Nursing Notes

Patient nursing documentation and clinical notes

All Notes (10)

RM

Rahul Mehta

B-104/2

Assessment
Morning Shift
Jun 21, 2026 — 06:15 AMMaria Chen RN

Patient awake and oriented x3. Surgical wound clean and dry with minimal serous drainage noted. Abdomen soft, bowel sounds present in all 4 quadrants. Patient reports pain 4/10, improved from 6/10 at midnight. IV site right AC patent, no signs of infiltration. Ambulated to chair with minimal assistance. Tolerating sips of clear fluids without nausea. Foley catheter draining clear yellow urine. All vital signs within acceptable parameters. Continue post-op care plan. Notify Dr. Kapoor if pain escalates or surgical site shows signs of infection.