The document contains notes from a nurse on their care of a patient experiencing acute pain after a hysterectomy surgery. On July 18 at 8:00 am, the nurse assessed the patient and found signs of pain like an 8/10 on the pain scale. The nurse monitored vitals, encouraged relaxation techniques, adequate fluid intake and rest, administered pain medication as ordered, and reassessed the patient at 12 pm when the patient reported their pain had decreased to a 5/10 scale.
The document contains notes from a nurse on their care of a patient experiencing acute pain after a hysterectomy surgery. On July 18 at 8:00 am, the nurse assessed the patient and found signs of pain like an 8/10 on the pain scale. The nurse monitored vitals, encouraged relaxation techniques, adequate fluid intake and rest, administered pain medication as ordered, and reassessed the patient at 12 pm when the patient reported their pain had decreased to a 5/10 scale.
The document contains notes from a nurse on their care of a patient experiencing acute pain after a hysterectomy surgery. On July 18 at 8:00 am, the nurse assessed the patient and found signs of pain like an 8/10 on the pain scale. The nurse monitored vitals, encouraged relaxation techniques, adequate fluid intake and rest, administered pain medication as ordered, and reassessed the patient at 12 pm when the patient reported their pain had decreased to a 5/10 scale.
The document contains notes from a nurse on their care of a patient experiencing acute pain after a hysterectomy surgery. On July 18 at 8:00 am, the nurse assessed the patient and found signs of pain like an 8/10 on the pain scale. The nurse monitored vitals, encouraged relaxation techniques, adequate fluid intake and rest, administered pain medication as ordered, and reassessed the patient at 12 pm when the patient reported their pain had decreased to a 5/10 scale.
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DATE/TIME FOCUS DATA ACTION RESPONSE
July 18, 2022 D: Recieved patient lying on
8:00 am bed awake but appears weak and in pain. She has an Acute pain secondary to onging IVF of D5LRS, surgical procedure dripping well with the ff. Vital (hysterectomy) signs of: BP: 100/70 mmHg PR: 105 cpm RR: 40 bpm Temp: 37 C (+) Irritability >facial grimaing >Pain scale of 8/10 > on the first day post-op A: > assessed pain regularly noting characteristics, location, and intensity > identified specific activity limitations > repositioned the patient as indicated >monitored and recorded I&O accurately > encoureged to do relaxation technique like deep breathing exercise > encouraged to increased fluid intake > encouraged patient to eat iron rich foods such as green leafy vegetables, red meat, fish , eggs etc. >encouraged safety at all times > provied divertional activities like watching t.v or reading books > provided adequete rest periods. > administered analgesic medication as ordered.
July 18, 2022 R: Resting in bed “medyo
12 pm Acute pain secondary to nabawasan po ang sakit ng surgical procedure sugat ko” with the pain scale (hysterectomy) of 5/10