The patient underwent a postoperative procedure on their left ear extending down to their neck. They had a 6 inch incision site with sutures intact and a Jackson Pratt drain in their left neck measuring 20mL of bloody drainage. The patient felt nauseated and vomited clear fluid. They felt dizzy upon standing but were assisted back to bed. The patient was encouraged to deep breathe, cough and turn frequently. Antiembolism pads were applied to prevent blood clots. The patient continued to feel nauseated and was given Compazine which relieved their nausea. Their vital signs and pain level remained stable.
The patient underwent a postoperative procedure on their left ear extending down to their neck. They had a 6 inch incision site with sutures intact and a Jackson Pratt drain in their left neck measuring 20mL of bloody drainage. The patient felt nauseated and vomited clear fluid. They felt dizzy upon standing but were assisted back to bed. The patient was encouraged to deep breathe, cough and turn frequently. Antiembolism pads were applied to prevent blood clots. The patient continued to feel nauseated and was given Compazine which relieved their nausea. Their vital signs and pain level remained stable.
The patient underwent a postoperative procedure on their left ear extending down to their neck. They had a 6 inch incision site with sutures intact and a Jackson Pratt drain in their left neck measuring 20mL of bloody drainage. The patient felt nauseated and vomited clear fluid. They felt dizzy upon standing but were assisted back to bed. The patient was encouraged to deep breathe, cough and turn frequently. Antiembolism pads were applied to prevent blood clots. The patient continued to feel nauseated and was given Compazine which relieved their nausea. Their vital signs and pain level remained stable.
05/31/07...2245...Pt 4 hours postoperative: awakens easily: oriented X3 but
groggy. Incision site in front of L ear extending down and around ear and into neck-approximately 6" in length - without dressing. No swelling or bleeding, bluish discoloration below L ear noted, sutures intact. Jackson Pratt drain in L neck below ear with 20 mL bloody drainage measured. Drain remains secured in place with suture and anchored to L anterior chest wall with tape. Pt denied pain but stated she felt nauseated and promptly vomited 100 mL of clear fluid. Pt attempted to get OOB to ambulate to bathroom with assistance but felt dizzy upon standing. Assisted to lie down in bed. Voided 200 mL clear, yellow urine in bedpan. Pt encouraged to deep-breathe and cough QH and turn frequently in bed. Antiembolism pads applied to both lower extremeties. Explanations given re: these preventive measures. Pt verbalized understanding.--------------- Joe Schmoe, RN 05/31/07...2255...Pt continues to feel nauseated. Compazine 10mg I.M. given in R gluteus maximus.----------------------------------------------Joe Schmoe, RN 05/31/07...2335...Pt states she is no longer nauseated, remains pain free. No further vomiting. Pt demonstrated taking deep breaths and coughing effectively.------------------------------------------------------------------Joe Schmoe, RN
Example for NG insertion. 16 F NGT placed with ease through the right nares using clean technique after prep with cetacaine spray and xylocaine jelly for pt comfort. Placement checked per auscultation and return of gastric contents. 100 ml yellow liquid gastric contents returned immediately. NG connected to LIWS per order. Pt tolerated the procedure well and vital signs remain within normal limits.
Prior to documenting the placement procedure, of course you would also need to document what the patient looked like ie: why they needed intubated, then any medications that were given to relax or sedate the patient. Don't forget the soft restraint documentation if you are using those. Most places require separate papers for soft restraints or safety devices. For an ET I will usually chart this: 8.5 ET tube placed successfully after two attempts per respiratory or MD (whichever). Placement initially checked by positive breath sounds bi-lat and positive end tidal Co2. Stat x-ray ordered to confirm placement. Tube placed 22 at the lip and tube secured. Pt's SpO2 now 98% and pt's color is pink, patient is warm and dry. Then you would chart either the patient is being bagged per RT or pt placed on a vent and be sure to document the vent settings. If there is anything suctioned from the lungs you would need to document the consistancy, the color and the amount.
Narrative Nursing Notes:10/13/2010. 1735. Chief complaint: SOB. Age 28, Orient x3. HR 70 BPM (pacemaker), Respiration 20,BP: 100/60 mmHg, O2: 95%. Dimished breath sounds, crackles in lower right lung. T 37.0 C. PT inserted, 600 mL of urine, dark yellow,clear, no odor. Unable to walk without assistance. Unable to move from chair to bed without assistance.Breathing with nasal canunli. O2 is humidified. PT states no pain, 0 on pain scale, but 4-5 when pressureulcer is bothering him. Pressure ulcer on sacral area. Did not assess. PEARLA. Can respond to commands.Hearing loss in left year. Motor responses are +2. No facial drooping noticed. Skin tugor: dehydrated,cool to touch. Notable edema on lower extremities, Pitting on lower leg. Pedal purse difficult to feel
07:30 Alert, awake, orientated to person place and time. Follows commands. Skin warm and dry. Respirations unlabored @18. Apical Pulse = 82, regular. Bowel Sounds absent. Hand grasps equal. @ 4L via nasal cannula. IV D5/1/2NS infusing @100 to R forearm via pump. Site clean and dry with no swelling or redness. Abdominal dressing dry and intact. Foley draining clear amber urine. Compression boots in place. TEDS in place. Bed in low position, call bell in reach, siderails CNS Documenting diet. The amount of fluid in CCs is recorded in the I&O sheet. In the narrative note document the type of diet, percentage consumed, and any pertinent information : 08:00 Took 100% of low sodium, soft diet. Had difficulty swallowing chopped meat._M. Nurse, BCNS Documentation of complete physical assessment. Complete your assessment before 9 a.m. and before giving any medications or treatments. It may not all be actually completed at the same time, but document it in one paragraph making sure that any abnormal or critical findings are documented and reported immediately. Ask the patient specifically when he had last BM. In addition to stating of stating no complaints of constipation diarrhea or flatus, describe your patients specific status. 0830 Awake, alert, oriented to person, place & time. Skin warm and dry. Turgor recoil brisk. Face symmetrical. PERRLA. EOM intact. Follow spoken commands. Mucous membranes pink & moist. Swallows without difficulty. Neck supple, trachea midline, carotids equal, no lymph nodes palpated. JVD (-) @ 45. Respirations even and unlabored, rate 16. Breath sounds clear bilaterally & A&P. Apical Pulse=72, regular. Abdomen soft, non-tender, bowel sounds present in all 4 quadrants. No complaints of constipation, diarrhea, flatus. States last BM yesterday evening. Urine amber, no complaints of burning. MAE without difficulty. Peripheral pulses 2+. Homans sign (-). Capillary refill brisk. Bed in low position, call light within reach. SR BCNS Documentation of hygiene care: Most institutions have a check-off list of nursing interventions for hygiene, such as back care, pedicure, Foley care, mouth care. However, they should be included in a narrative note. Also indicate how much of the care the patient did independently and any pertinent observations. 09:30 Complete bath care given with mouth care, peri-care, Foley care, back care.__M. Nurse, BCNS Documenting ambulation: Describe gait, strength, amount of assistance needed, how tolerated. 09:30 OOB to chair with the assistance of two staff members. Gait steady, but slow. Ambulated in hallway 5 minutes. C/O feeling tired., assisted back to bed________________________________M. Nurse, BCNS Documenting a problem such as pain: State the problem, what was done to solve it, and record result. 10:15 States sharp pain points to LLQ of abdomen, 8 on a scale of 1-10. States gets a little better when lying on left side. Respirations 20. Demerol 75 mg IM R ventral gluteal site by M. RealNurse, RN. Side rails position, call light in reach. M. Nurse, BCNS and the result (or evaluation of whether your intervention was successful): 11:00 States pain 3 on scale of 1-10. Watching TV.__________________M. Nurse, BCNS Documenting a physician visit, a test, therapy, treatment, specimen: 10:30 Dr. Jones in to see patient._________________________________M. Nurse, BCNS 10:40 To x-ray via w/c for chest x-ray_____________________________M. Nurse, BCNS 11:45. Sputum Specimen to lab.__________________________________M. Nurse, BCNS 12:00 Abdominal dressing change. 8" midline, vertical abdominal incision well- approximated. Staples intact. No redness, swelling or drainage noted. Dry sterile dressing applied._________M. Nurse, BCNS FINAL ENTRY: Verify status of your patient and include safety check 12:15 States pain almost gone, now a 1 on 1-10 scale. Husband visiting. Watching TV. Side rail reach, bed in low position.___________________________________M. Nurse, BCNS
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