Right Open Hemicolectomy

[melkay60]

I am a second semester ADN student. My patient is a 57 yr old male, obese BMI 33.9, I have several questions about the post-op care of this patient. This is not an actual patient, but with the information I have I am confused about a few things. Can anyone help me to understand my role in a 12 day with this patient?

[melkay60]

Oops 12 hour day.

[nurseprnRN, BSN, RN]

What is confusing to you? Tell us that, and we'll be able to help better.

[melkay60]

The documentation, I have vital sign sheet to document on but do I also put in nurses note? I/O has a seperaye sheet but do I put these in nurses notes also? Medication? in MAR only? or nurses notes also? Not a lot of focus on written documentation so far, just EHR.

[KelRN215, BSN, RN]

The documentation, I have vital sign sheet to document on but do I also put in nurses note? I/O has a seperaye sheet but do I put these in nurses notes also? Medication? in MAR only? or nurses notes also? Not a lot of focus on written documentation so far, just EHR.

No, you don't have to copy all of these things into the nursing note. That would be double documenting.

[melkay60]

Does anyone know of a template or examples of written documentation online? I need something like the PES format for nursing diagnosis, Problem, etiology, and signs and symptoms. Just questions to ask myself otherwise I end up writing a novel.

[melkay60]

Thank you so much! I am a non-traditional college student learning a new way to learn, lol

[Esme12, ASN, BSN, RN]

I am a second semester ADN student. My patient is a 57 yr old male, obese BMI 33.9, I have several questions about the post-op care of this patient. This is not an actual patient, but with the information I have I am confused about a few things. Can anyone help me to understand my role in a 12 day with this patient?

Are you doing a care plan or nursing charting. Is this a case study? Is this a care map? What do you mean non traditional student?

The easiest way to explain it for a care plan: pes. it stands for p (problem), e (etiology) and s (symptoms).

p (problem). this is the nursing diagnosis. a nursing diagnosis is nothing more than a label that has been decided by nanda to belong with a group of related problems the patient has.

e (etiology). this is what is causing, or is a major contributing factor to, the problem. in nursing diagnostic statements it is the information that immediately follows the r/t (related to) part.

s (symptoms). this is the patient data, signs and symptoms that you discovered in your physical assessment and review of the patient's chart. this is the evidence that supports the p (problem). these are also the items that any nursing interventions you decide to use will be focused on. in nursing diagnostic statements these are the items that immediately follow the aeb (as evidenced by) part.