Question

(documenting narrative )

1) While you give the patient his bath, he laughs and talks a great deal. He says nothing hurts him even though e had an open cholecystectomy three days ago. You check his dressing and it seems to be in the right place and is clean and dry. He walks in the hallway during the 10 minutes it takes you to make his bed and straighten his area. You complete his care at 9:45 am.

2) Dr Blue changes patient dressing while you assist him as he makes rounds at 8:30 am you notice that there is a lot of pus on the soiled dressing. The wound has an awful odor.

3)When you finish bathing the patient at 10:10 am, you assist her to a chair. She sits there for 10 minutes but cries and says her head hurts when she is up. She foes back to bed and falls asleep 15 minutes later.

4) Patient had a soap solution enema. 750 mL of solution were given she passed a large amount of dark brown stool that seemed hard, along with a little gas. The procedure was completed at 9:15 am. Patient and no problems receiving or expelling the enema.

5) After reporting for the morning sift you have completed an initial assessment for the patient. He had an open appendectomy yesterday, but today is doing well, with all findings within normal limits. He does say that he is tired of being in bed he has an abdominal dressing and e is receiving IV fluids of 5% Dextrose in Normal Saline. An infusion pump is being used.

documentation as a nurse

each one is a situation how shoul i document that on the pt chart?

Answer 1

1)Pateint bath given,whlie giving patient was active and well coperative.Patient had open cholecystectomy ,pain assessment done ,thre is no pain at incision site as evidenced by patient verbal commands,dressing site assessed the dressing is in right place and it is dry and cleaned.Ambulated the patient in the hallway10 minutes,Bed making done and all the patient care completed at 9:45 am.

2)Dr.Blue makes round at 8:30 am and he changed the dressing ,there is a lot of pus on the soild dressing and the wound has an awful odour.

3)Patient bath finished at10:10am and assist the patient to a chair and she sits there for 10 minutes and she complined that that she has pain on her head when she is up.

4)Soap solution enema 750 ml given to the patient and she passed large amount stool and the colour of stool was dark brown that seemed hard and also she passed flatus.The procedure was copleted at 9:15 am and she has no problems receiving and expelling enema.

5)Patient initial assessment done.He had an open appendectomy yesterday ,he is doing well today,all findings within normal limits.Patient has an abdominal dressing and also he is receiving IV fluids 5% Dextose in Normal Saline through infusion pump.