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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
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.
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,
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,
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,