Johnny Duodenum
Nursing 101
Narrative Nursing Notes
Due 30 November 2012
27 November 2012
0805 – Reported on to A. McCarthy RN.
0810 – Shift assessment. Pt awake, alert, oriented x3. Stopped PEG line feed, verified
patency with 10ml air, flushed with 60ml tepid tapwater, changed dressing, insertion
site with small amount of yellow bloody drainage, skin without redness, washed and
dried, 4x4 gauze applied. SS d/c to L forearm, scant to moderate bloody drainage, 2x2
gauze applied. PERRL, 3mm. MAE. No ambulation (OOB refused). No c/o pain. AP
70, regular. Nail beds pink with 3s refill; conjunctivae, skin, and oral mucosa also pink.
Dorsal pedal and posterior tibial pulses 2+. Non-pitting edema on ankles. BP 78/58 R
(reported to A. McCarthy). Homan’s sign negative. Respirations 22/min (reported to A.
McCarthy), unlabored, no adventitious sounds. No c/o dyspnea at rest, cough denied.
Pulse ox 100%R on 2L NC. Abdomen soft, round, nontender; no masses or distention,
BSx4. Pt denies N/V. Last BM previous day. Incontinent of bladder x1. Skin dry, intact,
without redness except rash on buttocks (#3 cream applied). Thoracentesis dressing
dry and intact, surrounding skin pink and dry.
0940 – Pt left resting in bed, eyes closed, bed down, call bell in reach.
1045 – re-check VS in advance of new Fentanyl patch placement. RR=20, AP=70,
BP=88/66R. Removed old patch from UR chest, washed site, applied new patch to UL
arm.
1144 – Transfer paperwork completed, Pt d/c in wc to ANH on 2L O2 NC.
1150 – Reported off to A. McCarthy RN
journal entry
28 November – My patient was discharged at the end of day 1, so I got to spend 3.5hrs in the OR on day
2. It was a great experience! I got to see 3 different procedures:
pt 1 – partial mastectomy with removal of sentinel lymph node. The partial mastectomy was rather
modest, a lumpectomy really, from adjacent to the right nipple. The determination and removal of the
sentinel node was fascinating though. A blue radioactive dye was injected into the right areola (prior to
the lumpectomy) and the primary node to be removed for analysis was detected by Geiger to find the
greatest concentration of dye, which was then confirmed by the blue color.
pt 2 – incarcerated umbilical hernia repair. There was a small hernia to the right of the umbilicus. a small
incision was made over the affected area, the intestine was replaced, and a mesh disc placed inside the
coelom to block the weak area and prevent recurrence and provide a framework for new tissue
development.
pt 3 – laproscopic cholecystectomy. The laproscopy was amazing, not just because the view on the
monitor was huge and clear, mostly because the entire procedure was done through a few small holes
through the abdomen that didn’t even require a stitch in the end. It was also interesting to see how the
abdomen was inflated with air to create a working space.
In addition to these specific procdures, it was good to see the whole surgical team in action. The scrub
nurse selected and placed all of the instruments prior to the procedure, then handed them to the
surgeon during the procedure. The circulating nurse managed the flow of activity in the OR, including
the initial time out as well as performing various tasks outside the sterile field during the procedure. the
anesthesiologist administered the anesthesia, monitored VS throughout the procdure, and helped the pt
wake up after. the surgeon performed the bulk of the procedure with the assistant helping throughout
and closing in the end. certainly not a hands on experience, but a fascinating opportunity to learn!
thanks!