DATE

FOCUS D (DATA) A (ACTION) R (RESPONSE)

&
TIME
04/27/2022 Heath Teaching: D= Subjective: Client stated “Kaylan ko ba pwede tong linisin at paano ngayon
3:00 Wound Care ko lang kasi naranasang mag pa opera”
Objective: (+) Incision in low in the center of neck or collar incision
(-) Signs of bleeding
4:30 A= Inform the Client that the first 24 to 48 hours wash it around the wound with
clean water 2 times a day and don’t use hydrogen peroxide or alcohol.
Demonstrate to the patient the methods of wound dressing and how to change.
5:00 Educate the client about the sign of infection and the importance of wound care.
R=Patient understand when the incision site allowed to wash and disinfectant
that prohibited to put in the incision site also client was demonstrate correctly
how to change and clean the wound and client was understands the importance
of wound care and verbalized the signs of infection
correctly--------------------------------------------------------------------------------------
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Medical Center NURSES’ PROGRESS NOTES

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