MAKE A TRADITIONAL CHARTING Patient 4hr Postop, awakens easily, oriented X 3 but groggy, incision site in front of Left ear extending and around the ear and into neck-approximately 6inches in length-without dressing. C. Jones, RN. No swelling or bleeding, bluish discoloration below left ear noted, sutures intact. Jackson-Pratt drain in left neck below ear with 20 ml blood drainage measured. C. Jones RN. Drains remains secured in place with suture and anchored to left anterior chess wall with tape. Patient denied pain buy stated she felt nauseated and promptly vomited 100ml of clear fluid. Pt. attempted to get OOB(out of bed) to ambulate to bathroom with assistance but felt dizzy upon standing. Assisted to lie down in bed. Voided 200ml clear, yellow urine in bed pan. Pt. encourage to deep breath and cough ghr, and turn frequent in bed, Lung sound clear bilaterally. Antiembolism stockings applied to both lower extremities. C. Jones RN Explanation given regarding these preventive measures. Pt verbalized understanding., Pt. continues to feel nauseated, Compazine 1mg IV. Pt. states she's no longer nauseated, No further vomiting, Rating pain in incisional areas as 7/10, on a scale of 0/10. Medicated with morphine 2mg iv. Pt. stated pain as 1/10. Demonstrated taking deep breaths and coughing effectively C. Jones RN, 12/25/2007 10:45 am 8:00am9:30am10:15am
MAKE A TRADITIONAL CHARTING Patient 4hr Postop, awakens easily, oriented X 3 but groggy, incision site in front of Left ear extending and around the ear and into neck-approximately 6inches in length-without dressing. C. Jones, RN. No swelling or bleeding, bluish discoloration below left ear noted, sutures intact. Jackson-Pratt drain in left neck below ear with 20 ml blood drainage measured. C. Jones RN. Drains remains secured in place with suture and anchored to left anterior chess wall with tape. Patient denied pain buy stated she felt nauseated and promptly vomited 100ml of clear fluid. Pt. attempted to get OOB(out of bed) to ambulate to bathroom with assistance but felt dizzy upon standing. Assisted to lie down in bed. Voided 200ml clear, yellow urine in bed pan. Pt. encourage to deep breath and cough ghr, and turn frequent in bed, Lung sound clear bilaterally. Antiembolism stockings applied to both lower extremities. C. Jones RN Explanation given regarding these preventive measures. Pt verbalized understanding., Pt. continues to feel nauseated, Compazine 1mg IV. Pt. states she's no longer nauseated, No further vomiting, Rating pain in incisional areas as 7/10, on a scale of 0/10. Medicated with morphine 2mg iv. Pt. stated pain as 1/10. Demonstrated taking deep breaths and coughing effectively C. Jones RN, 12/25/2007 10:45 am 8:00am9:30am10:15am
Chapter11: Administration Of Nonparenteral Medications
Section: Chapter Questions
Problem 20RQ
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Transcribed Image Text:MAKE A TRADITIONAL CHARTING
Patient 4hr Postop, awakens easily, oriented X 3 but groggy, incision site in front of Left ear
extending and around the ear and into neck-approximately 6inches in length-without dressing.
C. Jones, RN. No swelling or bleeding, bluish discoloration below left ear noted, sutures intact.
Jackson-Pratt drain in left neck below ear with 20 ml blood drainage measured. C. Jones RN.
Drains
remains secured in place with suture and anchored to left anterior chess wall with tape. Patient
denied pain buy stated she felt nauseated and promptly vomited 100ml of clear fluid. Pt.
attempted
to get OOB(out of bed) to ambulate to bathroom with assistance but felt dizzy upon standing.
Assisted to lie down in bed. Voided 200ml clear, yellow urine in bed pan. Pt. encourage to deep
breath and cough gbt, and turn frequent in bed, Lung sound clear bilaterally. Antiembolism
stockings applied to both lower extremities. C. Jones RN Explanation given regarding these
preventive measures. Pt verbalized understanding.,
Pt. continues to feel nauseated, Compazine 1mg IV.
Pt. states she's no longer nauseated, No further vomiting, Rating pain in incisional areas as
7/10, on a scale of 0/10. Medicated with morphine 2mg IV.
Pt. stated pain as 1/10. Demonstrated taking deep breaths and coughing effectively
C. Jones RN, 12/25/2007 10:45 am 8:00am9:30am10:15am
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