Nurses' Notes
0745: The client is scheduled for elective colorectal surgery at 0930. During teach-back, the client states that the possible permanent ostomy was not explained. The client correctly states that a blood transfusion may be needed if major bleeding occurs. The nurse confirms that the consent form is written in the client's preferred language. The signed form lists the planned procedure and the responsible surgeon. At 0755, 15 minutes after the medication was administered, the record shows midazolam was given before consent was signed. The client asks the nurse to watch while the client writes the signature. The client points to the marked abdominal site and identifies the planned operation. The record shows that a certified interpreter stayed for the entire consent discussion. The daughter is present because the client requested her support during the discussion. The client then states that the daughter pressured an unwilling client to sign. The client accurately repeats the expected recovery activities. The nurse confirms that the client received a copy of the signed form. The client asks when oral fluids may restart after surgery. The preoperative checklist shows the procedure and client identity were verified together before operating room transport. The client remains alert and oriented during the current assessment. The client states that additional questions can be asked before transport. No emergency condition is documented.
Nurses' Notes
0745: The client is scheduled for elective colorectal surgery at 0930. During teach-back, the client states that the possible permanent ostomy was not explained. The client correctly states that a blood transfusion may be needed if major bleeding occurs. The nurse confirms that the consent form is written in the client's preferred language. The signed form lists the planned procedure and the responsible surgeon. At 0755, 15 minutes after the medication was administered, the record shows midazolam was given before consent was signed. The client asks the nurse to watch while the client writes the signature. The client points to the marked abdominal site and identifies the planned operation. The record shows that a certified interpreter stayed for the entire consent discussion. The daughter is present because the client requested her support during the discussion. The client then states that the daughter pressured an unwilling client to sign. The client accurately repeats the expected recovery activities. The nurse confirms that the client received a copy of the signed form. The client asks when oral fluids may restart after surgery. The preoperative checklist shows the procedure and client identity were verified together before operating room transport. The client remains alert and oriented during the current assessment. The client states that additional questions can be asked before transport. No emergency condition is documented.