Nurses Notes 1100 Client Received From Pacu Initial Vital Signs Recorded Client Drowsy But Responds To Verbal Stimul 1 (84.5 KiB) Viewed 43 times
Nurses Notes 1100 Client Received From Pacu Initial Vital Signs Recorded Client Drowsy But Responds To Verbal Stimul 2 (26.12 KiB) Viewed 43 times
Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort.
Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. . • Neurological assessment • Incisional drainage • Urinary output Reported pain level • Gastrointestinal assessment • Vital signs .
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