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focus: nausea related to anesthetic

d: pt. states she's nauseated. vomited 100ml clear fluid at 2255


a: given compazine 1mg iv at 2300.
r: pt. reports no further nausea at 2335. no further vomiting.

focus: risk for infection related to incision sites


d: incision site in front of left ear extending down and around the ear and into neck--approximately 6
inches in length--without dressing. jackson-pratt drain in left neck below ear secured in place with suture.
a: assess site and emptied drain. taught patient s&s of infection.
r: no swelling or bleeding; bluish discoloration below left ear noted. jp drained 20ml bloody drainage.
patient states understanding of teaching.

focus: delayed surgical recovery


d: patient reported dizziness after trying to get oob to use the bathroom.
a: assisted patient back in bed and with use of bedpan. taught patient how to dangle legs and get oob
slowly. also taught coughing and deep breathing exercises, turning in bed, and use of entiembolism
stockings.
r: patient voided 200ml in bedpan. did cough and deep breathing appropriately. lungs clear bilaterally.
using antiembolism stockings.

focus: acute pain related to surgical incision


d: patient reports pain as 7/10 on 0 to 10 scale.
a: given morphine 1mg iv at 2335.
r: patient reports pain as 1/10 at 2355.

Example 1 Focus: Nausea related to anesthetic


D: States she's nauseated. Vomited 100ml clear fluid at 2255
A: Given Compazine 1mg IV at 2300.
R: Reports no further nausea at 2335. No further vomiting.

Example 2 Focus: Acute pain related to surgical incision


D: Reports pain as 7/10, grimaces and groans with movement BP 154/88. Had received PO analgesic at
2200.
A: Given morphine 1mg IV at 2335. Repositioned on left side.
R: Reports pain as 1/10 at 2355. BP 138/82.

Example 3 Focus: Risk for infection related to incision sites


D: Incision site in front of left ear extending down and around the ear and into neck14 cm in length-without dressing. Jackson-Pratt drain in left neck below ear secured in place with suture.
A: Assess site and emptied drain. Taught patient S&S of infection.
R: No swelling or bleeding; bruising below left ear noted. JP drained 20mL bloody drainage. States
understanding of teaching.

Example 4 Focus: Delayed surgical recovery


D: C/O dizziness after trying to get OOB to use the bathroom.
A: Assisted patient back in bed and with use of bedpan by CNA. Taught how to dangle legs and get OOB
slowly. Taught coughing and deep breathing exercises, turning in bed, and use of anti-embolism stockings.
R: Voided 200mL in bedpan. Did cough and deep breathing appropriately. Lungs clear bilaterally. Antiembolism stockings on.