Case scenario – admission notes and daily fluid balance

Mr Real Norman, 3 68year old gentleman was admitted to your ward following a tracheotomy on
the 12/9/2016 for progressive cancer of his trachea. It was undertaken for comfort-care purposes.
Mr. Norman had spent six days in the Intensive Care Unit prior to transfer.
Whilst in the ICU he also had a nasogastric tube inserted to assist with his nutritional requirements
and his incapacity to swallow food due to the trauma of his operation.
His condition is now stable, and he requires a daily dressing change to his tracheotomy.
His has also been ordered ZSOmils of Ensure four times a day via the NG tube by way of gravity
feeding. The Dietitian has reviewed Mr Normal and has ordered a 10oml flush before and after each
He is to remain on nil by mouth for the time being so requires mouth toilets four times a day.
He is also to remain on bed rest for at least 24 hours sol requires a sponge in bed and regular
pressure area care and repositioning. V
Mr Normal is to have 4*? hourly observations consisting of TPR, BSL, pain assessment, deep breathing
and coughing exercises and range of movement encouragement.
He is to have a urinalysis on admission to the ward and a daily bowel chart commenced.
His feeds and fluids are to be recorded on his fluid balance chart.
The Registered Nurse will manage his medications, intravenous infusion and pain management
The Physiotherapist, Dietitian and Tracheostomy Nurse will monitor daily.
Please document in Mr. Normol?s Progress Notes his admission to your word – be concise.
Try to limit your notes to % of a page.
it is to be dated and signed

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