NARRATIVE NOTE

Hamzah Usmangani Patel

Student ID 146149232

CNC220KAA Group GG: Clinical Practicum

Seneca College: King Campus

Erica-Lynn Wilson

February 4, 2024
 Subjective Data-

S
 Mr. Carter is recovering well from his umbilical hernia surgery. Being
oriented with time, place, and person is a good sign, indicating his mental
faculties are intact. The absence of pain is also positive, suggesting that
his discomfort is being effectively managed. His incision is dry and
unbroken, indicating a good healing process. Since he has no bowel issues
and can void, it suggests that his gastrointestinal system is functioning
normally post-surgery. Mr. Carter's healthy lifestyle choices, such as not
smoking, eating healthily, and exercising, are contributing to his smooth
recovery. It's essential to continue monitoring him closely to ensure he
continues to progress well.
Objective Data-

O
Mr. Carter's vital signs remain stable throughout the shift, which is a positive
indication of his continued recovery. His pulse rate, respiration rate, blood
pressure, and temperature are all within normal ranges.
Additionally, his general survey shows that he is alert, awake, and engaging in his
daily activities without any signs of drowsiness or distress. The pain level of 2/10
is relatively low and indicates that his discomfort is still being effectively
managed. Overall, Mr. Carter is progressing well and is stable. Regular
monitoring and continued assessment will be important to ensure his continued
recovery.

Assessment:

A  Vital signs of the patient are evaluated.

 To assess my pain, I utilized PQRSTU.
 The patient is completely focused.
 A comprehensive examination from head to toe.
Continuously monitor Mr. Bill's vital signs and overall well-being and strategize

P
his discharge post a thorough review of instructions, ensuring scheduled follow-
up appointments with his surgeon. Caution him against heavy lifting and driving
for a minimum of two weeks. Emphasize the need to vigilantly observe his
incision site for potential infection or dehiscence, urging him to promptly consult
his surgeon or primary care provider if any concerns or questions arise. This
comprehensive approach aims to safeguard his recovery and address potential
issues promptly
Intervention:

I
Supply comprehensive discharge instructions, both written and verbal, covering
wound care, pain management, activity limitations, and medication schedules.
Educate on incorporating light exercises, emphasize the importance of a balanced
diet rich in protein and calcium, and instruct Mr. Bill to abstain from caffeine
(found in tea, coffee), alcohol, spicy foods, and sodas. Provide health education
regarding hygiene maintenance and infection prevention. Stress the significance
 of adhering to the prescribed treatment plan and completing the entire course of
medication. This holistic approach aims to ensure Mr. Bill's understanding and
commitment to a successful recovery process.
Evaluation:

E
• Mr. Carter is in better health and ready for discharge. With stable vital
signs, maintained hygiene standards, and a well-healing surgical site, he
meets the criteria for discharge from the hospital. Before Mr. Carter leaves,
it's important to ensure that he has all the necessary information and resources
for his continued recovery at home. This includes providing instructions for
wound care, medication management, and any necessary follow-up
appointments. Additionally, it's crucial to address any questions or concerns
he or his family may have and to offer support as needed. Wishing Mr. Carter
a smooth transition home and continued good health!