DAR #1:

D: Abd round, soft, non-tender. Normoactive bowel sounds. Flatus absent. Diet: clear liq diet.
Last BM on 10/13/16. No NGT, GT, or ostomy. Incision at abd midline and LUQ. Approximated
with staples, no dressing, open to air. No drainage. Pain 0/10 to abd. Pain with movement.
Nausea present.
A: Assessed abd incisions, pain to site, and passage of flatus.
R: Incisions open to air, no dressing. No bleeding or draining. Approximated with staples. Pain
0/10 during AM assessment. Pt lying still in bed to avoid pain associated with movement. Flatus
continues to be absent. Continue to monitor.
DAR #2:
D: Abd round, soft, non-tender. Hypoactive bowel sounds. No N/V. Last BM on 10/17. No NGT,
GT. Diet NPO, sips of water with meds. New ostomy present LLQ. Stoma moist, edematous,
beefy red. No stool in colostomy bag. JP bulb to LLQ, small amount of serosanguinous drainage.
Pt c/o pain with movement when ambulating. Pain 5/10 to rectal area. Constant, aching.
Morphine 1mg every 8 minutes PCA.
A: Amb in room from bed to chair. Reminded pt to push PCA button when onset of pain occurs.
R: Pt pushed PCA. Upon reassessment, pt sitting and resting in chair. Reported pain 0/10, PCA
effective.
DAR #3:
D: Foley 16 Fr and CBI 24 Fr present. Drains patent and secured. Urine light pink, clear, no
clots. CBI w/ NS at 100ml/hr. UOP 200ml/hr.
A: Monitored I&O every 30-60 mins. Emptied foley bag prn.
R: Urine clear, light pink, no clots. UOP 200ml/hr. Pt tol CBI well. Continue to monitor.