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DAR Note Week 9

The document details a social worker's notes on providing care to a patient named Mrs. Johnson over the course of a day, including giving her a bed bath, changing her incontinence pad and caring for her catheter, and assisting in changing the dressing on her pressure ulcer wound.

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aejelasanamarqueses
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287 views

DAR Note Week 9

The document details a social worker's notes on providing care to a patient named Mrs. Johnson over the course of a day, including giving her a bed bath, changing her incontinence pad and caring for her catheter, and assisting in changing the dressing on her pressure ulcer wound.

Uploaded by

aejelasanamarqueses
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Clinical Notes: Patient’s Name: Mr.

Johnson
DOB: 10/11/1977 Room#: 122

Date/Time Discipline Focus DAR: Data, Action, Response

11/10/2023
D- Mrs. Johnson requested for bed bath. Obsereved
to have dirt and sweat accumulation, indicating the
1500H SPSW Hygiene and need for a bed bath. A.Marqueses SPSW
comfort
A-
 Arrived at Mrs. Johnson's room promptly.
 Greeted Mrs. Johnson warmly and
explained the purpose of the bed bath.
 Ensured privacy and maintained dignity
throughout the process.
 Prepared the necessary supplies for the bed
bath, including warm water, soap, towels,
and fresh linens.
 Carefully performed the bed bath, focusing
on areas that required special attention.
 Dried and dressed Mrs. Johnson in clean,
comfortable clothing. A.Marqueses SPSW

R- Mrs. Johnson reported feeling refreshed and


clean. She expressed gratitude for the bed bath and
the respectful care provided Documented the bed
bath in Mrs. Johnson's care plan. A.Marqueses
SPSW

1730H SPSW Hygiene and


Catheter D-
Care  Mrs. Johnson reported discomfort and
stressed the need to change the incontinent
pad.
 Incontinent pad was soiled and needed
changing. Urinary catheter was secure with
no sign of dislodgement or leakage.
A.Marqueses SPSW

A-
 Responded promptly to Mrs. Johnson
request for a pad change and catheter care.
 Entered Mrs. Johnson and maintained her
privacy throughout the process.
 Wore appropriate personal protective
equipment.
 Safely and hygienically changed the
incontinent pad.
 Inspected and maintained the urinary
catheter, ensuring it was secure and clean. -
A.Marqueses SPSW

R- Mrs. Johnson expressed relief after the pad


change and catheter care. She felt comfortable and
appreciated the thorough attention to detail.
Documented the incontinent pad change and
catheter care. A.Marqueses SPSW

1920H SPSW Collaborative


Wound Care D- Mrs. Johnson reported discomfort and a desire
and Healing for a dressing change due to the pressure ulcer's
sensitivity, mentioning increased tenderness and
mild pain around the ulcer site." The dressing
covered the wound site, and visual inspection
indicated a Stage 2 ulcer with partial skin loss and
exposed dermis. – A.Marqueses SPSW

A-
 Assisted the nurse promptly in responding to
Mrs. Johnson’s request for a dressing change
Collaborated with the nurse in gathering the
necessary supplies for the dressing change,
including clean gloves, sterile dressings, and
wound care materials.
 Supported the nurse in removing the old
dressing carefully and assessing the pressure
ulcer site.
 Assisted in applying an appropriate wound
care product and securing a fresh dressing.
 Ensured Mrs. Johnson’s was comfortable and
educated her on proper wound care, working
in coordination with the nurse. - A. Marqueses
SPSW

R- Mrs. Johnson expressed relief and satisfaction


with the collaborative care provided during the
wound dressing change. Documented the dressing
change in Mrs. Johnson’s care plan. A.Marqueses
SPSW

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