaitd Sk Integuily f ds T8861, FR 102 bpm AR’ IY cpm, BP :IO)FO, O2 =9F % ‘Stih care by cleaning trading se 1 aint all aF} Kept beds linens. clothes dey and whi si fF wy Poided adequak clothing and encouraged pat u #2 ftulch or Scratch wie Fhe Wound bt Mame = even ath fh non healing wound wath “Doky sicin On jeft leg ofes) still hafed- gee A 55 Be Sb ¥2_ISKNA Fa 2 [sma f Sam ving-Rotes ). F -hmpaired Physical mobility PU Retirld Wog6 = cantintd im bed asleep In seini -Fowler 5 position witty ann limited cong of motion with body weakness, OF the Fo receiving noies : figh cide hited ; ptcreastd muscle stenighh ard tore, neods ,_osibonce in perjorming acitties of dally jing. | 4° 1SES500 rHemrs eyectmg_ impaiked physical mobility + Pevfomed simey: waning of side to ade -every 2 houte- range ‘hal bed cide ras a ahvoys.up.1ssisted With + Recdied_on bed, asleep in 0 stmi-Fonters postin = Taina ecsacae of €-non-OVspreie end elie, FEE Jo najegagme Tube clised tip at iotrorenous fuld OF NS TL a KUEp ein spen cole Foley, CANE ached 1 ufobag, Win the YoleWin ‘SORS* T: 39.6, PR: BY bpm RR j20Gpm, BFT 139] core, GR Ph ade, ate ands \S ti @ Benches asa) Connula ay are ante a oat ‘noting started Trees: at 2-at/inin pamhed mg Omfortabe resign. (ase eon ~ 8 BoNTUYay 9 powruynnd V pid Om gecelvng nokes m9 in moderofe ‘on bed.gsieep in p eee vw 02 inhalation of asd) cannuia,, with deplock + vith the fonowing’ nial abas Ri lepm , gp + 100) 70m af riya " 1 hoa ner eaten ite JA nwemed focters afeumig. exces fhid valve , toshiba” © Hurd WILE and whe - Ingacted h Inaik oral Auld intake. tp-crdudapd Aaviied on OW salt ancl Jan fad aie a Elevakd offeded part with & pillow. Encowraged the use of SFE Itns. kept dens ry and clean - i ain A ~ seen compottadie sitting on bed, with Cievakd Joni eAbremiiks, deere wp-avred vemanys jane txtrem fad. re6AM F—Recelving notes D ~ Received on bed, asleep, non-dyspneic in ‘moderate high back rest with patentintravenous fluid of PNSS 1 at 20 gtts/min at right hand at keep vein open rate in place, wearing a diaper, and gangrenous foot with the following. vital signs: T:_, PR:_, RR:_, BP:_, 02 Sat:_. 6AM F=Receiving notes D ~ received on bed, asleep, non-dyspneic, in moderate high backrest with patent intravenous fluid of PNSS at 20 gtts/min in place at right hand, Attached to Foley bagcatheter attachedto turobag with the following vital signs: T:_, PR:_, RR:_, BP:_, 02 Sat 6AM F—Receiving notes D ~ Received on bed, asleep, non-dyspneic, in ‘moderate high back rest with muscle weakness noted at the left side of the body with nasogastric tube close tip in place with ongoing ravenous fluid of PNSS 1L at 20 gtts/min at ‘ight arm infusing well with Foley bag catheter attached to urobag, with the following vital Signs: T:_, PR:_, RR:_, BP:_, 02 Sat: Intravenous fluid of PNSS 1L at 20 gtts/min, noted pressure ulcers at the gluteal site, attached to Foley bag catheter attached to turobag with the following vital signs: T:_, P RR, BP: 02 Sati. 6AM F Receiving notes D— Received on bed, awake, with sleepy face, in ‘a high — Fowler's position with 02 inhalation at l/min via nasal cannula with ongoing Intravenous fluid of PNSS attached to infusion ‘pump with piggy back dobutamine drip infusing ‘well at the right arm with the following vital signs: Ts, PR: RR: BP:_, O2 Sati_. 7AM F=Impaired Physical Mobilty D— Confined on bed in moderate high back rest with limited range of motion with body ‘weakness at the left side noted; Decreased muscle strength and tone, needs assistance in performing activities of daly living. ‘A~ Assessed factors affecting impaired physical mobility, performed timely turning side to side ‘every 2 hours. Ensured that bed side rails are always up. Assisted with range of motion, performed massage and skin care, supported affected body parts with a pillow. Encouraged the use of a soft mattress. Kept bed linens dry ‘and clean and positioned In a comfortable position. auam R— Seen comfortable, still in limited ‘Tange of ‘motion, sil needs assistance when per activities of dll living Performing 7am F—Risk for aspiration D~Seen with nasogastric tube close tip in place in fowler’ position with no muscle tone on both Upper and lower extremities and weak. A~ Assessed factors affecting risk for aspiration, Positioned in high back rest prior to feeding, checked for gurgling sounds, NGT patent. Given blenderized feeding and medications for SAM and positioned in high back rest for 1 hour after feeding. Monitored vita signs. 2AM R~ Blenderized feeding tolerated, no aspiration noted. Seen comfortable and relaxed on bed in moderate high back rest. 7AM F—Impaired skin integrity D—Noted redness and dryness of the skin at left sacral area with slight purulent discharges. A ~ Assessed factors affecting impaired skin integrity. Provided skin care by applying cintment, developed regularly scheduled repositioning of every 2 hours. Kept bed linens dry and clean and wrinklefree. Provided R~ Stil seen with redness and slight purulent discharges at left sacral area. 7AM F=Impaired skin integrity D — Noted gangrenous non-healing wound with slight purulent discharges, flaky with foul. smelling wound. A ~ Assessed factors affecting impaired skin integrity. Provided skin care by applying ointment. Turned side to side every 2 hours, kept bed, lines, and clothes dry and wrinkle-free. Covered wound with clean and dry dressi Provided adequate clothing and changed diaper ‘and blue pads. 1AM R-Seen still with redness of the skinat left sacral area and repositioned patient. 7AM F~Activty Intolerance D— Body weakness is noted, with limited range of movement, complains of *kapoyan gihapon kayo ko mag lihok-lihok". A = Assessed factors affecting activity Intolerance, provided patient with adequate rest periods, maintained a clean, wrinkle-free bed, performed passive exercises such as finger flexion and extension, elevated the extremities ‘with 4 pillow, reposttioned side-to-side every 2 hours, Instructed not to strain, avolded physicalcxeton, Instructed to refer to healthcare ere Is chest montoredvnen arches Pat and dsconfor, am R~Seen on comfortable position, participated in basive execs cen et and Of daily living. phigerared sam F— Receiving notes D ~ Received sitting, awake, coherent to time, place, and person, non-dyspnele, with 02 inhalation at 21/min via nasal cannula, with heplock at right hand, with #2 pitting edema on both hands and non-pitting edema on both lower extremities, with the following vital signs: ‘Temperature: 35.0, Pulse rate: 68, Respiratory Fate: 17, 02:98, and BP: 110/70 7AM F—Fluid volume excess D~ Presence of +1 pting edema on both hands and non-pitting edema on both lower extremities A ~ Assessed factors affecting fluid volume ‘excess, restricted fluid intake of 300 ml per 8 hours, elevated edematous extremities with 2 pillow, changed positions every 2 hours, placed ‘on semi-Fowler’s position when at bedrest, censured bed side rails are always up, emphasized the need of mobility, monitored vital signs. 2AM R — Seenion bed)with elevated) ‘maintained fluid restriction at 300 mL 6AM F = Receiving notes D — Received on bed, awake, non-dyspnelcy ‘oriented to time, place, and person, on a moderate high back rest, with ongolng Intravenous fluid of PNSS at 1L at 20 atts/min Infusing well at right hand, at 400 mb level, wearing diaper, with the following vital signs: 8AM Fatigue D — Complains dizziness when lying down, isnoted. A-Assessed Mabad ako ulo, kapoy sad”, feeling of drowsiness factors affecting fatigue, mentored leep I signs, determined presence Vicgurbances, encouraged movement on Sparemites, assisted with self-care needs. 1AM R- Seen sitting, Independ care activities like combing froisturizer, and wiping the wipes. ently performed self- ‘of halr, applying skin face with facial nn jing notes = Recelv ceed Jn bed, awake, letharale with skin 4 mm rented to time, place, a sure a arb Ialation a in la nah person tn patent heplck on the rt Ma cannula, at keep vein open rate, with warm, distended ‘abdomen, with the following vital sign: gam F—Acute pain D — Seen restless, with facial grimace, pointed the abdomen as the source of pain, with susan behavior, rated pain scale 28 out of ‘A Assessed factors affecting acute pain, pain noted at the site of incision at right lower quadrant, provided wound care and hygiene, observed guarding behaviors for pain, monitored vital signs, ensured bed is clean and wrinkle free. 1AM R~ ‘Seen still lying on bed, with noted facial grimace when participating on an intervention, ‘administered 02 inhalation at 4U/min via nasal cannula.