NURSING PROGRESS NOTES
DATE /
TIME PROBLEM / OBSERVATION COMMENTS
9/17/1 Wound Care Pt. A/O, explained procedure; denies pain at this time. BRP provided. JP
9
1345 Emptied, had 35 mL serosanguinous drainage. JP port cleansed with alcohol
wipe and secured. Abdominal wound assessed, incision approximated, 12
sutures intact, no redness or swelling noted. JP site clear, no redness, one
suture intact and securing tubing. Incisions cleaned with sterile normal saline,
pat dry, covered with 2 4x4 guazes, 1 4x4 drain sponge over JP site, covered
with large ABD dressing. Dressings secured with tape. Removed dressing
from left lateral thigh, dressing has moderate serous drainage. Open wound
meas. 7.5 x 1.75 x 1.2 cm. No drainage noted, wound bed red and moist,
periwound skin intact, pink color with minimal redness on edges of wound;
slight tenderness. Wound irrigated with sterile NS 0.9% until clear, excess
irrigating fluid removed. Aerobic and anaerobic cultures obtained, labeled and
sent to the lab. Periwound skin cleansed with sterile NS. Wound packed with
one moistened sterile NS, covered with 2 4x4 gauzes and ABD cover
dressing. Dressing secured with tape. Patient tolerated procedure with minimal
Discomfort, repositioned for comfort, call light within reach, bed in low
position. ────────────────────────── [Link], RN MSN
9/17/1 Pain Pt complained of pain left lateral thigh wound 7/10 numeric pain scale. States
9
1510 Pain began to increase gradually after wound dressing change. Pain centralize
to wound area, constant low intensity. Vicodin PO given with water, Pt.
Requesting apple juice. Repositioned pt. on right side, call light in reach.
────────────────────────── [Link], RN MSN ─────
9/17/1 Pain reassessment Upon entering room, patient resting, verbalizes pain 3/10. [Link], RN MSN
9 1540
PATIEN
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