Tub bath taken. Patient able to bathe self, but needed assistance getting in and out of tub. Skin on both legs dry and flaking; patient reports severe itching. Emollient lotion applied after bath.
Patient states itching is less now. (Tub Bath or shower)
After complete bed bath, provided back massage using pétrissage and friction. Patient reported muscle tension and rated pain a 4 before back massage; reported muscle relaxation and rated pain a 2 after back massage. Skin is moist, pink, and intact with no bruises, swelling, or redness. After back massage, patient’s respirations decreased from 20 to 16 per minute and pulse decreased from 78 to 70 beats per minute. (Back Massage)
Complete bed bath given. Patient unable to assist but cooperative with turning. Skin on both legs dry and flaking, complains of severe itching.
Bath oil added to bath water. Emollient lotion applied after bath. States itching is less after bath. (Complete or Partial Bed Bath)
Perineal care given. Patient unable to assist but cooperative with positioning. No redness, drainage, or open areas noted. Patient complained of mild itching before perineal care. Patient reports reduced itching after perineal care. (Perineal care for Female Pt)
Perineal care given. Patient unable to assist but cooperative with positioning. External genitalia show no signs of redness, swelling, or drainage. Indwelling catheter is intact and draining clear amber urine.
Patient denies pain but states that he feels “very weak.” (Perineal care for a male Pt)
Last BM 5 days ago. C/O abdominal fullness and rectal pressure.
Abdomen distended, firm. 1,000-ml soap suds enema given with “mild” abdominal cramping during administration. Solution returned with large amount of dark-brown, soft-formed stool. (Cleansing Edema)
States, “I feel better now.” Abdomen soft, nondistended. Resting in bed with side rails up X2. (Cleansing Edema after 1 hour)
Urinary dribbling constant for 1 week. Perineal area reddened, even with frequent washing, drying, and application of barrier lubricant.
Skin of penis intact without edema. Self-adhesive condom catheter applied and connected to leg drainage bag. (Condom Catheter)
Voided 200 ml in leg bag. Denies discomfort from condom catheter.
Penis without swelling or discoloration.
C/O abdominal cramping. Patient used fracture pan appropriately.
Eliminated large, loose, light-brown stool in bedpan. No incontinence or straining noted. (Bedpan)
Patient reported urge to urinate and requested urinal. Sat on bedside with assistance and used urinal appropriately. Voided 240 ml of pale yellow, clear urine with faint urine odor. No incontinence or voiding problems noted. (Urinal)

Incontinent of large amount of liquid brown stool after breakfast.
Perineal area cleansed, and catheter care given. No inflammation of perineum or meatus. No secretions or encrustations at catheter insertion site. Urine in catheter tubing and bag light amber and clear, draining well. (Catheter Care)
Sitting up in chair for breakfast. Able to feed self 5 bites with encouragement. Reported, “That’s all I can do.” Remaining meal fed to patient. No coughing or difficulty swallowing noted.
Consumed 70% of meal. (Assisting with Meals)
Patient states she feels as though she cannot eat or drink anything; refused lunch. 300 mL PO fluid intake in 8 hours; temperature 38.5° C.
Urine dark amber, output 200 mL this shift. Physician notified. (Measuring I&O)
IV of 1,000 mL D5NS started in back of right hand with #18 angiocath.
Infusing per pump at 125 mL/hr without signs of swelling or redness.
Patient denies discomfort at site.
Fed half of pureed diet and 4 oz juice thickened to honey consistency, with much encouragement. Patient refused additional food. Tolerated diet with no coughing or aspiration noted. Unable to assist with meal.
Consumed 70% of meal. (Taking aspiration precaution)
Dentures cleaned as part of mouth care. Dentures intact, with no cracks. Gums and mucous membranes pink and intact.
Patient denies pain. (Cleaning Dentures)
Right great toe red, inflamed, and tender. Patient states this was first noted before admission, 1 week ago. Feet soaked for 10 minutes in warm water and dried thoroughly. Lotion applied. Instructed patient on appropriate foot care and continued observation of reddened area.
Patient is able to perform foot care independently at home and verbalized understanding of teaching. Toe inflammation reported to nurse in charge. (Nail and Foot Care)
Mouth care given. Mucous membranes moist, pink, no inflammation.
Lips dry, cracked. Moisturizing gel applied to lips. Patient unresponsive.
No gag reflex elicited. Oropharynx suctioned frequently during oral hygiene. (Oral Care for unconscious Pt)
Patient has repeatedly attempted to get out of bed. Remains disoriented to name, date, and location. Provided sitter and attempted to reorient repeatedly without success. Conferred with Dr. Lynch.
Patient must remain on bed rest postoperatively after spinal surgery.
Dr. Lynch here to assess patient, ordered belt restraint for next 24 hours. (Applying Restraints)
Belt restraint applied around waist. Patient able to breathe deeply without restriction. Skin under restraint is intact, without redness.
Patient able to move extremities. Initiating hourly observations of patient and temporary release of restraints. Family at bedside verbalized understanding of need for restraints postoperatively to reduce risk of disrupting surgical site.
Up and dressed; oriented to person but not time or place. Upset and crying when unable to call wife on telephone. Pacing in room.
Reoriented to place. Explained to patient that wife is due to visit later in afternoon, verbalizes understanding. Set radio to favorite talk show. (Restraint alternatives)
Participated for 15 minutes with ball toss to music at OT; then resting in rocking chair, smiling, and interacting socially with roommate.
Applied size medium, knee-length, elastic stockings to patient’s legs bilaterally. Before application, skin warm, pink, and intact; 2! dorsalis pedis and posterior tibial pulses. No edema noted. Patient denied pain and tenderness to touch in lower extremities. (Elastic Stockings)
Removed elastic stockings from patient’s legs for 30 minutes during skin care and assessment. On stocking removal, skin warm, pink, and intact; 2! dorsalis pedis and posterior tibial pulses. No edema noted.
Patient denied pain and tenderness to touch in lower extremities.
Stockings reapplied.
Ambulated 100 feet in hall with gait belt and assistance of one. Gait steady. States, “I am so tired and I feel a little bit dizzy. I don’t know if I can make it back to my room.” BP 118/66, HR 120, R 30. Placed in wheelchair and returned to room. (Ambulation with gait belt)
Back in bed with assistance. BP 130/78, HR 88, R 20. Denies dizziness.
Assisted to turn from back to left lateral position. Area of erythema approximately 3 cm in diameter noted over coccyx. Blanches easily.
Urged not to lie on back; tolerating side-lying position without complaints of discomfort. (Moving and Positioning a Pt in Bed)
Found lying on back. Assisted to turn to right side and supported with pillows. Coccyx remains reddened, blanches to fingertip pressure.
Reinforced importance of repositioning to patient and family members.
Medicated with two Tylenol with codeine #3 tabs PO 30 minutes before initiation of passive ROM exercises. Exercised patient’s left knee while in bed. Achieved 40 degrees flexion. Joint moved smoothly with mild, normal resistance, and displayed no crepitus, swelling, redness, or heat. Patient reports no pain on joint ROM and says “It wasn’t as hard as last time.” Vital signs remained within normal limits. (ROM Exercises)
Transferred patient from bed to stretcher with slide board and assistance of two. Cooperative and able to assist with encouragement. (Bed to a Stretcher)
Patient returned to room on stretcher after X-rays were taken.
Stated, “I feel tired and dizzy. I think I need a nap.” Needed assistance of two with transfer back to bed. Patient unable to assist as much as with transfer to stretcher. Vital signs remained within normal limits.

Transferred patient from bed to chair with transfer belt and assistance of one. Full weight bearing, cooperative, and able to stand erect and pivot with assistance in balancing. (Bed to a wheelchair)
Asked to return to bed. Stated, “I’m so tired, I just can’t sit up any more.” Needed assistance of two with transfer back to bed. Knees buckled and legs shook during attempt to stand. Vital signs remained within normal limits.
Transferred patient from bed to wheelchair, using hydraulic lift.
Transfer required one assistant. Before transfer, patient reported extreme weakness and pain at 3 on 0-10 scale, but no dizziness.
Patient is highly motivated to “get out of bed” and can follow directions.
After transfer, patient reports no change in weakness or pain.
Vital signs are unchanged. (Hydraulic Lift)
Applied SCD sleeves to patient’s right and left legs. Used large, thigh-length SCD sleeves. Before application, skin had no edema and was warm, pink, and intact; !2 dorsalis pedis and posterior tibial pulses. Patient denied pain and tenderness to touch in lower extremities. (Sequential Compression Device)
Removed SCD sleeves from patient’s legs for 30 minutes during bed bath and assessment. On SCD removal, skin had no edema and was evenly warm, pink, and intact; !2 dorsalis pedis and posterior tibial pulses. Patient denied pain and tenderness to touch in lower extremities. Moaning, moving about in bed frequently; reports severe frontal headache (7 on scale of 0 to 10) worsened by bright lights. Headache is constant. States cannot sleep. Tylenol #3, 2 tablets administered orally. Participated in deep breathing exercise and a 10-minute progressive relaxation exercise. (Assessing Pain)
States frontal headache is relieved (3 on scale of 0 to 10), now only intermittent. Lying supine in bed, quiet, eyes closed.
Respirations 24, regular and shallow. Radial pulse 84. Temperature
36.8° C tympanic. Blood pressure 104/56 right arm, supine. Skin pale, pink, warm, and dry. O2 at 2 L/min by nasal cannula. Physician present and aware of vital signs. (Assessing Respiration)
Apical pulse 94 and irregular. Respirations 24, regular. Temperature
36.8° C tympanic. Blood pressure 104/56 right arm, supine, dropping from baseline of 124/72. Reports dizziness. Denies dyspnea, nausea, or pain. Skin pale. Physician notified. Orders received. (Assessing Apical Pulse)
Apical pulse 117. Left radial pulse 112, weak, thready. Pulse deficit 5.
Respirations 24, regular. Temperature 36.8° C tympanic. Blood pressure 104/56 right arm, supine. Skin pale, warm, and dry.
Denies nausea, but complains of dyspnea, fatigue, and palpitations.
Physician notified. Orders received. (Assessing Apical_Radical Pulse)
Radial pulse 112, weak, thready. Respirations 24, regular. Temperature
36.8° C tympanic. Blood pressure 104/56 right arm, supine, dropping from baseline of 124/72. Reports dizziness. Denies dyspnea, nausea, or pain. Skin pale. Physician notified. Orders received. (Assessing Radical Pulse)
5’8” 170 lb. (Assessing Height and Weight)
Continuous pulse oximetry on right index finger. Sensor relocated to left index finger. Capillary refill R ! L, 2 seconds. Skin intact, no redness noted. SpO2 93% with 3 L O2 via nasal cannula. ABG SaO2
91% at 1600. RR 24, patient denies dyspnea, remains in semi-Fowler’s position. (Assessing O2 Sat with pulse oximetry)
Blood pressure 104/56 right arm, supine, dropping from baseline of
124/72. Radial pulse 112, weak, thready. Respirations 24, regular.
Temperature 36.8° C tympanic. Reports dizziness. Skin pale.
Denies dyspnea, nausea, or pain. Physician notified. Orders received. (BP wt 1 step Method)
Blood pressure 104/56 right arm, supine, dropping from baseline of
124/72. Radial pulse 112, weak, thready. Respirations 24, regular.
Temperature 36.8° C tympanic. Reports dizziness. Skin pale.
Denies dyspnea, nausea, or pain. Physician notified. Orders received. (BP wt 2 Step)
Temperature 100.6° F tympanic. Skin warm and flushed, mucous membranes dry. Reports generalized aching. Denies nausea, diarrhea, or pain. Physician notified. Orders received, and administered acetaminophen 325 mg P.O. (Tympanic Temperature)
Temperature 99.0° F tympanic. Reports reduced aching.
Temperature 100.6° F oral. Skin warm and flushed, mucous membranes dry. Reports generalized aching. Denies nausea, diarrhea, or pain. Physician notified. Orders received, and administered acetaminophen 650 mg P.O. (Temp wt Electronic Thermometer)
Temperature 99.0° F oral. Reports reduced aching.
Inserted 16-Fr NG tube into left naris, advanced to 500-cm mark on NG tube. Patient able to swallow during insertion and states he is comfortable after procedure. NPO status acknowledged. 50 ml of light-green secretions aspirated with a pH of 3.0. Tube secured with tape and attached to low intermittent suction. Bowel sounds absent. (Inserting a NG Tube)
NG feeding tube placement confirmed. Aspirated 50 ml of residual volume
(pH 3.0) and returned it to stomach. Active bowel sounds in all four quadrants. Abdomen soft and nondistended. Full-strength Osmolite hung on infusion pump set at 60 ml/hr. Infused freely and without any difficulty.
Head of bed elevated 45 degrees. Lungs clear to auscultation.
Patient denies abdominal discomfort. (Proving Enteral Feeding)

Removed NG tube without difficulty. Mouth care provided after removal.
Bowel sounds auscultated in all four quadrants before and after removal.
Abdomen remains soft and nontender. Skin at left naris red and intact.
Nasal area cleaned and dried, and lotion applied. Patient denies abdominal discomfort. Instructed patient to notify nurse of any nausea or abdominal discomfort. (Removing a Feeding Tube)
Colostomy stoma is ½” in diameter, round, slightly swollen, and red.
Peristomal skin intact, no irritation noted. Stoma draining 700 ml dark-brownish liquid stool. Active bowel sounds in all quadrants.
Two-piece ostomy pouching system with hydrocolloid skin barrier in place without leaks. Patient has not yet looked at stoma. ET nurse began instruction of patient’s ostomy self-care technique. (Pouching a Colostomy)
Ileal conduit stoma shiny, moist, and beefy red. 250 ml clear yellow urine with whitish mucus present in pouch. Peristomal skin intact, no irritation noted. Suture line dry and approximated. Urinary pouch with antireflux flap changed with patient assisting. Patient correctly reapplied pouch with verbal cues. Patient verbalized understanding of procedure for emptying pouch. Family observed procedure, verbalized anxiousness about assisting patient. (Pouching a Ureterostomy)
#16-Fr NG tube present in left naris, attached to low intermittent suction.
Tube secured with tape. Draining scant amounts of green liquid. Position of tube verified, pH 3.0. Irrigated with 30 ml NS. Withdrew 20 ml light-green
"uid at end of irrigation. Patient stated he had been feeling mild nausea.
Bowel sounds absent, abdomen soft and nondistended. NPO status acknowledged, denies discomfort. (Managing a Ng Tube)
Increased volume of light-green gastric secretions draining from NG tube at low suction. Patient states he no longer feels nauseated. Abdomen remains soft, nondistended, and nontender.
Complains of continuous burning incisional pain, rated as a 7 on a scale of 0 to 10. HR 102, R 20, BP 126/78. Morphine 5 mg given by IV push.
Repositioned onto right side, lotion applied to lower back. (Managing Pain)
States pain is “better,” rated as a 3 on a scale of 0 to 10. HR 88, R 18,
BP 120/72.
Received from PACU via stretcher. Alert and oriented X3. Abdominal dressing dry and intact. IV infusing with lactated Ringer’s at 150 ml/hr into left forearm without redness at insertion site. Foley catheter draining clear amber urine. Abdomen soft, no bowel sounds present. Lungs clear to auscultation. BP 110/60, HR 98, R 22, SpO2 96%. Remains NPO.
Denies discomfort at this time. (Proving Postoperative Care)
Verified that patient has been NPO since midnight. Dentures, gold metal ring, and wallet given to patient’s wife. Fleets enema given, resulting in large amount of soft brown stool. Elastic stockings applied. Stated he did not take his morning dose of 20 units of NPH insulin. Bedside blood glucose
110. Dr. Thompson notified. 10 units of NPH insulin administered subcutaneously per order. IV of 5% dextrose and ½ normal saline started in right hand with #18 angiocath per order. Voided and taken to OR on stretcher by transporter. (Preparing a Pt for Surgery)
Preoperative teaching completed. Instructed patient and daughter on continued need to be NPO; routine events to expect in OR and recovery room; presence of oxygen; IV fluids; postoperative drains; and postoperative activities including turning, coughing, deep breathing, incentive spirometry, and leg exercises. Daughter expressed concern about her mother being able to care for herself at home after surgery. Home health nurse contacted to see patient before discharge. Physician notified regarding possible need for home health or extended care referral postoperatively. (Promoting Family Support & Participation)
Preoperative teaching completed. Instructed patient on postoperative activities, including deep breathing, incentive spirometry, coughing, splinting, turning and sitting, and leg exercises (ankle rotation and leg extension and flexion). Reviewed pain management by PCA pump.
Patient can perform all activities by herself correctly. (Teaching Postop Exercises & Pain Mang)
Alert and oriented. Respirations 20, even and nonlabored. Lungs clear to auscultation. Mucous membranes pink. O2 4 L/min by mask with humidification. SpO2 94%. Fluids encouraged as tolerated. Resting quietly and comfortably. (Applying NC or Face Mask)
Reddened area noted behind right ear. Foam ear protector added to oxygen tubing.
Denies discomfort from tubing. No further redness noted behind ears.
Discussed purpose of oxygen therapy with patient. Applied O2 at 2 L per nasal prongs. Posted Oxygen in Use sign. Discussed home safety for oxygen use, including no smoking. Patient reports less shortness of breath with O2. (Ensuring O2 Safety)
Observed sleeping, without snoring. Respirations 18, even and non-labored.
Lungs clear to auscultation. SpO2 is 94%. No jerking movements noted.
CPAP continues per face mask with good seal at 7.5 cm H2O. Nonproductive, dry cough occasionally. (Maintaining an Airway)
Occasional productive cough. Patient restless, respirations labored.
Requires hourly nasotracheal suctioning with 12 Fr catheter. Moderate amount (5 ml or less) of thick, yellow sputum with no odor. Lungs clear after cough and suctioning. SpO2 92% to 94%. Respirations nonlabored after suctioning, 14/minute. Heart rate: 88 before suctioning, 112 during suctioning, 84 after suctioning. Patient states he is able to breathe easier, less congested. (Performing Nasotracheal Suctioning)
Occasional productive cough. Requires hourly oropharyngeal suctioning with Yankauer catheter. Moderate amount (5 ml or less) of thick, yellow sputum with no odor. Lungs clear after cough and suctioning. SpO2 92% to
94%. Respirations nonlabored after suctioning, 14/minute. Family observed procedure, no concerns voiced. (Performing Oropharyngeal Suctioning)
Respirations 18, even and easy. Lungs clear to auscultation. Trach tube and inner cannula patent, clear of secretions. Trach care done, ties secure, small amount of clear drainage around stoma. Patient tolerated procedure without discomfort. Skin around trach site slightly reddened. Afebrile. 37.0.
Dr. Levin notified. (Providing Tracheostomy Care)
Alert and oriented. Respirations 20, even and slightly labored. Lungs clear to auscultation. Mucous membranes pink. O2 @ 2 L/min by nasal cannula.
SpO2 90%, physician notified. Oxygen increased to 4 L/min by nasal cannula per order. (Setting O2 Flow Rates)
Occasional productive cough. Requires hourly suctioning via tracheostomy tube with 12 Fr catheter. Moderate amount (5 ml or less) of thick, yellow sputum with no odor. Able to use Yankauer catheter to suction mouth with clean technique afterward. Lungs clear after cough and suctioning. SpO2
92% to 94%. Respirations nonlabored after suctioning, 14/minute. Heart rate 84 and regular, no significant change after suctioning. Patient tolerated procedure and is breathing more easily. (Suctioning an Artificial Airway)
Obtained midstream urine specimen of 130 ml dark amber urine with no odor. Specimen sent to hospital lab for C&S testing. Patient tolerated specimen collection procedure with no problems. Reports frequent urge to void, burning sensation with voiding, and voiding small amounts. (Collecting Midstream Urine Specimen)
Complains of pain from surgical site. Dressing change reveals 4-cm wound separated at top with yellow purulent drainage. Lower half of incision remains well approximated. Aerobic culture obtained from drainage site and sent to lab as ordered. Patient tolerated procedure without increase in discomfort; denies need for analgesia at this time. (Collecting Specimen for a Wound Culture)
Suctioned 13 ml thick green sputum; immediately transported to hospital lab for C&S. Complains of mild dyspnea during procedure. Respirations 26.
Rales noted bilaterally in all lung fields. Color pink, skin warm and dry. (Collecting a Sputum Specimen)
Blood glucose 110 mg/dl. No sliding-scale insulin administered. (Performing Blood Glucose Testing)
Blood glucose 240 mg/dl. Regular insulin (4 units) administered subcutaneously as prescribed per sliding scale. Denies pain at puncture site.
Verbalized importance of blood glucose testing in managing his diabetes.
Large, liquid, dark brown stool tested negative for occult blood. (Fecal Occult Blood Testing)
Aspirated 5 ml of dark brown fluid with coffee-ground appearance from NG tube. pH was 3.5. Fluid tested positive for occult blood. Physician notified.
Patient informed that test is to be repeated x2. (Fecal Occult Blood and pH Testing)
Obtained 40 ml of clear yellow urine by double-voided technique. Multistix test strip was negative for glucose, ketones, protein, and blood. pH 6.2. (Screening Urine for Chemical Properties)
Suprapubic catheter draining 100 ml of clear yellow urine in 2 hours.
Dressing removed from suprapubic catheter site. Small amount of dark-brown drainage on gauze. No redness, edema, drainage, or odor at the site. Cleansed with normal saline solution and dressed with drain dressing. Denies pain at insertion site. (Caring for a Suprapubic Catheter)
Bladder distended. C/O full sensation but unable to void. 16 Fr Foley catheter inserted without difficulty, 400 ml of clear yellow urine returned.
Balloon inflated with 10 ml sterile solution. Catheter attached to bedside drainage. Denies discomfort or pain. (Inserting Indwelling catheter for Female Pt)
C/O suprapubic pressure, bladder distended. Has not been able to void since returning from procedure at 1400. 18 Fr Foley catheter inserted without difficulty, 375 ml of clear, dark yellow urine returned. Balloon in"ated with 10 ml sterile solution. Catheter attached to bedside drainage bag. Denies discomfort or pain; states suprapubic pressure is relieved. (Indwelling Catheter for a Male Pt)
Lower abdomen soft and flat. Catheter drainage of 225 ml of bright-red urine with moderate-size dark bloody clots. 3000 ml of NS infusing at 60 gtt/minute. Patient rates bladder spasms at 2 on 0-to-10 scale. Lying on left side, knees flexed. (Irrigating a Urinary Catheter)
Temperature 100.2° F, reports suprapubic discomfort. Urine dark amber, cloudy, and foul-smelling. Obtained 3 ml of urine via port in indwelling catheter using aseptic technique. Urine specimen placed in sterile container and sent to laboratory for STAT culture and sensitivity testing as ordered. (Obtaining Sterile Urine)
Test results called to Dr. Ferguson, antibiotic order obtained.
Voided 200 ml clear urine without discomfort. Catheterized with a #14 Fr straight catheter for a residual of 125 ml of clear yellow urine. Reported minimal discomfort during the procedure but expressed concern about how many more times this procedure needs to be done. (Performing Intermittent Straight Catheter)
Indwelling urinary catheter removed without difficulty after deflating balloon. Instructed on need to increase fluids and measure first voiding.
Informed that first void may be uncomfortable and is expected within 6 to 8 hours. Instructed to report signs and symptoms of UTI. (Removing a Indwelling Urinary Catheter)
Voided 350 ml of clear, odorless, yellow urine without difficulty.
Denies discomfort.
Abdominal dressing dry and intact. Skin around dressing is pink with no swelling, bruising, discoloration, or excessive warmth. Patient denies pain on palpation and appears comfortable during assessment. (Assessing Wounds)
Removed initial surgical dressing per physician’s order. 3” wound is red with granulation tissue. Suture line is approximated, Steri-Strips intact. Small amount of serous drainage, no foul odor. Sterile dressing applied.
Sacral pressure ulcer, stage II, 2 × 3 cm irregular shape. Base of wound covered 100% by granulation tissue, no drainage present. Surrounding skin intact. Wound cleansed with NS and hydrocolloid dressing applied. On a low–air-loss overlay, repositioned q2 hr as condition allowed. Nutritional supplements offered. Patient and family have read AHCPR booklets
Preventing Pressure Ulcers: A Patient’s Guide and Pressure Sore Treatment and are practicing positioning technique. (Caring for Pressure Ulcers)
Changed wet-to-damp dressing on R medial malleolus using clean technique. First layer of gauze had 1.5-cm spot of light-yellow drainage.
Ulceration 4 cm x 2 cm, 0.5 cm deep, wound bed of pink tissue with pinpoint spots of yellow drainage along the border; erythema noted on surrounding skin. Drainage appears more yellow today. Physician notified.
One moist 4 x 4 gauze applied to wound bed, covered with a dry 4 x 4 gauze, and wrapped with Kling gauze. Reported 0 pain on a scale of 0 to 10. (Changing a Dressing)
On dressing removal, 3” abdominal wound is red with small, dime-sized area of granulation tissue and crusts. Scant amount of serous fluid with no odor. Irrigated wound with 30 ml of normal saline using a sterile 35-ml syringe and soft angiocatheter. After irrigation, wound appears clean with no crusts or debris. Applied 4 × 4 dressing. Patient denies pain and appeared comfortable during irrigation. (Irrigating Wounds)
Dark red drainage (300 ml) emptied from Hemovac. Dressing changed around insertion site. Site is pink. 2-ml spot of serosanguineous drainage noted on dressing. Drain remains secured with one suture. 4 × 4 drain dressing applied around drain site. No reports of discomfort with dressing change. (Using Wound Drainage Systems)
Small, deep purple, soft, and nontender bruise approximately 1 cm noted on LLQ of abdomen when 0900 dose of heparin administered. Urine clear; stool negative for occult blood. (Administering a Subcutaneous Injection)
PPD injection site in left lower forearm; approximate 6 mm diameter bleb formed at injection site marked with skin pencil. Patient instructed not to wash off the skin pencil and to return to the clinic in 48 hours to read the results. Patient remained in clinic waiting room for 20 minutes and was discharged after no allergic response was noted. (Administering an Intradermal Injection)
Patient states abdominal incision pain is an 8 on a 0 to 10 pain scale.
Morphine sulfate 10 mg IM given as ordered in right ventrogluteal site.
Repositioned patient for additional comfort. (Intramuscular Injection)
Patient states he is more comfortable and that pain score is now a 4 on a 0 to 10 pain scale. Injection site clean, intact, no erythema.

Instructed in insulin storage and use. Patient correctly identified insulin to use and injection site rotation pattern. Patient demonstrated self-administration of insulin and blood glucose monitoring.
Patient accurately described signs and symptoms of hypoglycemia and hyperglycemia. (Preparing Insulin)
Redness noted, and patient complains of tenderness and burning at IV site.
Phlebitis score of 4. Charge nurse notified and IV discontinued. 21G, 1” catheter tip intact. Patient tolerated procedure well. Warm cloth applied to
IV site and arm elevated on pillow. N. Jenkins notified about IV discontinuation. (Discontinuing Intravenous Therapy)
IV inserted with 20G Insyte catheter into right arm cephalic vein with first attempt. Patient tolerated procedure without difficulty. Stated insertion was not painful and “felt !ne” afterward. (Venipuncture and Initiating an Infusion)
D5W infusing by pump at 100 ml/hr. Infiltration and phlebitis scores of 0.
T 99.6°, P 70, R 15, BP 128/84. Patient reports pain at right forearm IV site.
Site appears swollen, warm, and red. Phlebitis scale 2. Infusion is 100 ml behind volume expected at this time. No kinks in tubing, no leaks or bleeding at tubing/catheter hub. Dressing intact. Infusion discontinued.
Extremity elevated and warm towel applied. Patient reports less pain.
IV restarted in left forearm without difficulty on first attempt. (Troubleshooting Intravenous Infusion)
Administered 20 mg of Lasix by IV bolus through saline lock. Flushed with 2 ml NS before and after drug administration. Patient reported “cold feeling” but no discomfort during administration. (Adm. Med. By Intravenous Bolus)
During initial 5 minutes of infusion of 1 g Vancomycin in 100 ml D5W, complained of sudden onset of “can’t catch my breath,” clutching at throat; high-pitched inspiratory stridor noted. Macular rash generalized over face and upper extremities noted. Vancomycin stopped immediately, IV fluids infused at 125 ml/hr. VS 98/60, 120, 26. Dr. Wills notified. Epinephrine 0.5 mg
IV push given, with inspiratory distress subsiding within 30 seconds of administration. Vancomycin recorded on patient’s medical record; new. (Adm. Med. By Intravenous Piggyback)
VS 120/84, 96, 18. States “breathing feels normal.” Expressing some fear over
“how fast it came on.” Signi"cance of allergy, implications for future administration, and noti"cation of dentists, physicians, and other health care providers discussed. Aware that vital signs will continue to be monitored and to notify nurse immediately for any signs of respiratory.
During initial 5 minutes of infusion of 500 mg Levaquin in 20 ml D5W, complained itching. Macular rash generalized over face and upper extremities noted. Levaquin stopped immediately, IV fluids infused at 125 ml/hr. VS 98/60, 120, 26. Dr. Barnett notified. Allergy noted in medical record, and new allergy band applied. (Adm. Med. By Mini-Infusion Pump)
VS 120/84, 96, 18. States itching subsided. Expressing some fear over
“how fast it came on.” Significance of allergy, implications for future administration, and notification of dentists, physicians, and other health care providers discussed.
IV dressing became wet during shower; new transparent dressing applied; insertion site without redness, edema, or drainage. Infusing at 125 ml/hr.
No report of discomfort or tenderness in the hand or extremity. (Changing IV Dressing)
1000 ml D5W infusing at 125 ml/hr. IV site without redness or edema; IV dressing dry and intact. Patient states there is no pain or discomfort at the site. (Changing IV Tubing and Fluids)
Right cephalic site IV patent and infusing D5½NS at 125 ml/hr without difficulty per infusion pump. Phlebitis and infiltration scores of 0. IV dressing intact. Patient denies any IV site discomfort. (Regulating an IV Infusion)
Right cephalic site IV patent and infusing 500 D5W at 63 ml/hr without difficulty by infusion pump. Phlebitis and infiltration scores of 0. IV dressing intact. Patient denies any IV site discomfort. (Using an Infusion Pump)
Reports pain in both ears. Redness noted on external ear structures and ear canals. Removed scant, yellow drainage with cotton-tipped applicator.
Eardrops instilled in each ear as ordered. Patient resting. (Adm. Eardrops)
Patient reports dry, irritated eyes. Redness noted on both sclerae. Artificial
Tears 2 drops instilled into each eye after eyes cleansed. Patient states discomfort relieved after eye drops administered. (Adm. Eye Meds.)
Apical pulse 50 regular; complains of nausea. Digoxin held and Dr. Jay notified. (Adm. Oral Med.)
Skin on the back of both hands and wrists is dry, red, and flaky. Complains of itching. Hydrocortisone cream 1% applied sparingly to affected areas as prescribed. (Adm. Topical Meds.)
Reported that itching is relieved.
Removed previous nitroglycerin dose from left side of patient’s upper back.
Skin on back and chest is clean, dry, and intact. Applied 1½” of nitroglycerin
(Nitro-Bid) paste to patient’s left upper chest using dose-measuring paper. (Applying an Estrogen patch or Nitroglycerin Paste)
Complains of constipation. Has not had bowel movement for 3 days.
Abdomen slightly distended and !rm. Dulcolax suppository x 1 given per rectum as ordered. Expelled large, hard, dark-brown stool. States feeling much relieved. Encouraged to drink more fluids, choose high-fiber foods from menu, and ambulate as much as possible to prevent further problems.
Verbalized understanding and willingness to comply. (Adm. a rectal Suppository)

Patient is coughing violently and reports difficulty breathing. Wheezing noted in all lung fields. Respirations 32/min, pulse 98. Patient self-administered DPI correctly with no verbal coaching. Reported relief from shortness of breath within 1 minute. Respirations 24/min, pulse 96.
Lung fields clear of wheezing. (Using a Dry Power Inhaler)
Coughing violently and reports difficulty breathing. Wheezing noted throughout all lung fields. R 32, P 98. Pulse oximetry of 92%, diaphoretic, and anxious. Self-administered MDI (2 puffs) correctly with no verbal coaching. Reported relief from shortness of breath within 1 minute. (Using a Metered-Dose Inhaler)
Reports breathing more at ease, R 24, P 94. Pulse oximetry of 96%. Less wheezing heard on auscultation. Resting calmly.
Lipid emulsion infusion initiated at 2000 ml/day, as ordered. Weight stable at 52 kg for past 48 hours. No redness, swelling, pain, or drainage at insertion site. IV dressing dry and intact. Phlebitis score of “0”. Vital signs stable. Blood glucose 106 mg/dl. Patient denies discomfort from catheter.
No nausea. Voided 220 ml clear yellow urine. (Providing a Liquid Infusion)
Weight stable at 58 kg for 1 week. No redness, swelling, pain, or drainage at central line insertion site. Vital signs stable. Blood glucose 110 mg/dl.
Patient denies discomfort from catheter. Bottle #2 of 3-in-1 TPN infusion continues at 2000 ml/day as ordered. Taking sips of water without problems. Urine output adequate at 700 ml this shift. (Providing Total Parenteral Nutrition)
Patient reported pain score of 8/10. Percocet 5 mg P.O. given for complaint of knee pain. Repositioned patient to left side for comfort. (Documenting Med Administration)
Patient states pain score is now a 4/10 and is more comfortable.
Patient reports allergy to amoxicillin with rash and GI upset. Amoxicillin withheld and Dr. Gupta notified. (Handling Variations in Med. Adm.)
Dosage of Humulin R clarified with MD before administration. Verified dosage of 15 units and administered sub-q in left upper arm before breakfast. (Preventing Med. Errors)
Proximal lumen of right subclavian triple-lumen catheter accessed to obtain blood for culture and sensitivity testing. No redness, drainage, or swelling at site. Stabilization device intact. All ports with good blood return and !ush without difficulty. IV fluids infusing per distal port at 100 ml/hr per infusion pump without difficulty. Middle port attached to CVP monitoring. Injection cap to proximal port changed. (Drawing blood and Adm. Fluid)
Central line dressing change to right subclavian triple-lumen catheter per protocol. No redness, drainage, or swelling at site. Stabilization device intact. All ports with good blood return and flush without difficulty.
Injection cap to proximal port changed. (Performing Dressing Care for a Central Venous Acess Device)
T 99.6°, P 70, R 15, BP 128/84. Patient reports pain at right subclavian triple-lumen catheter. Site appears swollen and red. Infusion is 100 ml behind volume expected at this time. Dressing intact. Dr. Gallen notified. (Troubleshooting Vascular Access Device)
As ordered, blood cultures drawn per CVAD.