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Pain

D:

Reports of sharp pain on the abdominal


incision area with a pain scale of 8 out of 10

Facial grimacing

Guarding behavior

Restless and irritable

A:

Administered Celecoxib 200mg IV

Encouraged deep breathing exercises and


relaxation techniques

5/20/20108:00pm

Hyperthermia

Kept patient comfortable and safe

R:

Patient reports pain was relieved

D:

Temperature of 38.9 OC via axilla

Skin is flushed and warm to touch

A:

Tepid Sponge Bath (TSB) done7:30pm

Administered 250mg IV Paracetamol as per


doctors order

Encouraged adequate oral fluid intake

Encouraged adequate rest

instructed SO to let patient wear loose


clothing

> instructed SO to provide blanket to


patient when shiver

> instructed SO to include in his diet


foods rich in Vitamin C such as oranges R:

10:00pm>Temperature decreased from 38.9 to


O

37.1 C

F1: Ineffective Breathing Pattern


D1: increase respiratory rate of 24 cpm
D2: use of accessory muscle to breath
D3: presence of nonproductive cough

F2: Hyperthermia
D1: skin warm and flush to touched
D2: increased body temperature of T= 38.9 degree celsius/axilla
F3: Fatigue
D1: less movement noted
A: 9:00am

monitored v/s and charted

regulated IVF and charted

morning care done

assessed patient needs and performed handwashing before handling the patient

advised SO to always stay on patient bedside

promote proper ventilation and a therapeutic environment

elevated the head of the bed (moderate high back rest)

provided comfort measures and provide opportunity for patient to rest

due meds given

9:30am

tepid sponge bath done

instructed SO to provide blanket and let patient wear loose clothing

F4: Discharge Plan (12:00nn)


D1: discharged order given by Dr.Name/Time

M advised SO to give the ff. meds at the right time, dose, frequency and route

E encouraged to maintain cleanliness of the house and surroundings

T advised to go to follow-up consultations on the prescribed date

H encouraged to do chest tapping to facilitate mobilization of secretion

O observed for signs of super infections such as fever, black fury tongue and foul
odor discharges

D encouraged to eat fresh vegetables and fish

S advised to continue praying to God and hear mass on Sunday

2:00pm out of the room per wheelchair with improved condition

Discharge plan for patient who undergo Surgery


H Health Teachings
A Anticipatory Guidance
S Spirituality
M Medications
I Incision in Care

N Nutrition
E - Environment
DEFINITIONS:

Focus Charting - is a method for organizing health information in the individual's record. It is a
systematic approach to documentation, using nursing terminology to describe individual's health status
and nursing action.

Focus a key word or diagnostic category from a nursing diagnosis or collaborative problem on the
plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit
a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital
admission
a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan,
i.e. fever, constipation, hypertension, incontinence, lethargy
an acute change in an individual's condition, i.e. respiratory distress, seizure, fever, discomfort a
significant event in an individual's care, i.e. begin treatment regimen (oxygen), change in diet,
catheterization
a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self
medication teaching plan, transition COMPONENTS OF A FOCUS NOTE:

Data: Subjective and/or objective information supporting the stated focus or describing observations
at the time of significant events.

Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures
initiated.

Response: Description of individual's response to medical and/or nursing care. Statement that
the Action Plan of Care outcomes have been attained or are progressing toward attainment.

Example: Need: Comfort (or, Relief of pain)


D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I need something for
pain now!" States pain is 9 on a scale of 10.
A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to
abdomen to help splint wound.
R - Patient stated pain was "much better" 30 minutes later and rated it 3 on a scale of 10.