Nursing Notes
Nursing Notes
7:00 AM.
I receive a pediatric patient of xx years of age, male/female, awake,
conscious alert, in the company of his mother/father, in the immediate postoperative
period
-medium-late (or health situation for which you are hospitalized)
with spontaneous respiratory pattern with/without oxygen support, with/without
nasogastric - orogastric tube for feeding – or drainage, symmetrical mobile neck,
symmetrical chest and expansion, without evidence of respiratory effort, with vein
canalized in the right - left upper limb with insertion date 06/10/14 passing saline
solution - ringer's lactate - 10% or 5% dextrose plus electrolytes
12 cc of natrol + 5 cc of katrol in 500 or 250 cc of the solution (corresponding),
increasing to 50 cc/hour, without signs of infiltration or phlebitis, or central venous
catheter
bilumen or trilumen (as appropriate) permeable passing parenteral nutrition to
12cc/hour, soft depressible abdomen with/without the presence of a surgical wound in
the recovery process, intact genitalia, symmetrical mobile lower extremities, rest of the
skin intact without evidence of injuries.
Hospitalization handle and fall risk handle on the right hand.
Awaiting XXXX lab or exam. Xxxxxxxxx — UIS Nursing Teacher
8:00 AM.
Vital signs are taken and recorded without complications or describe if any were altered
and what behavior was taken or to whom it was reported................xxxxxxxx— UIS
Nursing Teacher
8:15 AM.
When evaluating domains, the following alterations are found.
1. Health promotion domain evidenced by what the patient presents............ 2. Nutrition
domain since..... 3. Activity and rest because..... 3.
Security and protection....According to the above, the following PLAN is proposed
NURSING CARE: Main nursing diagnosis...... nursing outcome (initial outcome) ......
intervention ..... and activities to be developed..................... xxxxxxxx—UIS Nursing
Teacher
9:00 AM.
User receives and tolerates orally....................xxxxxxx— UIS Nursing Teacher
9:30 AM.
Record of nursing activities carried out according to the diagnosis. Xxxxxxxxx — UIS
Nursing Teacher
It is important to always record the education of parents about the risk of falls in
children and the activities that were indicated to be carried out to prevent them.
10:00 AM
.
The user's bathroom and unit arrangement are carried out. The patient is transferred to
a procedure table, the post-surgical appendectomy wound is healed in the abdominal
area, the wound is observed in the healing process in the granulation phase, cleaning
is carried out under sterile technique with normal saline solution and gauze, it is left
covered with a dressing. and micropore...............................xxxxxxxxx UIS Nursing
Teacher
10.30 AM.
Patient is evaluated by doctor or medical round, whoever orders.... (it is necessary to
register the name of the professional who gives the medical instructions)
.xxxxxxxxx—UIS Nursing Teacher
.
11:00 Child who is transferred in adequate health conditions, to perform an abdominal
ultrasound at the diagnostic media service, has a complete medical history and
procedure order, is transferred by an orderly from the service, in the company of the
mother. Vital signs Tº, BP, RR, HR.
11:20 Child who returns from diagnostic services in good condition, accompanied by a
family member and orderly, brings a complete medical history. Vital signs are taken
Vital signs Tº,xx ºC BP xx mmHg RR xx resp/min, HR xx beats/min
11:30 AM.
Evaluation of the result in relation to the interventions developed).
Evolution of the nursing plan: final evaluation.
NOTE OF HOW THE PATIENT HAS EVOLVED IN THE HOURS OF THE
TOMORROW.
12:00 AM.
Vital signs are taken and recorded without complications.................... xxxxxxxx—UIS
Nursing Teacher
Critical components include maintaining a sterile environment during dressing changes to prevent infection, assessing the wound for signs of healing such as granulation, and educating caregivers on signs of complications. Proper wound care facilitates faster healing, reduces the risk of infection, and results in better surgical outcomes .
Nurses can prevent falls in pediatric patients by conducting risk assessments, implementing safety protocols like bed rails, and ensuring a clutter-free environment. Education of parents is vital and should include demonstrations and discussions about potential risks and preventative actions. Effective strategies involve clear communication, hands-on demonstrations, and the use of straightforward language to ensure understanding and compliance .
Pediatric nurses should promptly identify signs of complications through vigilant monitoring and assessment, report these to appropriate team members, and initiate interventions as per the established protocols. Continuous education of caregivers about symptoms of complications is also important to ensure immediate reporting and intervention, thereby optimizing care and reducing morbidity .
A nasogastric or orogastric tube might be used in post-operative pediatric care for feeding if the patient is unable to eat by mouth, or for drainage to prevent abdominal distention and aid in recovery. Nursing staff must consider correct tube placement, patency to prevent blockages, and monitor for signs of infection. Regular checks and proper documentation are essential for effectively managing these tubes .
Nurses should regularly evaluate patient outcomes against expected outcomes from the care plan, using vital signs, patient's physical and behavioral responses as benchmarks. If discrepancies are noted, they should reassess the condition and consult multidisciplinary teams if needed to adapt the plan. Continuous communication with family and incorporating their feedback is also important to ensure the plan remains relevant and focused on the patient's needs .
Careful preparation and execution of a transfer to diagnostic services can minimize stress and disruption for the patient, ensuring that necessary equipment, personnel, and safety checks are in place. It promotes a seamless transition between services, avoiding delays and ensuring the patient receives timely investigations, which are critical in formulating accurate diagnoses and subsequent treatment plans .
Interdisciplinary team rounds contribute to comprehensive care by integrating multiple healthcare perspectives for well-rounded patient management. Documentation should include updates on the patient's status, any changes to the care plan, inputs from different specialists, and clear instructions for the ongoing management of the patient. This documentation facilitates accountability and continuous quality improvement in care delivery .
Documenting vital signs and patient observations in pediatric nursing post-operative care is crucial for monitoring the patient's recovery and detecting any deviations from expected progress that may signal complications. It ensures that healthcare providers have accurate, up-to-date information for clinical decision-making and effective communication among the care team. Documentation also serves a legal purpose, providing a detailed account of the care provided and the patient's response to treatment .
Caregiver education is pivotal in ensuring adherence to care plans, recognizing signs of complications early, and providing supportive care at home. Education should be clear, concise, and use layman terms. Tailoring this education to the caregiver's understanding and involving them actively in learning activities enhances retention and ensures effective collaboration in the child's recovery process .
The Nursing Process, which includes assessment, diagnosis, planning, implementation, and evaluation, offers a structured method for delivering individualized care, enhancing consistency and thoroughness. For pediatric patients, it ensures age-appropriate interventions and adjustments in care plans, actively involving parents or guardians, and focusing on both physical and psychological needs, which are crucial for recovery and overall wellbeing .