Question

Documentation Activity Upon arrival to your shift, you introduce yourself to your patient (J.F.) who was admitted yesterday for monitoring following a syncopal episode while she was walking to her car after work. When you walked into the room and turned on her bedside light, she covered her eyes with her blanket. J.F. complains of a throbbing headache behind her eyes and is a 7 on a pain scale of 0-10. Her VS are as follows: Temp 98.7, RR 20, HR 86, BP 128/62. You find no abnormalities in her physical assessment. You administer 650 mg Tylenol by mouth according to a PRN order left by the physician, help her reposition in bed for comfort and turn off the lights and TV in her room. When you return at 0800, J.F. states that her pain is at a 3 on a 0-10 scale and that the pain is tolerable at this time. Write a Narrative note about this situation

Answer 1

Mr. J. F was admitted yesterday to monitor the syncopal episode. When i took the charge of patient care, i visited the patient and introduced myself. When i switched on the light, immediately ge covered his eyes with the blanket and he complained about the throbbing headache behind the eyes. This is a kind of tension headache which can be caused by eye strain. He had severe pain of 7 on pain scale. He is been administered with Tab. Tylenol 650 mg orally, which is an analgesic. I helped him to repositioned in the bed, switched off the light and T.V, so that he gets a calm environment which helps to reduce the tension headache. After 8 am pain is reduced to 3, which means mild pain.