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  • FDAR

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    Roxanne Ganayo Claver
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    The document summarizes a patient's post-operative care following excision of a sebaceous cyst on their upper back. On the morning of August 5th, the nurse monitored the patient's vital signs, assessed the surgical site for signs of infection, and encouraged hand washing and a protein-rich diet. No issues were observed. Later that morning, the patient reported mild pain and restlessness, so the nurse provided comfort measures and repositioning. By noon, the patient reported not sleeping well, so the nurse encouraged comfort measures like warm baths and positioning assistance, which helped the patient sleep well.

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    The document summarizes a patient's post-operative care following excision of a sebaceous cyst on their upper back. On the morning of August 5th, the nurse monitored the patient's vital signs, assessed the surgical site for signs of infection, and encouraged hand washing and a protein-rich diet. No issues were observed. Later that morning, the patient reported mild pain and restlessness, so the nurse provided comfort measures and repositioning. By noon, the patient reported not sleeping well, so the nurse encouraged comfort measures like warm baths and positioning assistance, which helped the patient sleep well.

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    791 visualizzazioni2 pagine

    FDAR

    Caricato da

    Roxanne Ganayo Claver
    The document summarizes a patient's post-operative care following excision of a sebaceous cyst on their upper back. On the morning of August 5th, the nurse monitored the patient's vital signs, assessed the surgical site for signs of infection, and encouraged hand washing and a protein-rich diet. No issues were observed. Later that morning, the patient reported mild pain and restlessness, so the nurse provided comfort measures and repositioning. By noon, the patient reported not sleeping well, so the nurse encouraged comfort measures like warm baths and positioning assistance, which helped the patient sleep well.

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    di 2

    FDAR

    DATE/TIME FOCUS DATA, ACTION, RESPONSE


    8/5/13
    8am

    Risk for infection r/t surgical site
    excision

    D > post op excision of
    sebaceous cyst
    Post op dressing @ left
    upper back
    VS:
    T: 36.4 PR: 81
    BP: 110/80 RR: 20

    A > monitored VS
    Assessed for the surgical
    site for any foul odors,
    swelling and puss
    Encouraged pt. as well as
    watcher to do hand
    washing every now and
    then
    Encouraged to eat foods
    rich in protein when able

    R > absence of foul odors,
    swelling and puss
    Dressing was dry and
    intact
    10:00 am Mild Pain D > post op excision of
    sebaceous cyst
    Restlessness
    Irritability

    A > monitored VS
    Provided comfort
    measures
    Placed pt. on a side-lying
    position

    R > dili na kayo sakit ang akong
    likod as verbalized by pt.
    Left on bed asleep

    12NN Promotion of comfort and Sleep D > wala ko nakatulog ug
    tarong mam as verbalized
    by pt.
    Lethargic
    Irritability

    A > provided comfortable
    beddings such as a pillow
    Encouraged comfort
    regimens like warm bath
    Encouraged position of
    comfort with assistance

    R > nakatulog na ko ug tarong
    tarong as verbalized by the
    pt.

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