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FDAR

The document is a post-operative care record for a patient who underwent a laminotomy and discectomy surgery. It documents the patient's care over two days, including encouraging deep breathing exercises, monitoring pain levels and administering warm compresses, changing the IV site, and ensuring the dressing remained dry with minimal fluid drainage. On the second day, the patient's temperature was normal and pain had reduced to a level of 2/10 at the original site.

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Rafael Basa
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1K views2 pages

FDAR

The document is a post-operative care record for a patient who underwent a laminotomy and discectomy surgery. It documents the patient's care over two days, including encouraging deep breathing exercises, monitoring pain levels and administering warm compresses, changing the IV site, and ensuring the dressing remained dry with minimal fluid drainage. On the second day, the patient's temperature was normal and pain had reduced to a level of 2/10 at the original site.

Uploaded by

Rafael Basa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Medical Logs: September 21, 2015: Logs detailing postoperative care and body temperature management for September 21, 2015, including patient status and nursing actions.
  • Medical Logs: September 22, 2015: Logs for September 22, 2015, describing postoperative observations and care measures undertaken by medical staff.

FDAR

Date and Time


Focus
9/21/15
Post-operative
9:30PM care

9:45PM

10:45PM Body
temperature

11:25PM Pain

Data, Action, Response


D Received patient from PACU s/p
Laminotomy, Discectomy L5-S1, Left
under Dr. Bernal and Dr. Pineda; with
dressing over
D With minivac drain maintained on
negative pressure; noted bloody
drainage---------------JN
A Hooked to oxygen source at 2Lpm
via
nasal
cannula--------------------------------------------JN
A Encouraged deep breathing
exercises----JN
A Minivac drained and recorded with
an
output
of
7ml
-------------------------------------JN
A

Placed
call
light
within
reach---------------JN
A Assisted to a comfortable
position--------JN
A - Instructed to call if in need of
assistance
A Instructed to maintain side rails up
when
in
bed-----------------------------------------------JN
D Temperature of 37.9OC and skin is
flushed
and
warm
to
touch-------------------------------JN
A Encouraged deep breathing
---------------JN
A Encouraged adequate oral fluid
intake--JN
A

Encouraged
adequate
rest-----------------JN
D Ang sakit ng kaliwang kamay ko,

11:30PM

11:50PM

9/22/15

Post-operative
care

4:15PM Body
Temperature
5:45PM Pain

kung san nakatusok yung swero., as


verbalized by the patient. Pain scale
6/10;
swollen
upon
inspection.----------------------------------------JN
A Placed warm compress on area for
10
minutes.------------------------------------------JN
A Reassessed patient, with 5/10
pain.-------JN
A- Changed IV site to right hand with
IVF
infusing
well.--------------------------------------JN
R Dressing dry and intact; total
minivac output for entire shift of
15mL,
with
bloody
drainage-------------------------------------------JN
R Reassessed patient; with a body
temperature
of
37.4
O
C--------------------------JN
R Onting sakit na lang yung dito sa
left hand ko., as verbalized by the
patient. With no complaints of pain on
the new site. 2/10 on the previous
site. -------------------------------------JN

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