Question

write an information you would document when you changing shifts and leaving the unit

Case Study: You are working an eight hour shift, from 7:30am to 3:30pm. Mr. Jones, in room 412, is 2 days post op cholecystectomy and is receiving IV therapy. The physician's order reads: 1000 mL. D51/2 NS QSH. His diet has been advanced bag, You assess the IV assessment at 8am you determine that his V/S.are stable and BS are present in all 4 quadrants, dietary delivers to clear liquids. At 7:30am while making rounds you note that there is 500 mL left in the site and there is no evidence of infiltration, phlebitis or infection at the site. On physical the morning tray, Mr. Jones consumes 100% o broth, 8 oz tea and 2- 8oz glasses of water f the food on the tray. This includes: 4 ozjelo, 6 oz. chicken At 10 am Mr. Jones complains of pain in his right arm. You assess the IV site and note redness at the insertion site and swelling. The temperature of the skin surrounding the IV site is cool to touch. You check the IV bag and the L-in the bag. The physician discontinues the IV and Mr. Jones' foley catheter at 11am. You measure the urine in the drainage bag: 450 mL clear yellow urine. His diet is advanced to full liquids as tolerated. Lunch is served around noon and Mr. Jones eats a cup of vanilla custard, a 6 oz serving of creamed soup and tea with milk and 2 sugars. At I pm Mr. Jones' wife tells you her husband is complaining of nausea. You immediately check on Mr. Jones and find that he is pale and diaphoretic. He is holding his abdomen and an emesis basin to his mouth. As you continue your assessment Mr. Jones vomits 300mL of green drainage into the emesis basin 2pm The physician is called and writes an order to restart Mr. Jones' IV therapy of: 1000 mL D5 0.5% NS 08H and places him on NPO status. Mr. Jones asks for the urinal at 2:30pm and voids 250 mL clear yellow urine 3:15pm Change of shift

Answer 1

Ans) Over to be given for change in shift:

Patient name: Me Jones

Room no:412

Operated: Cholecystectomy

Post op day: 2nd

IV: 1000ml D5 1/2 Ns Q8H.

Diet:Clear liquids to full liquids as vomited so NPO

Will note the intake accurately which he has taken.

Urine output: 450ml, clear yellow

IV is discontinued so veinflow will be removed as redness so theombophobe ointment & ice pack application.

Vomiting:300ml, green color

Reinsertion of veinflow to start IV therapy