FDAR CHARTING

SURGICAL UNITS NURSE’S NOTES: PREOPERATIVE

Date/ Focus D-A-R Signature
Shift/
Time
16, 2021 Black Tools , D: S> Mr. Jones complaining of the passage of black tools x 3 days and an associated
7-3am lightheadedness, Sticky lightheadedness. He also relates that he cannot keep up with his usual schedule because
7:30am malodorous stools, of fatigability. upon further questioning he said that his stools are not only b;ack but are
NSAIDs, Postural sticky and malodorous.
hypertension.
O> received patient with his physical examination. it appears an alert, oriented,
overweight male. he appears anxious and somewhat restles;
VS of BP 120/80 mmHg; HEART RATE110/min- supine; BP 90/60 mmhg; HEART RATE
THREADY STANDING( patient complains of dizziness upon standing); RESPIRATORY RATE-
20/minute; TEMPERATURE 98 F.
A: Established rapport; monitored VS and recorded; preoperative care rendered; verified
surgery schedule, patient identification band, chart, and signed operative consent for
surgical procedure; Noted pain with ABDOMEN/RECTUM with the rating of 9 out of 10;
provided laboratory tests.

1:15 R: >Reported pain rating as 5/10;

pm
NURSING CARE PLAN

ASSESSMENT EXPLANATION OF GOALS/OBJECTIVES INTERVENTION RATIONALE EVALUATION

THE PROBLEM
Subjective Data: Black stool is not STO: Diagnostic: Goal Met if:
⮚ “I’m passing always a sign of a After 8 hours of nursing ⮚ ⮚ When disease or Blood that comes
balck stool” Mr. bigger problem. interventions the patient Black stool is a condition in the outcome of from higher up in
Jones There are many will be able to: which the feces are very disease the digestive tract,
reasons stool could a. When disease or dark or black in color. Black treatments such as the
Objective Data: appear black, and the outcome of stool may be normal in confuse the esophagus or
⮚ 50 year old male iron supplements or disease some cases and caused by standard stomach, may turn
he has a BLACK even Oreos could be treatments ingesting certain mechanisms stool black, which is
STOOL to blame. This is confuse the substances or medications, that maintain called melena. As
⮚ He states that his especially true for standard such as iron supplements. hemostasis, a the blood passes
stools are not people who have had mechanisms that However, black stool can patient may be through the body
only black, but ostomy surgery or a maintain also be caused by a serious at risk for and interacts with
are sticky colectomy, because hemostasis, a condition, such as bleeding bleeding. enzymes in the
malodorous. food is not being patient may be in the digestive tract Certain diseases digestive process,
⮚ O> BP 120/80 digested as fully as it at risk for caused by a peptic ulcer. like hemophilia the blood changes
mmHg; HEART is in people who have bleeding. Certain interfere with from red to black.
RATE110/min- not had any diseases like ⮚ Note response to genetic This makes it a bit
supine; BP 90/60 abdominal surgery. hemophilia medication and expression of more difficult to see
mmhg; HEART However, if you have interfere with report to physician. normal clotting in or on the stool
RATE THREADY had gastrointestinal genetic factors. Risk for than if there is red
STANDING( patie bleeding in the past, expression of bleeding blood.
nt complains of there is a foul smell, normal clotting Therapeutic: happens with
dizziness upon or the problem goes factors. Risk for Black stool is a condition in disorders that Red blood in or on
standing); on for longer than a bleeding which the feces are very reduce the the stool, called
RESPIRATORY few days, that's happens with dark or black in color. Black quality or hematochezia, is
RATE- reason to see your disorders that stool may be normal in quantity of typically from lower
20/minute; doctor. reduce the some cases and caused by circulating in the digestive
TEMPERATURE quality or ingesting certain platelets tract, such as the
98 F. quantity of substances or medications, (thrombocytope rectum or the colon.
circulating such as iron supplements. nia) Blood from lower in
platelets However, black stool can the gastrointestinal
Nursing Diagnosis: (thrombocytope also be caused by a serious system will be
BLACK STOOL nia). A reduction condition, such as bleeding A reduction in exposed to less of
in production of in the digestive tract production of platelets the digestive
 platelets from caused by a peptic ulcer. from the bone marrow process and may
the bone marrow Black stool that is tarry in is linked to cancers of keep its red color.
is linked to texture and foul smelling is the blood and blood- Red blood in or on
cancers of the often a symptom of upper forming organs. the stool, called
blood and blood- gastrointestinal bleeding Increased destruction of hematochezia, is
forming organs. from the esophagus, platelets is linked to typically from lower
Increased stomach or small intestine. immune in the digestive
destruction of This is called melena. thrombocytopenic tract, such as the
platelets is linked Rectal bleeding of bright purpura (ITP). Reduction rectum or the colon.
to immune red blood with clots, in the synthesis of Blood from lower in
thrombocytopeni sometimes mixed with clotting factors is due to the gastrointestinal
c purpura (ITP). stool, is called liver impairment. system will be
Reduction in the hematochezia. exposed to less of
synthesis of Risk for bleeding may the digestive
clotting factors is arise in any condition process and may
due to liver that disturbs the “close keep its red color.
impairment. circuit” integrity of the
circulatory system.
Examples of these
LTO: conditions include
traumatic injury, major
After 2 days of nursing organ surgery, and the
intervention, the patient many inflammatories
will able to verbalize his and ulcerative disorders
feelings if there is a of the gastrointestinal
improvement of the system like
surgical process. inflammatory bowel
disease and peptic ulcer
disease.