1520 - C/of upper abdominal pain; Intermittent and sharp; Rated 4/10; Denied need for intervention; Psychosocial: Accepts situation and facial expressions are appropriate; Family support available and patient receives visitors; Able to communicate without assistance; Education: Report on any teaching completed. For example: health status, health promotion, tests/procedures/therapies, medication, nutrition, equipment. Provide Erickson's developmental stage and any pertinent information concerning the stage for that patient. Sleep: (7/4) Complains of not sleeping due to flank pain during the night. (7/5) Stated sleep was improving. Reported she feels rested as long as her pain is controlled.
Drains, tubes, equipment in use. Chart on any equipment currently being used Vascular access: IV site free of redness, swelling, pain, bleeding, drainage, IV patent, dressing occlusive and intact; Right forearm; NS @ 120 mL/hr; Change date: _____ Sample adapted from Reference: Perry, A. G., & Potter, P. A. (2010). Clinical Nursing Skills & Techniques (7 th ed.). St. Louis, MI: Mosby Elsevier.
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- Fall '19
- pulse, Defecation