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ACTUAL CARE MANAGEMENT

DAY 1 (August 16, 2010)

I. SUBJECTIVE (patient’s actual complaint):

OJT ORIENTATION

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: PR:
Temperature: RR:
Heart Sounds: Auscultation (lungs):

Findings/Remarks:

III. INTERVENTIONS GIVEN:

IV. AFTER CARE EVALUATION:


ACTUAL CARE MANAGEMENT

DAY 2 (August 17, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of weakness on both LE with numbness especially when on


supine position.

II. OBJECTIVE FINDINGS:

VITAL SIGNS (Before and after duty hours)


BP: 130/70 mmhg : 120/60 mmhg PR: 62bpm : 60bpm
Temperature: 36.0 C : 36.0 C RR: 14cpm : 15cpm
Heart Sounds: Normal Auscultation (lungs):Normal

Findings/Remarks: Involuntary contraction of R ankle seen on supine


position

III. INTERVENTIONS GIVEN:

Interaction with pt. Assist pt. back to


bed
Vital signs taken and recorded Rechecked vital
signs
Repositioning (from supine  R sidelying to After Care
L sidelying q 30 mins. Per pt.’s request)
ROME (Active on R UE, AAROME on B LE)
Transfer from bed  WC with an extension
brace
Assist pt. in bathing, eating (at the dining table),
Grooming, personal hygiene

IV. AFTER CARE EVALUATION:

Pt. was freshen up, still feels numbness due to weakness of B LE after
exercise and transfer activities but stated that he is still satisfied and happy
because he accomplished all the activities given at his best.

2
ACTUAL CARE MANAGEMENT

DAY 3 (August 18, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of pain during involuntary contraction of his R ankle

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 120/70 mmhg : 120/70 mmhg PR: 66 bpm : 68 bpm
Temperature: 36.1 C : 36 C RR: 13 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Pt. cannot normally and fully flex, rotate and extend
neck

III. INTERVENTIONS GIVEN:

Interaction with pt.


Vital signs taken and recorded
Reposition pt. from supine R and L sidelying
Every 30 mins. Per pt. request
Stretched the calf ms. By dorsiflexing the R ankle
Massage on the calf ms.
Transfer to WC
Assist in meds taking, defecation (@the bathroom),
Lunch (@dining table), brush teeth, WC ride and
Back to bed
Re-checked vital signs and recorded
After care
IV. AFTER CARE EVALUATION:
Pt. still has involuntary contraction of his R ankle but
experienced less pain.

3
ACTUAL CARE MANAGEMENT

DAY 4 (August 19, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of having trouble of not passing out stool

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/70 mmhg : 120/60 mmhg PR: 64 bpm : 60 bpm
Temperature: 36.1 C : 36 C RR: 14 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: During pt’s nap, he was awaken by the involuntary


contraction of his R ankle.

III. INTERVENTIONS GIVEN:

Interaction with pt.


Vital signs taken and recorded
Reposition pt. from supine  R and L sidelying
Every 30 mins.
Assist in meds taking
Assist pt. to sit at the edge of the bed
Transfer to WC and accompany him in watching
Television
Assist in taking lunch and prepared foods high
In fiber such as vegetables and fruits
Assist in brushing teeth
Assist back to bed
Re-checked vital signs and recorded
After care
IV. AFTER CARE EVALUATION:
Pt. was still not able to pass out stool for the day.

4
ACTUAL CARE MANAGEMENT

DAY 5 (August 20, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of pain during involuntary contraction of the R ankle

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/60 mmhg : 120/70 mmhg PR: 61 bpm : 61 bpm
Temperature: 36 C : 36.1 C RR: 14 cpm : 19 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Blood stains seen on diaper after pt. sits on WC,


when pt. was placed back to bed.

III. INTERVENTIONS GIVEN:

Interaction with pt. Assist in bathing,


personal
v/s taken and recorded hygiene
Assist in meds taking assist pt. back to bed
Reposition pt. from supine  R and L Re-checked v/s and
recorded
Sidelying simultaneously after care
Stretched and massage calf ms.
Informed by the private caregiver that the
Pt. was on suppository
Prepared fruits and vegetables for lunch, assist pt.
For lunch
Transfer to WC and transport to bathroom
For defecation( a little stool passed out)

IV. AFTER CARE EVALUATION:


Pt. has less pain and was relieved after massaging the calf ms. But
involuntary
Contraction recurs. Pt. was advised not to do valsalva maneuver especially if under suppository
To prevent from bleeding.

5
ACTUAL CARE MANAGEMENT

DAY 6 (August 21, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of not passing out stool completely for the day, feels that
something is blocking his anus.

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 120/70 mmhg : 120/70 mmhg PR: 64 bpm : 60 bpm
Temperature: 36 C : 36 C RR: 20 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: noticed that pt. turned to L sidelying on his own by


grabbing the edge of the bed with his R hand.

III. INTERVENTIONS GIVEN:

Interaction with pt. assist back to bed


v/s taken and recorded Re-checked v/s and
Assist in meds taking recorded
ROME (AROME on R UE, AAROME on After Care
B LE, PRE’s on R UE, B LE)
Transfer to WC
Transport to bathroom
Assist in bathing, taking lunch and let him
Take high fiber foods
Accompany him in watching television
Transport to the front of the house

IV. AFTER CARE EVALUATION:


Pt. was still not relieved for not passing out stool completely but very
positive that he will, by the end of the day. Was informed by the next
caregiver that he did.

6
ACTUAL CARE MANAGEMENT

DAY 7 (August 23, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of body pains due to prolonged immobilization

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/70 mmhg : 100/60 mmhg PR: 70 bpm : 72 bpm
Temperature: 36.2 C : 36 C RR: 14 cpm : 16 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots seen on B medial thigh

III. INTERVENTIONS GIVEN:

Interaction with pt. v/s rechecked and


recorded
v/s taken and recorded
Assist pt. in changing positions from
Supine to sidelying (R and L)
Assist pt. to sit on the edge of the bed lasted
For an hour
Massage on B LE
Assist in eating, personal hygiene
Assist in shaving
Assist pt. during bedtime

IV. AFTER CARE EVALUATION:


Pt. felt much better after being placed in a sitting position and felt
more relaxed after the massage on B LE.

7
ACTUAL CARE MANAGEMENT

DAY 8 (August 24, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints pain at the lumbar area

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 90/60 mmhg : 110/70 mmhg PR: 69 bpm : 71 bpm
Temperature: 36.6 C : 36 C RR: 14 cpm : 16 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots seen on B medial thigh

III. INTERVENTIONS GIVEN:

Interaction with pt. assist pt. during bedtime


v/s taken and recorded rechecked v/s and recorded
Assist pt. in changing position from After Care
Supine to sidelying (R and L)
Massage on the lumbar area
(presence of Ms spasm)
Performed back rub
Assist pt in eating, grooming and
Personal hygiene
Assist pt. after defecation

IV. AFTER CARE EVALUATION:


Pain at the back lessened but still persists when it is moved.

ACTUAL CARE MANAGEMENT

8
DAY 9 (August 25, 2010)
I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of back pains at the lumbar area

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 100/70 mmhg : 110/70 mmhg PR: 70 bpm : 69 bpm
Temperature: 36.6 C : 36.3 C RR: 14 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots on B medial thigh


White skin flakes on R distal forearm

III. INTERVENTIONS GIVEN:

Interaction with pt. assist pt. in eating,


grooming
v/s taken and recorded and personal hygiene
Assist pt in changing positions from assist during bedtime
Supine to R sidelying to L sidelying rechecked v/s and
recorded
Transfer pt. to WC and brought to the After Care
Front of the house
ROME (AROME on R UE, AAROME on B LE)
Massage at the lumbar area
Performed back rub
Apply ointment on areas with red spots
Apply lotion on R distal forearm

IV. AFTER CARE EVALUATION:


Pt. was relieved after massaging the back area but can still tolerable
pain when moved.

ACTUAL CARE MANAGEMENT

9
DAY 10 (August 26, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of pain on the R shoulder when being positioned to R sidelying

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 120/70 mmhg : 120/70 mmhg PR: 65 bpm : 66 bpm
Temperature: 36.5 C : 36 C RR: 15 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots seen on B medial thigh


White skin flakes on R distal forearm and R distal leg

III. INTERVENTIONS GIVEN:

Interaction with pt. Apply lotion on R forearm, R


leg
v/s taken and recorded Apply ointment on the red spots
assist pt. repositioning from supine Assist pt. during bedtime
to R and L sidelying Re checked v/s and recorded
Transfer pt. to WC and accompany him After care
In watching television
AROME on R shoulder and massage on
The shoulder area
Cleanse pt. after defecation
Assist pt. in eating, grooming, personal
hygiene

IV. AFTER CARE EVALUATION:


Pt. still feels pain after ROME and massage to the shoulder area but
stated that he can tolerate R sidelying more than the usual period of being
placed in the position.

ACTUAL CARE MANAGEMENT

10
DAY 11 (August 27, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of not passing out stool for the day and felt that there’s
something blocking his anus.

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/60 mmhg : 100/60 mmhg PR: 60 bpm : 66 bpm
Temperature: 36.3 C : 36.6 C RR: 14 cpm : 16 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots on B medial thigh


White skin flakes on B lower leg

III. INTERVENTIONS GIVEN:

Interaction with the pt. Prepared food rich in fiber such


v/s taken and recorded fruits and vegetables
Assist pt. in changing positions from v/s re checked and recorded
Supine to R and L sidelying After Care
Assist pt. towards the edge of the bed
In a sitting position
Assist pt. in eating, grooming and
Personal hygiene
ROME (AROME on R UE, AAROME on
B LE)

IV. AFTER CARE EVALUATION:

Pt. was still not able to pass out stool by the end of the day

ACTUAL CARE MANAGEMENT

DAY 12 (August 28, 2010 )

11
I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of R shoulder pain when being positioned to R sidelying

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 120/60 mmhg : 120/70 mmhg PR: 65 bpm : 60 bpm
Temperature: 36.6 C : 36.6 C RR: 16 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots on B medial thigh


White skin flakes on B lower leg

III. INTERVENTIONS GIVEN:

Interaction with the pt. Assist in repositioning from supine


v/s taken and recorded to R and L sidelying
AROME on R shoulder Assist Pt. during bedtime
Massage on R shoulder area Re checked v/s and recorded
Strengthening exercises on R UE using After Care
Elastic band
Assist pt. in eating, grooming, personal hygiene
Apply ointment on red spots
Apply lotion on B lower leg

IV. AFTER CARE EVALUATION:

Pt. experienced less pain than usual during repositioning to R sidelying but can’t tolerate
more than 1 hour on the position.

ACTUAL CARE MANAGEMENT

DAY 13 (August 30, 2010)

I. SUBJECTIVE (patient’s actual complaint):

12
Pt. complaints of pain upon involuntary contraction of the R ankle

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 100/60 mmhg : 110/70 mmhg PR: 60 bpm : 60 bpm
Temperature: 36 C : 36.6 C RR: 15 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots on B medial thigh extending to the L


lower leg
White flakes still present on R distal forearm

III. INTERVENTIONS GIVEN:

Interaction with the pt. Re-checked v/s and recorded


v/s taken and recorded After care
Assist pt. in meds taking
Repositioning from supine to R sidelying
To L sidelying
Assist pt. to the edge of the bed
Transfer to WC
Assist in feeding, bathing, grooming, personal hygiene
Stretch R ankle towards dorsiflexion
Assist PT in ROME on R UE and B LE
Assist PT in ambulation exercise

IV. AFTER CARE EVALUATION:


Pt. felt refreshed but involuntary contraction of his R ankle still
persists.

ACTUAL CARE MANAGEMENT

DAY 14 (August 31, 2010)

I. SUBJECTIVE (patient’s actual complaint):

13
Pt. complaints of pain upon involuntary contraction of the R ankle

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 120/70 mmhg : 120/60 mmhg PR: 66 bpm : 72 bpm
Temperature: 36.6 C : 36.2 C RR: 13 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots seen on spreads from B medial thigh to B


LE
White skin flakes still present but lesser in size than
yesterday

III. INTERVENTIONS GIVEN:

Interaction with the pt. Stretch and massage the calf area
v/s taken and recorded assist pt. urination and defecation
Assist in meds taking Re-checked v/s and recorded
Reposition pt. from supine to R and After care
L sidelying
Transfer pt. to WC and accompany pt. in
Watching televison
Assist pt. in feeding, grooming, personal
Hygiene
Apply ointment on red spots

IV. AFTER CARE EVALUATION:

Pt. still felt pain upon involuntary contraction of the R ankle but stated that he felt more
relaxed after the massage to the area.

ACTUAL CARE MANAGEMENT

DAY 15 (September 1, 2010)

I. SUBJECTIVE (patient’s actual complaint):

14
Pt. complaints on having trouble sleeping the night before due to pain on R
shoulder, waist and B LE

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 100/60 mmhg : 120/70 mmhg PR: 64 bpm : 66 bpm
Temperature: 36.6 C : 36.3 C RR: 19 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots on B LE


White skin flakes present on B LE

III. INTERVENTIONS GIVEN:

Interaction with the pt. Re-checked v/s and recorded


v/s taken and recorded After care
Assist in meds taking
Repositioning form supine to R sidelying,
To L sidelying
Assist in sitting towards the edge of the bed
Assist in feeding, bathing, grooming and
Personal hygiene
Assist in ROME (AROME on R UE, AAROME on
B LE)
Pt. was advised to take a nap after the physical
Therapy session

IV. AFTER CARE EVALUATION:

Pt felt much better after taking a nap but can still feel body pains

ACTUAL CARE MANAGEMENT

DAY 16 (September 2, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of not passing out stool for the day

15
II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 120/70 mmhg : 120/70 mmhg PR: 60 bpm : 64 bpm
Temperature: 36 C : 36.6 C RR: 14 cpm : 19 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Pt. became irritable, gets angry when needs were


not taken cared of immediately

III. INTERVENTIONS GIVEN:

Interaction with the pt.


v/s taken and recorded
assist in meds taking
assist pt in changing positions from supine to
R and L sidelying
Massage pt.’s body for relaxation
Transfer pt. to WC and transport to the
Front part of the house
Prepared and assist pt. eat fruits and vegetables
Assist in feeding, bathing, grooming and personal hygiene
Re-checked v/s and recorded
After care
IV. AFTER CARE EVALUATION:

Pt. felt refreshed and relaxed after a series of interactions but was not still able to pass out
stool by the end of our shift.

ACTUAL CARE MANAGEMENT

DAY 17 (September 3, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of not having enough sleep the night before

16
II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/60 mmhg : 110/60 mmhg PR: 64 bpm : 71 bpm
Temperature: 36.3 C : 36.6 C RR: 16 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Pt. is irritable and easily gets angry when needs


were not well taken cared of.

III. INTERVENTIONS GIVEN:

Interaction with the pt.


v/s taken and recorded
assist pt. in meds taking
Assist pt. in changing positions from supine
To R and L sidelying per pt. request
ROME on R UE (AROME), AAROME, strengthening
Exercises on B LE using elastic band
Pt. was advised to take a nap
Assist pt. in bathing, feeding, grooming and personal
hygiene
Re-checked v/s and recorded
After care
IV. AFTER CARE EVALUATION:

Pt. was able to take an hour sleep after lunch and stated that he felt much better after
doing it.

ACTUAL CARE MANAGEMENT

DAY 18 (September 4, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of R shoulder pain when being positioned to R sidelying

II. OBJECTIVE FINDINGS:

17
VITAL SIGNS
BP: 120/60 mmhg : 110/70 mmhg PR: 61 bpm : 66 bpm
Temperature: 36.8 C : 36.3 C RR: 15 cpm : 16 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots still present on B LE but white skin flakes


disappeared

III. INTERVENTIONS GIVEN:

Interaction with the pt.


v/s taken and recorded
Repositioning from supine to R and L
Sidelying per pt. request
Transfer pt. to WC
AROME on R UE and massage on the R shoulder area
Assist pt. in meds taking, feeding, grooming and
Personal hygiene
Re-checked v/s and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. felt relaxed after being placed in a sitting position on the edge of the bed, but pain was
intermittent on his R shoulder.

ACTUAL CARE MANAGEMENT

DAY 19 (September 6, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of muscle soreness on B LE

II. OBJECTIVE FINDINGS:

VITAL SIGNS

18
BP: 120/70 mmhg : 110/60mmhg PR: 59 bpm : 60 bpm
Temperature: 36.8 C : 36 C RR: 12 cpm : 16 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots still present on B medial thigh, red spots


turned to black on his B lower leg

III. INTERVENTIONS GIVEN:

Interaction with pt.


Vital signs taken and recorded
Assist pt. in repositioning from supine to
R and L sidelying per pt. request
Apply liniment on B LE (Efficascent oil was
Replaced with shane herbal oil)
Assist pt. in eating, grooming, and personal hygiene
Assist pt. during bedtime
Assist in meds taking
Vital signs rechecked and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. felt relaxed after applying liniment on B LE but muscle soreness still persists with less
discomfort.

ACTUAL CARE MANAGEMENT

DAY 20 (September 7, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of itchiness of the head, back and B LE

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 100/60 mmhg : 110/60 mmhg PR: 64 bpm : 60 bpm

19
Temperature: 36.3 C : 36 C RR: 16 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots still present on B medial thigh, scattered


black spots on B lower leg. White flakes appeared on the head, posterior
lower leg

III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Assist pt. in meds taking
Assist pt. in bed bath giving priority on itchy areas
Apply lotion on R UE and B LE
Assist pt. in sitting at the edge of the bed
Assist pt. in feeding, dressing, grooming and personal hygiene
Assist pt. during bedtime
Vital signs rechecked and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. was freshen up and stated that he was relieved of itch after giving CBB

ACTUAL CARE MANAGEMENT

DAY 21 (September 8, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of heaviness of his upper body during ambulation exercises

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 100/60 mmhg : 110/70 mmhg PR: 60 bpm : 66 bpm
Temperature: 36.2 C : 36.8 C RR: 16 cpm : 20 cpm

20
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Red spots turned into scars on B medial thigh and


Lower leg

III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Assist pt. in repositioning from supine to R and L sidelying per pt. request
Assist pt. in meds taking, feeding, grooming and personal hygiene
Advised pt. to lose weight, less meat and more fruits and vegetables on
meals
Advised to maintain shane herbal oil as liniment
Massage B LE
Assist pt. during bedtime
Vital signs rechecked and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. stated that he will follow the advice concerning his eating habit in order to lose weight

ACTUAL CARE MANAGEMENT

DAY 22 (September 9, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of having trouble sleeping the night before due to frequent
change of positions

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 100/60 mmhg : 110/60 mmhg PR: 65 bpm : 70 bpm

21
Temperature: 36.1 C : 36.2 C RR: 14 cpm : 18 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Scars on B LE due to burn on liniment used


(Efficascent oil)

III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Assist pt. in repositioning from supine to R and L sidelying
Transfer pt. to WC and accompany in watching television
Assist pt. in meds taking, feeding, grooming and personal hygiene
Advised pt. to take a nap after brought back to bed from WC
Assist pt. during bedtime
Vital signs taken and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. felt much better after taking an hour sleep.

ACTUAL CARE MANAGEMENT

DAY 23 (September 10, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of not passing out stool for the day

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/70 mmhg : 100/60 mmhg PR: 61 bpm : 66 bpm
Temperature: 36.6 C : 36.3 C RR: 14 cpm : 18 cpm

22
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Pt. was irritable and has less energy in performing


exercises

III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Assist pt. in changing positions from supine to R and L sidelying per pt.
request
Assist pt. in meds taking, feeding, grooming and personal hygiene
Performed AAROME on B LE the massage B LE thereafter
Let pt. eat more fruits and vegetables high in fiber
Assist pt. during bedtime
Vital signs rechecked and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. was still not able to pass out stool but was relaxed after giving massage to B LE

ACTUAL CARE MANAGEMENT

DAY 24 (September 11, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of itching on the head, back and B LE

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/70 mmhg : 110/60 mmhg PR: 65 bpm : 70 bpm
Temperature: 36.6 C : 36.1 C RR: 19 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

23
Findings/Remarks: White flakes on the head, B LE and R forearm

III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Reposition from supine to R and L sidelying per pt. request
Assist pt. in bed bath
Apply lotion on R UE, B LE and back area
Assist pt. meds taking, feeding, grooming, dressing and personal hygiene
Change bed linens
ROME (AROME on R UE, AAROME on B LE
Assist pt. during bedtime
Rechecked vital signs and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. was freshen up and felt less itch on his head, back and B LE

ACTUAL CARE MANAGEMENT

DAY 25 (September 13, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of pain on his waist area

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 120/70 mmhg : 110/60 mmhg PR: 64 bpm : 60 bpm
Temperature: 36.2 C : 36.6 C RR: 19 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

24
Findings/Remarks: White flakes on skin already gone and lightened
scars on B LE

III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Assist pt. in meds taking, bathing, feeding, dressing. Grooming and personal
hygiene
Assist PT in performing ROME (AROME on R UE and AAROME on B LE)
Assist pt. in transferring to the WC
Housekeeping
Meal preparation
Assist pt. in repositioning from supine to R and L sidelying per pt. request
Assist pt. back to bed
Rechecked vital signs and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. experienced less pain on the waist area after being mobilized

ACTUAL CARE MANAGEMENT

DAY 26 (September 14, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of having trouble sleeping the night before due to pain upon
involuntary contraction of the R ankle

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/70 mmhg : 110/70 mmhg PR: 65 bpm : 66 bpm
Temperature: 36.8 C : 36.6 C RR: 13 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Less and less scarring on B LE

25
III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Assist pt. in repositioning from supine to R and L sidelying per pt. request
Transfer pt. to WC and accompany to the front part of the house
Housekeeping
Meal preparation
Assist pt. in bathing, feeding, grooming, dressing, and personal hygiene
Stretch the calf muscle towards dorsiflexion and massage the area
Let the pt. take a nap
Vital signs rechecked and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. was able to take a 45 mins. Sleep but involuntary contraction of the R ankle still
awakened the pt

ACTUAL CARE MANAGEMENT

DAY 27 (September 15, 2010)

I. SUBJECTIVE (patient’s actual complaint):

No complaints for the day

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 130/70 mmhg : 120/60 mmhg PR: 65 bpm : 70 bpm
Temperature: 36.7 C : 36.5 C RR: 15 cpm : 15 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Scars still present on B LE but less in size and


number

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III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Assist pt in meds taking, feeding, bathing, dressing, grooming and personal
hygiene
Assist pt. in transferring to the WC and accompany him in watching
television
Housekeeping
Meal preparation
Assist pt. in changing positions from supine to R and L sidelying per pt.
request
Assist pt. back to bed
Vital signs rechecked and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. felt refreshed after taking a bath and felt much better after being mobilized from a
supine lying position.

ACTUAL CARE MANAGEMENT

DAY 28 (September 16, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of pain upon involuntary contraction of the R ankle

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/70 mmhg : 110/70 mmhg PR: 66 bpm : 72 bpm
Temperature: 36.7 C : 36.2 C RR: 14 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Tried walking with an assistive device (quad cane),


still lack balance during ambulation

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III. INTERVENTIONS GIVEN:

Interaction with pt.


Vital signs taken and recorded
Assist pt. in repositioning from supine to R and L sidelying per pt. request
Assist pt. in meds taking, bathing, dressing, feeding, grooming and personal
hygiene
Housekeeping
Meal preparation
Assist PT in transferring pt. to WC and ambulation exercises
Stretch calf muscles towards dorsiflexion
Vital signs rechecked and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. felt exhausted after having been practicing the use of cane for the first time but tried
his best to be independent in walking; he still experienced involuntary contraction of R ankle
with less pain.

ACTUAL CARE MANAGEMENT

DAY 29 (September 17, 2010)

I. SUBJECTIVE (patient’s actual complaint):

No complaints for the day

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 120/60 mmhg : 110/70 mmhg PR: 70 bpm : 65 bpm
Temperature: 36.1 C : 36.3 C RR: 16 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Pt. feared that he might fall when balance is being


challenged in short sitting position at the edge of the bed

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III. INTERVENTIONS GIVEN:

Interaction with the pt.


Vital signs taken and recorded
Repositioning from supine to R and L sidelying per pt. request
Assist pt. in meds taking, bathing, dressing, grooming, feeding and personal
hygiene
Meal preparation
Assist pt. to sitting position at the edge of the bed
Transfer to WC
Assist in shaving
Vital signs rechecked and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. felt refreshed after taking a bath and stated that his body is much heavier now than
before which is the reason why balance is more difficult for him now

ACTUAL CARE MANAGEMENT

DAY 30 (September 18, 2010)

I. SUBJECTIVE (patient’s actual complaint):

Pt. complaints of heaviness of his upper body during ambulation exercises

II. OBJECTIVE FINDINGS:

VITAL SIGNS
BP: 110/60 mmhg : 110/70 mmhg PR: 66 bpm : 70 bpm
Temperature: 36.6 C : 36 2 C RR: 16 cpm : 20 cpm
Heart Sounds: Normal Auscultation (lungs): Normal

Findings/Remarks: Pt. bends forward during ambulation exercises with


2 assist

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III. INTERVENTIONS GIVEN:

Interaction with pt.


Vital signs taken and recorded
Repositioning from supine to R and L sidelying per pt. request
Housekeeping
Meal preparation (advised to eat less meat)
ROME (AROME in R UE, AAROME on B LE)
Strengthening exercise (on B LE using elastic band)
Assist pt. in meds taking, feeding, grooming and personal hygiene
Rechecked vital signs and recorded
After care

IV. AFTER CARE EVALUATION:

Pt. was bothered on gaining weight but taking the advice seriously to eat less meat and
add more fruits and vegetables on the diet.

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