NURSES NOTES

DATE/SHIFT/TIME FOCUS D-DATA A-ACTION R-RESPONSE

4/24/21 Pre-Op D: Received patient from E.R via stretcher, accompanied
assessment by E.R NOD and significant others, conscious and
coherent with going 0.9%Normal Saline; infusing well;

A: Placed on bed side rails up and locked. Checked the

patency of IVF drop factor, name of patient and IVF
hooked. Reviewed and checked the patient chart if all
laboratory results were attached, surgery consent signed
and availability of surgical materials and pre-operative
medicines. Checked and reviewed operating room
checklist, jewelries, dentures and nail polish, name tag of
patient.

R: Responsive to stimuli and pain, with spontaneous eye

opening.

D: Patient is transferred to PACU via stretcher. Patient is

not in respiratory distress, with facial grimace, with
ongoing 0.9%NORMAL SALINE.. Vital signs shown on
monitor.
BP: 105/70mmhg
Post-Operative
HR:104bpm
management
RR: 18cpm
O2sat: 98% on room air

A: Encouraged feelings, to deep breathing exercise.

Instructed NPO until further orders. Vital Signs
monitored for 5minutes, for 30 minutes, then hourly. I
and O was monitored every 1hour.

- Ampicillin 336mg IV times 3doses

- Acetaminophen 325 PO q4
- Morphine 1mg IV q4 PRN
- Morphine PO q4
- CBC AND ELECTROLYTES tomorrow;
requested----------

R: The patient was stable and Vital signs are now stable.
The patient went out the operating room via stretcher.