COURSE IN THE WARD

Date and
Time
Focus Progress Notes
May 13,
2014

7:00 am to
3:00 pm

Imbalance
nutrition:
more than
body
requirements

Received sitting on bed awake and oriented to time,
person and place
Data:
Verbalization of excessive eating pattern
Weight changes from 69 to 74 kilograms
BMI: 27.11 kg/ m

Action:
Encouraged to limit high calorie foods

Instructed to ambulate with the proper
use of an assistive device and have rest
periods in between activities


Encouraged to have high protein foods

Response:

The patient verbalized an understanding
about the ways to reduce weight.



















Date and
Time
Focus Progress Notes
May 14,
2014
7:00 am to
3:00 pm

Safety

Received sitting on bed awake and oriented to time,
person and place
Data:
Limited range of motion

Uses an assistive device for walking

Altered mobility


Action:
Encouraged self-care activities such as
bathing

Assisted with mobility by means of
loftman stand, as soon as possible.

Instructed in safe use of mobility aids.


Schedule activities with adequate rest
periods

Identified energy conserving techniques
for activities


Response:

The patient was able to understand ways how
to decrease incidence of injury.