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VII.

PROGRESS NOTES

Day # Existing Cues/Problems


Interventions Actually Done (Nursing and
Collaborative)
Client Responses
Day 1 In the first day of contact, patient was awake,
September 16, 2010 conscious and coherent lying on bed in a
Fowler’s position. His V/S was: Temp.: 36 degree
Celsius, PR: 60 beats per minute, RR: 15 cycles
per minute and BP: 150/90 mmHg. The patient
was irritable at that time since she verbalized that
she wanted to go home. She showed s/sx of
facial grimace and guarding behavior. She also
added that the doctor have not visited her
regarding her present condition. Patient had a
meat free, decrease CHON and limit OFI 1L per
day diet. She actually took long rest periods to
alleviate her anxiety. Student nurse provided
health teaching about the importance of
maintaining patient’s medications and positioning
during rest periods. She also stated that she’s
already ok. Student nurse maintained a
conducive environment, assisted patient prn,
instructed to perform DBE and coughing
exercises to alleviate his pain condition.
Day 2 The client has been discharged.
September 17, 2010

VIII. DISCHARGE HEALTH TEACHING PLANS

Content Strategy
1. Compliance
Medication Health Teaching
-Patient The patient should
always follow her Doctor’s
prescribed medication
-Patient was taught the
possible side effects of
drugs and the rationale why
she should take the drugs
-Patient was also taught to
report immediately the
symptoms she is not familiar
with
-Advised the family
members to avoid using
non-prescription drug unless
approved by the physician.
Diet
-Encouraging the family
members to follow the diet
and fluid intake
recommended to the patient
-Educating the family
members as well as the
patient about foods that are
healthy yet appropriate for
the diet of the patient
Exercise
Activity/Lifestyle -After long periods of bed
rest, client was advised to
ambulate and do simple
range of motion exercises
- Educate the patient’s
relatives about how to assist
the patient do simple ROM
exercises like flexion of
upper and lower extremities
or walking for a short
distance
- Taught patient that
exercise regularly can
increase his HDL to promote
optimum health and
development
-The patient should be extra
careful in doing her activities
of daily living
-Patient should know the
limitations upon doing her
activities

2. Follow up/ Check-up -The patient should always


comply to her scheduled
meeting with her doctor to
check for improvement or
complications
-Any neurologic or mental
changes should be attended
and prompt check up is
required

IX. SUMMARY OF CLIENT’S STATUS OR CONDITION AS OF LAST


DAY OF CONTACT

Date: September 16, 2010

Medications:

-The family together with the patient will continue the prescribed medications with proper dosage
and frequency in order to hasten the recovery of the patient.
Informing the family members about the prescribed medications and its importance regarding
the condition of the patient.
-Reminding and reviewing the family members about the drugs in order to make familiarity with
the treatment.
-Advise the family members to avoid using non-prescription drug unless use is approved by the
physician.
-Encouraging the family members to administer medications exactly as prescribed by the
physician.

Diet:

-Family members will know and follow patient’s restrictions in foods and proper eating healthy
foods.
-Encouraging the family members to follow the diet and fluid intake recommended to the patient.
-Educating the family members to follow the diet and fluid intake recommended by the physician
for the patient.
-Educating the family members as well as the patient about foods that are healthy yet
appropriate for the diet of the patient.

Exercise
Activity/Lifestyle:

-The patient will be engaged in doing simple ROM exercises in order to maintain muscle and
bones integrity as well as maintaining a good body circulation.
-Educate the patient’s relatives about how to assist the patient do simple ROM exercises like
flexion of upper and lower extremities or walking for a short distance.
-Educating the relatives about the importance of exercise in the body and its benefits to once
health.

Follow up/ Check-up:


-To give importance if there are any concerns or abnormal conditions, effects of medication that
aggravate or alleviate the patient’s condition outside the hospital premises.
-Stress to the patient the importance of scheduling and keeping check-up appointments and
make sure she has the doctor’s office or telephone number.
-Provide health teachings to the patient and relatives about the importance of having a regular
check-up after hospitalization.

Sienna, binago ko yung discharge teaching plans kasi ang alam kong
ilalagay dun sa content yung content tlga tapos yung strategy kung anu
yung ginamit kaya health teaching nilagay ko. Tapos itong summary, ang
alam kong ilalagay dito yung nangyari lang nung last day of contact eh
hndi ko naman mabago kasi baka mali ako. Ayun lang. :)