Documentation of FON Procedures

1. Death Care

12/03/2018
10:30 – Patient stopped breathing.
10:33 – No apical pulse detected. Dr.Grover notified.
10:40 – Pronounced dead by Dr.Grover family present and assisted in washing and
preparing the body transport to morgue. Foley catheter removed.ID tags
attached to right toe, right wrist, and outside of shroud. Transported to
morgue at 11:20

2. Using personal protective equipment (PPE): Gown, Mask, Gloves, and Eyewear.

16/03/2018 09:00 Wound irrigated with 10 mL NS: site clean, no s/s of infection or
drainage noted: gown, mask, goggles, and gloves worn throughput procedures.

3. Catheteration:

12/04/2018 14:35 – Straight Catheterization performed using sterile technique with

14-Fr.catheter. No problems encountered: 190 mL clear, yellow urine drained: sterile
specimen obtained.

4. Positing the patient:

14/03/2018 08:00 – Placed in supine position. Correct alignment maintained with

pillows, hand rolls, and foot splints.

5. Moving the Patient Up in Bed :

16/04/2018 09:00 – Feet over end of mattress: moved to head of bed with assistance;
repositioned supine for comfort; placed in proper alignment. Bed down, call bell
within reach.

6. Passive Range – of – Motion (ROM) Exercises.

17/04/2018 09:00 – Passive ROM exercises carried out to all extremities, head, and
neck. No evidence of contractures. Slight discomfort noted with left ankle flexion. All
other motions carried out with ease.

7. Transferring the Patient to a Wheelchair.

11/04/2018 10:00 – Assisted out of bed to wheelchair by standing and pivoting,

(turning) with assistance of one nurse. No weakness or difficulty noted during
transfer. Returned to bed after 30 minutes.
8. Transferring the patient to a Stretcher.

17/03/2018 1:30 – To x-ray. Transferred from bed to stretcher by three staff members
using a pull sheet without incident. Safety belt applied.

9. Ambulating the patient.

20/03/2018: 2:30 – Assisted to ambulate the length of the hall. Walked slowly with
minimal assistance. No complaint of weakness or dizziness. Back to bed, placed in a
semi-fowler position for comfort. Bed down, call bell in reach.

10. Administering a Bed Bath and Perineal Care.

21/03/2018 09:30 – Complete bed bath given and back rub performed. Reddened area
2 cm in diameter found on sacrum. Repositioned on right side in correct body
alignment and maintained with pillows. Informed patient of the importance of
avoiding pressure on the sacral area. Bed down. Call bell in reach.

11. Administering Oral Care to the Unconscious Patient.

23/04/2018 08:00 – Mouth heavily crusted. Cleansed with mouthwash. Teeth brushed.
No signs of aspiration during procedure. No bleeding or areas of inflammation noted.

12. Providing Denture Care.

25/04/2018 22:00 - Dentures cleaned; c / o irritation of small area on front gum line of
lower denture; 1- cm diameter area of redness noted. Mouth swished with mouthwash.
Denture left in labeled denture cup on the bedside stand; reassess area in after 8 hrs.

13. Hair wash.

23/04/2018 10:30 - Bed shampoo given. Complained of being tired and weak. Stated
“Very good to have clean hair again.” No abnormalities of hair or scalp noted. Bed
down and call bell within reach.

14. Making an Unoccupied Bed

27/04/2018 07:00 - Patient out of bed in chair. Linens changed, bed locked and in low
position, call bell within reach.

15. Making an Occupied Bed

22/03/2018 07:00 - Linens changed on occupied bed, which is in a locked, low

position.
16. Applying a Protective Device (Restrain)

Oriented to person only, thrashing in bed, and unable to understand directions to

prevent dislodgement of IV line. Physician notified, order obtained for right wrist
protective device, and device applied. Skin intact; fingers warm, dry, and with quick
capillary refill. Call bell within reach.

17. Measuring Temperature with an Electronic Thermometer

16/03/2018 08:00 – Temperature - 101F

08:10 – Cold Sponge given

18. Measuring the Radial Pulse

16/03/2018 08:00 – Pulse – 74 b/m (Note any abnormality)

19. Measuring Respirations

16/03/2018 08:00 – Respiration = 18 br /m, Shallow and moist sounding.

20. Measuring Blood Pressure

16/03/2018 08:15 – 110/70 mm/Hg (If muffing occurs, record as 136/92/84).

21. Performing a Neurologic Check

Awake, alert and oriented follows simple command, PERRLA, normal strength noted
in all extremities, c/o Headache and intermittent N/V

22. Phlebotomy and obtaining Blood Samples with a Vacutainer System

17/03/2018 07:00 - Successful venipuncture; 3 tubes drawn and sent to lab for CBC,
SMA – 12, and VDRL. No hematoma at site; bleeding stopped and bandages
applied. Patient tolerated procedure without problems.

23. Performing a Capillary Blood Test: Blood Glucose

18/03/2018 10:30 - Fingerstick glucose 126.

24. Obtaining Culture Specimens: Throat and Wound

20/03/2018 Throat: 11:00 Throat culture obtained and sent to lab.

Wound: 13:00 Wound culture obtained from wound on right upper
thigh. Wound redressed using sterile technique. Culture sent to lab.

25. Assisting with a Pelvic Examination and Pap Test (Smear)

22/03/2018 10:15 - Pap smear and pelvic examination done by Dr. Smith;
tolerated without problems. Smear fixed and sent to pathology lab with requisition.

26. Assisting a Patient with Feeding

22/03/2018 12:00 - Fed lunch; at 50% of meal. Had difficulty chewing and
swallowing meals. Occasional coughing when swallowing. Discussed with physician.
Diet changed to pureed meats.

27. Using a Feeding Pump

22/03/2018 10:00 Feeding via pump initiated with 200 mL formula at 50 mL / hr.
Tube patent and in place with return of gastric secretions. Positioned at 30 degrees.
Bowl sounds present all 4 quads.

28. Administering a Nasogastric, Duodenal, or Percutaneous Endoscopic

Gastrostomy Tube Feeding.

22/03/2018 13:00- 240 ml soup given viva PEG tube. Checked for residual before
feeding. 25 ml gastric contents aspirated and reinstalled. Abdomen soft, bowel sounds
present in all quadrants. Tolerated feeding without evidence of discomfort. Head end
of bed remains at 30 degrees.

29. Using a Pulse Oximeter.

26/03/2018 14:00- Spo2 92 %; O2 by nasal cannula at 4 L/min

30. Administering Oxygen.

28/03/2018 9:45 - Spo2 89 %; O2 ordered. Nasal cannula at 3 L/min applied.

11:00 - Spo2 94 %. Tolerating flow by cannula without complaint; ears not irritated
by tubing.

31. Nasopharyngeal Suctioning.

29/03/2018 10:15 – Noisy respirations 24 br/min and congested nasal passages.

Stated cannot get secretions out. 16 Fr.catheter used to suction nasopharynx and oral
cavity. Caused considerable coughing. Moderate amount of yellow secretions
obtained. Respirations quite; no crackles or wheezes. Resting quietly.

32. Endotracheal and Tracheostomy Suctioning.

29/03/2018 14:30 – Coughing; gurgling sounds auscultated. Suctioned * 2 with sterile

technique preoxygenation. Moderate white secretions obtained; lungs clear, tubing
reattached to ventilator; no signs of arrhythmia.

33. Providing Tracheostomy Care.

30/03/2018 10:45 - Tracheostomy Care given with aseptic technique; reddening 1.5-
cm diameter around tube, no complaints of discomfort. Inner cannula cleaned and
replaced.

34. Placing and Removing a Bedpan.

30/03/2018 8:00 – Voided 240 ml clear, pale yellow urine in bedpan.

35. Applying a condom catheter.

01/04/2018 16:30 – skin on genitalia slightly reddened from contact with incontinent
urine. Area cleansed, prepped, condom catheter applied with Velcro strip. Patient
stated does not feel too tight. Attached to medical thick. Draining clear, yellow urine.

36. Catheterizing the female patient.

02/04/0218 08:00 No.16 - Fr.Foley inserted with sterile technique; balloon filled with
10mL of water. Closed drainage system Attached. Pt expressing sight discomfort
with catheter in place. Approximately 230 mL of dark yellow, clear urine obtained in
 bag. Catheter secured to inner right thigh. Bed into lowest position, call bell within
reach.

37. Catheterizing the male patient.

03/04/2018 08:00 No.18 - Fr.Foley inserted with sterile technique; balloon filled with
10mL of water. Slight resistance encountered, but catheterization successful.
Approximately 300 mL of dark yellow, cloudy urine obtained. Bed into lowest
position, call bell within reach.

38. Performing intermittent Bladder Irrigation and instillation.

03/04/2018 09:30 – Foley tubing clamped and catheter irrigated x4 per orders with 40
mL sterile saline using sterile technique. Unclamped between irrigations. Return
cloudy with debris x2, then cleared. Drained adequate urine; no bladder distention.
complained only mild discomfort with fist irrigation. Resting comfortably: bed into
lowest position, call bell in reach.

39. Changing an ostomy appliance.

03/04/2018 09:20 – Colostomy stoma red and moist; periostomal skin intact; cleaned
with warm water and dried. Stomahesive applied around stoma;2 ⅛”, new pouch
applied without wrinkles.

40. Operating a Transcutaneous Electrical Nerve stimulation unit.

04/04/2018 10:00 TENS unit applied to right shoulder at amplitude of 5 for 20

minutes, tolerated well. Patient states pain at a level of 1 on 0-10 scale following the
procedure.

41. Setting up (or monitoring) a patient controlled analgesia pump.

05/04/2018 08:00 Morphine sulphate via PCA started, 1 mg q 10 mi, not to exceed 4
doses/hr. No redness, swelling, drainage, tenderness at IV site. Instructions on PCS
use given t patient; able to self – administer a dose. Stated pain at 3 n a 0 to 10 scale.
42. Administering topical skin medications.

05/04/2018 10:45 – Old nitro-glycerine ointment removed from right anterior chest.
Skin cleansed. No redness or irritation noted. Advised to note condition of the skin
should be noted at each medication application change.

43. Administering an intradermal injection.

06/04/2018 16:00 - TST 0.1 mL on left inner forearm; to return in 48-72 hour for
reading.

44. Administering a subcutaneous injection.

12/04/2018 13:45- Allergy injection 0.5 mL of tress and grasses mixture, 50,000
mcg / mL in left upper outer arm subcutaneously.

45. Administering an intramascular injection.

12/04/2018 1:20 Morphine 8 mg IM/RVG (Right vetrogluteal) for complaints of pain

as evidence of 7 on a scale of 1 to 10at incision.
46. Starting the primary intravenous infusion.

13/04/2018 06:30 - #8 Angiocath x1 inch inseted in L interior forearm with aseptic

technique. IV 1000 mL of D5W infusing at 125 mL / hr per infusion pump.
Transparent dressing applied.

47. Administering Blood products.

14/04/2018 14:40 – Vital signs: T 98.40 F; BP 132/86; P 74; R 16. First unit of
packed RBCs via 18 angiocath in rt. forearm. Begun at 2 mL / min. No signs of
adverse effects in 15 min. Vital signs: T 98.4 0 F, BP 136/86; P 76, R 16. Flow rate
adjusted to complete unit in 2 hours. Patient reassured that someone will check on
her every 15-30 minutes, but also instructed to call for symptoms, such as chills,
shortness of breath, apprehension, or discomfort.
48. Applying antiembolism stockings.

14/04/2018 13:30 – Legs measured and medium regular thigh high stockings applied
.
49. Sterile Dressing change.

18/04/2018 14:30 – Dressing change with sterile technique using six 4*4 gauzes and
two combined ABDs. Incision clean, dry, and well approximated. Small amount of
serous drainage on dressing. Skin cleansed with alcohol swabs. Reinforced technique
for wound cleaning and dressing change, and signs and symptoms of infection to
report immediately.

50. Wound Irrigation.

19/04/2018 18:30 – Left buttock wound irrigated with 150 mL normal saline using
sterile technique. Wound with pink tissue and serous drainage; no odor noted. Sterile
dressing applied.

51. Applying a wet to damp or wet to dry dressing.

21/04/2018 14:30 – Wound packed with fluffed 4 x 4 mistened with normal saline.
Sterile technique maintained. Wound 2.2 x 3.4 cm area of black eschar at 3 o’clock
position; wound yellow at base. Pink tissue at edges.

52. Cast Care

22/04/2018: 10:15 Received from recovery room alert and stable. Fresh plaster cast
encases right leg from mid – thigh to mid – toes. Toes pink, warm, move well; sensation
present; capillary refill less than 2 seconds. Edge of cast easily admits fingertip. Leg.
elevated on pillows. Rated pain as 3 out of 10. Advised to request pain medication if pain
increases.
53. Care of the Patient in Traction

22/04/2018 13:00 Slight irritation and erythema on medial aspect of left leg where
traction boot meets skin, lateral aspect is clean and without signs or symptoms of
infection. Cleansed both aspects of leg with normal saline and dried with 4 x 4 gauze;
thin layer of lamb’s wool padding inserted between medial aspect of left leg and traction
boot.

54. Transferring with a Mechanical Lift

20/04/2018 09:45 Smooth transfer from bed to wheelchair using mechanical lift and an
assistant. Seatbelt in place; chair positioned next to nurse’s station.

55. Inserting a Nasogastric Tube

Document procedure on the nurse’s notes.

Document intake on the intake and output record.
Documentation should include:
 Reason for tube insertion
 Date & Time of procedure
 size of tube (French)
 Patient’s tolerance of procedure
 Amount and characteristics of stomach contents (Provides members of the health
care team with description of the procedure and the patient’s response.)

21/03/2018 1300 Number 16 Levin tube inserted in right nostril. 500 mL dark green
fluid returned. Vomited 200 mL dark green fluid during tube insertion. Tube taped to
nose. States nausea and abdominal pain relieved after tube insertion. Tube connected
to low, intermittent suction.

56. Administering medications through a feeding tube.

 Document the does given on the MAR. (The right Documentation is essential
for continuity of care).
 Enter the amount of fluid given on the intake portion of the intake and output
sheet. (Tracks patient’s intake).
  Document any problems encountered and corrective actions. (When a
problem is identified, always document steps that were taken to address or
correct the problem).

57. Injection.

Documentation: It should include the medication, the dosage, the route, and the site
at which the injection was given. The testing substance is noted for ID injections.
Routine injections are recorded on the MAR only. The PRN (as needed) and stat
doses may also be recorded in the nurse’s notes, along with the reason the medication
was given and the result and duration of effect of the injection.

58. Administering Medication via saline or PRN Lock.

Document insertion of the saline or PRN lock on the IV flow sheet. Document each
medication administered on the MAR. (Right documentation includes size of catheter,
date, amount and type of flush solution, and medication given).

ABD’s – Abdomenal
MAR – Medication Administration Record
SMA – Smooth Muscle Antibody