Date of care: 07/12/2013 Client Initials: EM Sex: F Age: 60 Rm# 1025
Religion: Catholic Allergies: NKA Admission date:07/09/2013 Code status: No Order
Admitting diagnosis: Ileostomy take down (Perforated bowel 3/20/13)
Social Hx: Patient denies any history of Smoking, ETHO, and Drug use
PMH: Diabetes mellitus Type II, Asthma, Hyperlipidemia, Perforated bowel
Recent Surgeries: Abdominal surgery, Perforated ielocolonic anastomosis with abscess
Chief Complaint: s/p ileocolonic/ ileostomy
(S) Patient is a 60 y/o female that presented with ileostomy take down (closure).
(B) Status post perforated bowel in 3/20/2012. Patient states that pain is 4/10 and is using her PCA to control pain.
(A) Patient is AOx3 with all pulses +2, with no edema rate and rhythm regular. Respirations course through out bilaterally with scant, clear, thick sputum. Abdomen is soft, distended, and round with large midline surgical incision that has been stabled shut and dressed with dry abd pads. Bowel sounds hyper-active x4. Skin consistent with genetic disposition, dry, warm and intact.
(R) Monitor Vital signs and ambulate patient to washroom when necessary. Help the patient to manage pain and teach patient how to use the incentive spirometer.
Patient participates in two-way conversations, care and treatment plans. Patient’s is accepting of her situation. Patient denies any history of Smoking, ETHO, and Drug use.
Test | Date | Result | Reason(s) Needed and if abnormal- why? |
CXR | 06/25/13 | Normal | Routine screening prior to surgery |
EKG | 06/24/13 | Normal | Pre-op, pre-procedure work up |
CT | | | |
Others | | | |
| | | |
Item | Reason (explain specifically why ordered for this patient) |
Diet | NPO (ICE CHIPS)- Post surgical procedure |
I/O | NA |
VS | Q4- Patient is post surgical and had a slight temperature. |
Activity | Light as...