Make a narrative charting based on the situation provided. On April 26, 2022, You have a 7 am-7 pm shift at Laoag City General Hospital; you are doing your nurse's rounds in the female-surgical ward in room 208. Mrs. Medina, a 68- year-old female, was admitted yesterday for Ruptured appendicitis and underwent "Emergency Appendectomy 10 hours ago. She appears weak
Read and analyze the scenario below. Make a narrative charting based on the situation provided.
On April 26, 2022, You have a 7 am-7 pm shift at Laoag City General Hospital; you
are doing your nurse's rounds in the female-surgical ward in room 208. Mrs. Medina, a 68-
year-old female, was admitted yesterday for Ruptured appendicitis and underwent "Emergency
Appendectomy 10 hours ago. She appears weak but coherent as she lies on her bed in a semi-
fowlers position with intact wound dressing and is currently under oxygen therapy via nasal
cannula regulated to 2 liters per minute. An Indwelling Folley catheter attached to the urine
bag is currently intact and draining to amber-colored urine at a 300 cc level. Her ongoing IVF
is D5NSS 1 L, inserted at her right forearm at 250 cc level when you checked it, you regulate
it at 40 gtts/min and will change it with the same IVF at the same rate after 2 hours. You take
her vital signs at 8 am, you notice that the patient feels warm, appears flushed or sweating more
than usual, and has a body temperature of 38 degrees Celsius, Pulse of 118, Respirations 24;
Blood Pressure 100/80. You check the patient's chart, do TSB( Tepid Sponge Bath) to the
patient, and give Paracetamol 300 mg IV for fever > 37.8 degrees Celsius as ordered. Her
dressing on her operative site is clean, dry, and intact. At 10:00 am, you observed that the client
was in pain because she was guarding her operative site, had a facial grimace, and rated her
pain as "9" on a scale of 0-10. You check the client's chart and administer her medication for
pain as ketorolac 1 amp SIVP ( Slow IV push) as needed for severe pain as ordered. You
advised the client to relax and to do a deep breathing exercise. Early ambulation is advised to
the patient. At 10:30 am, Dr. Dela Merced checked on Mrs. Medina's postoperative status. He
assessed the wound site and asked questions regarding how she was feeling. You informed the
doctor that the patient had already passed gas once but had no bowel movement. Dr. Dela
Merced's new orders are as follows: He shifted the client's diet from NPO to a clear liquids
diet, For CBC PC stat, and strictly I and O monitoring for every shift, shifted O2 inhalation via
n.c at 2 liters per minute as needed for the difficulty of breathing, IVF to follow of PLR 1L
every 12 hours for 3 cycles. At 11:10 am, you went back to the client's room to check her relief
from pain and rated her pain as 2 on a scale of 0-10. After 4 hours, you rechecked the body
temperature and went down to 37.5 degrees Celsius. At 5 pm, you changed IVF, laboratory
results in and referred to residents on duty.No other complaints were noted throughout the shift.
All orders have been carried out, and other medications have been administered during your
shift.
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