2.

NURSING MANAGEMENT (Actual FDAR)

February 2, 2018: Friday

F = Activity Intolerance related to immobility

D = Received patient on bed, lying on a supine position, awake, oriented to

time, place and person. Skin was warm to touch, pallor, weakness, with
dressing dry and intact covered with immobilizer on right thigh.

 Facial grimaces
 Inability to relax
 Irritability
 Prolonged immobility
 Needs support in moving
 Cannot be able to fully extend her right leg because pain will be
present
 With initial vital signs of the following: T=36.8°C, PR=64bpm,
RR=20bpm and BP=130/80mmHg

A=

 Assisted client in gradual changes in position.

 Assesed the physical activity level and mobility of the patient.

 Have the patient perform the activity more slowly, in a longer time with
more rest or pauses, or with assistance if necessary.

 Assisted with activities if needed.

 Encouraged client in doing Passive Range of Motion.

 Instructed patient to plan activities for times when they have the most
energy.

 Advised patient to monitor incision for pus and other signs and

symptoms.

 Advised patient to keep immobilizer to provide pressure on incision

site.
  Provides adequate rest and comfort measures.

R = The patient participated willingly on desired and necessary activities such

as PROM.
February 8, 2018: Thursday

F = Impaired Skin Integrity

D = Received patient on bed, lying on a supine position, awake, oriented to

time, place and person. Skin was warm to touch, CRT< 3seconds, weakness
with dressing dry and intact covered with immobilizer on right thigh.

 Facial grimaces
 Inability to relax
 Irritability
 Immobility
 Edema
 Disruption of the skin surfaces
 Incision site on right thigh with dressing dry and intact covered with
immobilizer.
 With initial vital signs of the following: T=36.6°C, PR=84bpm,
RR=19bpm and BP=140/100mmHg

A=

 Assessed skin for dryness.

 Assessed client for signs of infection like fever.
 Assessed Capillary Refill Test.
 Inspected incision every shift (REEDA).
 Advised patient to avoid having wounds d/t poor wound healing d/t
Diabetes by following a healthful balance diet and having regular
physical activity.
 Teached patient and SO self care hygienic practices.
 Teached patient on passive range of motion exercises.
 Administered antibiotics as prescribed
 Encouraged client to increase oral fluid intake.
 Changed and cleaned wound dressing.

R = The patient displayed timely wound healing and there were no signs of
infection.
February 9, 2018: Friday

F = Altered Comfort

D = Received patient on bed, lying on a supine position, awake, oriented to

time, place and person. Skin was warm to touch, CRT< 3seconds, weakness
with dressing dry and intact covered with immobilizer on right thigh.

 Facial grimaces
 Inability to relax
 Irritability
 Lethargic
 Confused
 With initial vital signs of the following: T=36 ° C, PR=80bpm,
RR=22bpm and BP=120/80mmHg

A=

 Provided comfort measures.

 Encouraged adequate rest periods.
 Emphasized proper hygiene.
 Encouraged client in doing Passive Range of Motion exercises.
 Encouraged Deep Breathing and Coughing exercise.
 Assisted in changing dressing.
 Assisted in self care activities.
 Maintained calm and quiet environment.
 Encouraged in early ambulation.
 Administered prescribed pain medication..

R = The patient verbalized an increased sense of comfort and understanding

of the treatment and other regimen measures.