OcampoLydiaMedRecordL1W10
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OcampoLydiaMedRecordL1W10

Course Number: LVL 1, Fall 2009

College/University: New Mexico

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Ocampo, Lydia MR #7691627451 Neighborhood Hospital Emergency Department Record Date: Tuesday Arrival Time: 0330 Method of Arrival: Ambulance Condition upon arrival: stable Triage Assessment Time: 0340 Information Obtained From: Husband Name: Ocampo, Lydia Age: 69 Vital Signs: T: 36.4C RR: 20 HR: 104 BP: 112/80 O2 Sat: 98% 2L 02 Pain: ? /10 Gender: F Race: Asian Occupation: Retired Marital Status: M Ht: Wt: LMP:...

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Lydia MR Ocampo, #7691627451 Neighborhood Hospital Emergency Department Record Date: Tuesday Arrival Time: 0330 Method of Arrival: Ambulance Condition upon arrival: stable Triage Assessment Time: 0340 Information Obtained From: Husband Name: Ocampo, Lydia Age: 69 Vital Signs: T: 36.4C RR: 20 HR: 104 BP: 112/80 O2 Sat: 98% 2L 02 Pain: ? /10 Gender: F Race: Asian Occupation: Retired Marital Status: M Ht: Wt: LMP: 15 years ago Pregnant: No Allergies: NKDA Medications: donepezil 5 mg po qd, MVI 1 tab po qd. Reason for Seeking Care: L hip pain Past Medical Hx: Significant Family Hx: Alzheimer's dementia X 5 Mother deceased age 72 breast Slipped while going to bathroom, fell on hard ceramic floor 1 years CA; Father deceased age 59 hour ago. Husband states she has been holding hip and crying in CAD. Brother deceased age 64 pain since the accident; 911 was called for treatment/transport to CAD; Brother deceased age 72 ED. Pt unable to provide additional history. CAD; Sister deceased age 70, sepsis. Examination Findings: Social Hx: Immunizations: Elderly F in acute distress, holding L hip; moaning. External Tob: neg Childhood: up to date rotation noted to L leg; + pulses LLE, warm. ETOH: neg Hep B: yes Influenza: yes Illicit Drug Use: neg Tetanus: >10 years Domestic Violence: neg Pneumococal: yes Possible Crime Victim: neg Others: Triage Interventions: None. Triage Level: B Disposition: ED Bed 6 Triage Nurse Signature: Katlin Rogers, RN Nursing Assessment: Time: 0355 Mental Status/Neuro Anxious, confused. PERRLA; pupil size 3 mm. Glasgow Score: N/A ER Bed #: 6 Skin Color: pinkish tones, even color Moisture: dry Temp: warm Head/Neck: Normocephalic, facial features symmetrical, carotid pulses +3 Respiratory: Breathing even, unlabored; RR= 20/min. Lungs clear to auscultation in all lung fields; oxygen saturation = 98% Oxygen: 2 liters by N/C Cardiovascular HRRR; no murmurs or extra heart sounds. Monitor Rhythm: Sinus Tachycardia; HR rate Eyes/Ears: Deferred. Visual Acuity: L: ________ Rt:_________ Both:_____________ Corrected Y N = 106 GU/Genitalia Deferred Musculoskeletal: External rotation & shortening of LLE; pedal pulses ++, foot warm, pink. Moves all other extremities well. Abdomen: Abd flat, + bowel sounds all quadrants; soft, non tender. RN signature: Angelo Bengy, RN Ocampo, Lydia HPI Elderly female fell to floor while ambulating 1 hour ago; complaining of severe pain since that time to L hip. Examination Findings Neuro: Confused; CN 2-12 grossly intact ENT: Neg CV: HRRR; no murmurs Resp: Lungs Clear; Resp even, unlabored, symmetrical chest rise/fall GU: WNL Mus/Skel: shortening L leg; external rotation hip; + pulses; + cap refill; moves toes; + sensation Impression: R/O L hip fx MR #7691627451 Physician Assessment/Notes: Time: 0415 Physician Orders: Time 0420 0420 0420 0420 0510 0510 0510 Order CBC, Chem 12, PT, PTT, UA, BUN, Creatinine IV 0.9% NaCl TKO L hip, Chest X-ray Morphine 2-4 mg IVP q 1 hour prn for pain. 12-lead EKG Foley Cath NPO Signature/Time Completed AB/ 0415 AB/0415 KK/0430 AB/ 0420 AB/0550 KK/0530 KK/ 0510 Comments Hgb 14 g/dl; Hct 41%; Na+ 137mEq; K+ 3.9 mEq; Ch 100 mEq; PT, PTT WNL; UA Neg; BUN 19 mg/dl; Creatinine 1.0 mg/dl Intertrochanteric fracture L hip; chest clear 2mg IVP 2 mg IVP NSR; tracing WNL Consultation: Charles Ryder, Orthopedics Diagnosis: Fracture, Left Hip Admit: OR Physician Signature: James Arrival Time: 0610 Gordon, MD Ocampo, Lydia Emergency Department Nursing Flow Sheet Time 0415 MR #7691627451 BP 114/80 HR 106 RR 20 T ---- O2 Sat 98% Pain ? Assessment/Response Assessment complete; IV #18g to R FA x 1 attempt; NaCL 1 liter hung TKO rate; blood drawn. Moaning unable to rate pain. 2 mg morphine sulfate IVP for pain. Pt. less restless; less moaning; husband states he believes pain medication has been helpful. To X-Ray. Returned from X-ray; stable; husband at bedside. 12-Lead EKG completed. Foley inserted per order. Moaning/crying out; husband states she is in pain. 2 mg morphine sulfate IVP. Sleeping; IV infusing at TKO rate; site without edema. Dr. Ryder here to evaluate patient. OR consent signed by husband; report called to Cheryl Wylie, RN in OR. Pt. is stable condition. Transported to OR via cart by Kevin Kendall Tech. Initials AB 0420 0430 0450 0510 0520 0550 0610 0645 0650 110/78 100 18 ----- 98% ? AB AB AB KK KK AB AB AB AB 112/82 112/80 110/82 98 94 96 18 16 16 ----36.8C 96% 97% 97% ? Fluid Intake Time Type 0645 IV fluid 0.9% NaCl Amount 150 cc Running Total 150 cc Fluid Output Time Type 0645 Urine Amount 240 cc Running Total 240cc Discharge Instructions Given N/A Time Discharged from ED: 0650 RN Signature Disposition: OR Angelo Bengy, RN RN Signature ___________________________ Tech Signature Kevin Kendall RN Signature ____________________________________ Ocampo, Lydia MR #7691627451 Neighborhood Hospital Physician Progress Notes Tues 1110 Tues 1730 S/P ORIF L hip, POD #1. Procedure without complications; blood loss < 200 cc; stable condition to recovery room. To be admitted to Orthopedics following PACU. Charles Ryder, MD S/P ORIF L hip. Stable, doing well. Pain controlled with morphine. Confused. CV: HRRR; Lungs Cl. JP output 56 cc. Temp 36.4.Hem 12 g/dl; Hct 38%. Distal pulses +, sensation intact. Charles Ryder, MD Wed 0630 S/P ORIF L hip POD #2 RNs report difficult night; pulling out tubes; emesis. Restraints/sedatives ordered after less invasive measures unsuccessful as reported by RNs. Dressing intact, minimal drainage; JP output: 96cc. Temp 37.3.Hem 11 g/dl; Hct 37%. CV: HRRR; Lungs Cl; Abd soft; + distal pulses, slight edema LLE. Charles Ryder, MD Disoriented, but calmer today. Moderate po intake. RN reports intolerance to morphine at 4 mg dose. Progressing well. Spoke with husband about nursing care. Charles Ryder, MD Wed 1700 Ocampo, Lydia MR #7691627451 Neighborhood Hospital Physician Order Sheet Drug Allergies: NKDA Date Time Order Tues 11:10 Admit to Orthopedics Service Diet: Cl liq; advance as tolerated to regular Vitals: hourly x 2, every 4 hours x 24 hours; then every 8 hours. Activity: Bed Rest with abductor pillow; Physical Therapy starting on Thursday Sequential Compression Device to Legs Incentive Spirometer q hour while awake Oxygen 2-4 liters n/c as needed to keep O2 Sat >90% Foley to gravity drainage JP drain L hip I&O q 8 hours IV D5 0.45% NaCl rate: 100/hour Meds: Ancef 1 gram IV every 8 hours Donepezil 5 mg by mouth every day Morphine Sulfate 2-4 mg IV every 1-2 hours as needed for pain Lovenox 30 mg SQ every day - beginning tomorrow AM Tylenol 650 mg by mouth every 4-6 hours as needed for temp > 38.0 C Promethazine 12.5-25 mg IV every 4-6 hours as needed for nausea. Labs: CBC, Lytes now and in AM Signature: Charles Ryder, MD Print Name: Charles Ryder, MD Drug Allergies: NKDA Date Time Order Wed 0200 Soft restraints upper extremities Lorazepam 0.5 mg slow IVP x 1 dose, now. Signature: Charles Ryder, MD Print Name: Charles Ryder, MD Drug Allergies: NKDA Date Time Order Wed 1700 Percocet 1-2 tablets by mouth every 4-6 hours as needed for pain. Reduce IV infusion rate to 50 cc/hour. DC infusion when oral intake is adequate. Change morphine dose to 2 mg IV every 1-2 hours as needed for breakthrough pain. Soft restraints to upper extremities as needed. DC Foley in am. Signature: Charles Ryder, MD Print Name: Charles Ryder, MD Ocampo, Lydia MR #7691627451 Neighborhood Hospital Medication Administration Record Scheduled Medications Order Medication Dose, Route, & Frequency Date Tues Ancef 1 gram IV every 8 hours 11:10 Tues 11:10 Tues 11:10 Sched Times 08 16 24 08 08 Date: 0700 Tuesday 0700 Wednesday Administered 1600 KN 2400 SD Donepezil 5 mg by mouth every day beginning tomorrow Lovenox 30 mg SQ every day - beginning tomorrow AM Non-Scheduled and One Time Medications Order Medication Dose, Route, & Frequency Date Tues Morphine Sulfate 2-4 IV mg every 1-2 hours as 11:10 needed for pain Administered 1210 2 mg KN 1600 2mg KN 1900 2 mg SD 0010 4 mg SD 0300 4 mg SD 1340 KN 1900 SD 0200 SD Tues 11:10 Tues 11:10 Wed 0200 Tylenol 650 mg by mouth every 4-6 hours as needed for temp > 38.0 C Promethazine 12.5-25 mg IV every 4-6 hours as needed for nausea. Lorazepam 0.5 mg slow IVP x 1 dose, now Diagnosis: Admission Date: Physician: Allergies: Left Hip Fx Tuesday Ryder NKDA Signature Initial KN SD Kim Nygen Steve Dawson Ocampo, Lydia MR #7691627451 Neighborhood Hospital Medication Administration Record Scheduled Medications Order Medication Dose, Route, & Frequency Date Tues Ancef 1 gram IV every 8 hours 11:10 Tues 11:10 Tues 11:10 Sched Times 08 16 24 08 08 Date: 0700 Wednesday 0700 Thursday Administered 0800 BS 1600 BS 2400 SR 0800 BS 0800 BS Donepezil 5 mg by mouth every day beginning tomorrow Lovenox 30 mg SQ every day - beginning tomorrow AM Non-Scheduled and One Time Medications Order Medication Dose, Route, & Frequency Date Tues Morphine Sulfate 2-4 mg IV every 1-2 hours as 11:10 needed for pain Tues 11:10 Tues 11:10 Wed 1700 Wed 1700 Tylenol 650 mg by mouth every 4-6 hours as needed for temp > 38.0 C Promethazine 12.5-25 mg IV every 4-6 hours as needed for nausea. Percocet 1-2 tablets by mouth every 4-6 hours as needed for pain. Morphine Sulfate 1-2 mg IV every 1-2 hours as needed for breakthrough pain. Administered 0800 4 mg BS 1120 2 mg BS 1500 2 mg BS 2215 2 tablets SR 0410 2 mg SR Diagnosis: Admission Date: Physician: Allergies: Left Hip Fx Tuesday Ryder NKDA Signature Initial Bobby Schofield Sandy Ryder BS SR Ocampo, Lydia MR #7691627451 Neighborhood Hospital Nurses Flow Sheet Medical Surgical Units Initial Shift Assessment (Day Shift) Mental Status/Neuro Orientation: Confused Pupils: 3mm bilaterally Glasgow: N/A Psychosocial: anxious Skin Braden Score: 10 High Risk Date: 0700 Tuesday 0700 Wednesday Other: Fall Assessment Score: 9 High Risk for Falls Time Assessment Completed: 12:20 pm Head/Neck: Eyes: clear, without drainage Color: pink Ears: hearing intact Moisture: dry Nose: clear, without drainage Temp: warm Mouth: mucous membranes pink, moist, no Wounds: L hip dressing clean, dry, intact lesions noted. Drains: JP to L hip; serousanguinous Lymph: deferred drainage Other: Respiratory: Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Equipment: Oxygen 2 L n/c Other: Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S 1 & 2; no murmurs Edema: absent Pulses: 2+ L and R lower extremities Cap Refill: < 2 seconds L & R LE IV Sites: RFA;site without redness/swelling Equipment: SCDs bilaterally Other: Other: Musculoskeletal: Movement: moves all extremities; Sensation: + sensation toes/feet bilaterally Equipment: Abductor Pillow between legs Abdomen: Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender Equipment: n/a Other: GU/Genitalia Urine: clear, yellow Genitalia: WNL, no breakdown noted Equipment: Foley; patent Other: Special Equipment or Additional Assessment Initial Shift Assessment (Night Shift) Mental Status/Neuro Orientation: Confused Pupils: 3mm bilaterally Glasgow: N/A Psychosocial: calm Skin Other: Fall Assessment Score: 9 High Risk for Falls Time Assessment Completed: 20:15 Head/Neck: Color: pink Eyes: clear, without drainage Moisture: dry Ears: hearing intact Temp: warm Nose: clear, without drainage Wounds: L hip dressing clean, dry, intact Mouth: mucous membranes pink, moist, no Drains: JP to L hip; serousanguinous lesions noted. drainage Lymph: deferred Braden Score: Other: Respiratory: Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Equipment: Oxygen 2 L n/c Other: Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S 1 & 2; no murmurs Edema: absent Pulses: 2+ L and R lower extremities Cap Refill: < 2 seconds L & R LE IV Sites: RFA; site without redness/swelling Equipment: SCDs bilaterally Other: Other: Musculoskeletal: Movement: moves all extremities; Sensation: + sensation toes/feet bilaterally Equipment: Abductor Pillow between legs Abdomen: Contour: flat, non-distended Bowel + Sounds: all quadrants Palpation: soft, non-tender Equipment: n/a Other: GU/Genitalia Urine: clear, yellow Genitalia: WNL, no breakdown noted Equipment: Foley; patent Other: Special Equipment or Additional Assessment Ocampo, Lydia MR #7691627451 Date: 0700 Tuesday 0700 Wednesday Vital Signs (day shift) Time BP HR RR T 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 O2 Sat Pain BG Vital Signs (night shift) Time BP HR RR T 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600 112/82 88 16 36.4 O2 Sat 97% Pain 8 2 BG 114/80 116/84 112/80 118/84 98 92 90 98 18 18 16 16 36.4 36.7 36.7 36.8 99% 98% 99% 98% 6 4 2 6 118/96 116/80 124/100 120/90 118/92 92 84 104 80 84 22 12 16 10 14 36.8 98% 94% 95% 90% 94% 36.2 37.4 8 2 4 8 2 2 Fluid Intake Time Type 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600 FROM OR D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl Ancef in D5W D5 .45% NaCl D5 .45% NaCl Oral D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl Ancef in D5W D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl 24 hour intake total Amount 340 100 100 100 100 100 50 100 100 220 100 100 100 100 100 100 50 100 30 100 100 100 100 Running Total 340 440 540 640 740 890 990 1310 1410 1510 1610 1710 1810 1960 2060 2090 2190 2290 2390 2490 2490 Fluid Output Time Type 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600 Emesis Urine JP Drain FROM OR Emesis Urine JP Darin Amount 500 100 200 32 Running Total 500 600 832 220 860 30 1032 1922 Urine JP Drain 24 hour output total 720 34 2676 2676 Ocampo, Lydia MR #7691627451 Date: 0700 Tuesday 0700 Wednesday Nursing Notes (Day Shift) Time 1210 1340 1600 Received from OR; assessment complete. New orders noted husband @ bedside; patient sleepy; anxious when awake. Medicated for pain. ------------------------------------------KN Crying out; emesis 100 cc yellow drainage. 12.5 mg Phenergan IVP for nausea/vomiting.------------------------KN Restless; moaning; pain estimated at 6 or 7. Pulses to lower extremities palpable bilaterally; feet warm; dressing dry and intact; serousanginous drainage in JP drain. SCDs and abductor pillow in place. Medicated for pain. Turned to right side. Husband remains at bedside. ----------------------------KN Patient sleeping; husband states she is less restless; believes pain medication helpful. --------------------------KN Nursing Notes (Night Shift) Time 1830 Assumed care; assessment complete. Patient is confused but calm at this time.; turned to supine position; abd pillow Is in place. Husband concerned about leaving wife in hospital alone at night due to her confusion and pain. Ate small amount dinner.---------------------SD Emesis 220 cc yellow fluid; patient crying out; Morphine And Phenergan administered IV. -------------------------SD Pt calm and sleeping since medication administered. Positioned on R side; abd pillow in place. Husband remains at beside. -------------------------------SD Patient continues to sleep; husband has elected to go home to get some sleep. ------------------------------------SD Patient yelling and screaming; completely disoriented. Medicated for pain 4 mg morphine IV. ---------------------SD Patient now calm; resting quietly; sleeping off and on. RR decreased to 12; respirations clear; oxygen sat 94% Turned to a supine position; abd pillow in place. -------SD Patient screaming; attempting to get out of bed; has Pulled out IV and Foley; has removed SCDs, and pulled off surgical dressing. Patient hitting and attempting to bite nsg tech. Dr. Ryder notified of change in status; new Orders noted.------------------------------------------------------SD Soft restraints placed; restraint protocol and flow sheet initiated. IV #20G catheter Inserted in right hand; Foley reinserted; dressing replaced over incision; SCD replaced Patient continues to be combative; Lorazapam administered IV--------------------------------------------------SD Pt. slept 45 minutes; awoke screaming; administered morphine for pain. Turned to R side.-------------------SD Pt sleeping soundly; RR decreased to 10; O2 sat 90% Increased oxygen to 4L n/c- repeat sat at 95%. ---------SD Pt remains quiet, sleeping well.------------------------------SD 1900 2030 2300 0010 0100 0145 1700 0200 0300 0400 0600 RN signature: Kim Nygen RN signature: Nursing Tech: Day Shift: Night Shift: RN signature: Steve Dawson RN signature: Nursing Tech: Bridget Harmon Ocampo, Lydia MR #7691627451 Neighborhood Hospital Nurses Flow Sheet Medical Surgical Units Initial Shift Assessment (Day Shift) Mental Status/Neuro Orientation: Confused Pupils: 3mm bilaterally Glasgow: N/A Psychosocial: anxious Skin Braden Score: 10 High Risk Date: 0700 Wednesday 0700 Thursday Other: Fall Assessment Score: 9 High Risk for Falls Respiratory: Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Equipment: Oxygen 2 L n/c Other: Time Assessment Completed: 0730 am Head/Neck: Eyes: clear, without drainage Color: pink Ears: hearing intact Moisture: dry Nose: clear, without drainage Temp: warm Mouth: mucous membranes pink, moist, no Wounds: L hip dressing clean, dry, intact lesions noted. Drains: JP to L hip; serousanguinous Lymph: deferred drainage Other: No breakdown noted. Cardiovascular Musculoskeletal: Cardiac Rhythm: HRRR Movement: moves all extremities; Heart Sounds: S 1 & 2; no murmurs Sensation: + sensation toes/feet bilaterally Edema: absent Equipment: Abductor Pillow between legs Pulses: 2+ L and R lower extremities Other: Soft restraints to upper extremities Cap Refill: < 2 seconds L & R LE for patient safety. Pulses 2+; cap refill <2 sec. Restraint protocol and flow sheet in IV Sites: R hand ;site without place. redness/swelling Equipment: SCDs bilaterally Other: Abdomen: Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender Equipment: n/a Other: GU/Genitalia Urine: clear, yellow Genitalia: WNL, no breakdown noted Equipment: Foley; patent Other: Special Equipment or Additional Assessment Initial Shift Assessment (Night Shift) Mental Status/Neuro Orientation: Confused Pupils: 3mm bilaterally Glasgow: N/A Psychosocial: anxious Skin Other: Fall Assessment Score: 9 High Risk for Falls Respiratory: Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Equipment: Oxygen 2 L n/c Other: Time Assessment Completed: 2010 Head/Neck: Eyes: clear, without drainage Color: pink Ears: hearing intact Moisture: dry Nose: clear, without drainage Temp: warm Mouth: mucous membranes pink, moist, no Wounds: L hip dressing clean, dry, intact lesions noted. Drains: JP to L hip; serousanguinous Lymph: deferred drainage Other: No breakdown noted. Cardiovascular Musculoskeletal: Cardiac Rhythm: HRRR Movement: moves all extremities; Sensation: + sensation toes/feet bilaterally Heart Sounds: S 1 & 2; no murmurs Edema: absent Equipment: Abductor Pillow between legs Pulses: 2+ L and R lower extremities Other: Soft restraints to upper extremities for patient safety. Pulses 2+; cap refill <2 Cap Refill: < 2 seconds L & R LE IV Sites: R hand ;site without sec. Restraint protocol and flow sheet in redness/swelling place. Equipment: SCDs bilaterally Braden Score: 10 High Risk Other: Abdomen: Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender Equipment: n/a Other: GU/Genitalia Urine: clear, yellow Genitalia: WNL, no breakdown noted Equipment: Foley; patent Other: Special Equipment or Additional Assessment Ocampo, Lydia MR #7691627451 Date: 0700 Wednesday 0700 Thursday Vital Signs (day shift) Time BP HR RR T 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 110/80 112/80 112/76 90 16 10 16 37.7 O2 Sat 96% Pain 8 8 BG Vital Signs (night shift) Time BP HR RR T 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600 114/72 88 18 37.8 O2 Sat 96% Pain 5 8 BG 84 36.4 99% 4 7 2 112/70 84 16 37.7 95% 2 116/84 92 16 36.8 98% 114/78 90 18 38.1 96% 8 Fluid Intake Time Type 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600 D5 .45% NaCl D5 .45% NaCl Ancef in D5W D5 .45% NaCl D5 .45% NaCl Oral D5 .45% NaCl D5 .45% NaCl oral D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl Ancef in D5W D5 .45% NaCl D5 .45% NaCl Oral D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl D5 .45% NaCl 24 hour intake total Amount 100 100 50 100 100 120 100 100 200 100 100 100 100 50 50 50 180 50 50 50 50 50 50 50 50 50 50 50 50 Running Total 100 250 350 570 670 970 1070 1170 1270 1420 1470 1700 1800 1900 2000 2100 2200 2300 2300 Fluid Output Time Type 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600 Foley Foley JP Darin Amount Running Total 970 cc 40 cc 1010 cc 620 1630 Foley JP Drain 24 hour output total 740 22 2392 2392 Ocampo, Lydia MR #7691627451 Date: 0700 Wednesday 0700 Thursday Nursing Notes (Day Shift) Time 0800 Report received. AM Meds given with difficulty; pt disoriented uncooperative with oral med; was administered, but with difficulty. MD notified during rounds. Soft restraints remain in place for patient safety. Administered pain med Due to restlessness and moaning. -------------------------------BS Reassessment following pain meds reveals RR of 10. Oxygen saturation = 94%; increased oxygen to 4L n/c. Turned to a supine position; ABD pillow in place. Patient is lethargic. MD notified.---------------------------------------------- BS 0915 1020 Pt RR up to 16; sleeping. ------------------------------------------ BS Husband in room; upset regarding restraints and confusion. ABD pillow found on floor next to bed. Attempted to explain Situation. Husband will attempt to feed patient breakfast - BS Medicated 2 mg Morphine for pain. ----------------------------- BS Husband at bedside; patient confused, but calm. RR=16; Positioned on R side, supported with pillows; ABD pillow In place. Restraints remain off; husband to inform staff if he leaves the unit. ----------------------------------------------BS Patient continues to be calm, but very confused; in pain morphine administered. Husband at bedside restraints are off. Turned to supine position with ABD pillow in place. Ate small amount of lunch; no emesis today. -------BS Husband asleep in chair; patient has pulled off dressing and Is scratching the incision. Replaced dry dressing over incision. Remains confused, but calm. -------------------------BS Fair appetite at dinner; husband in room feeding. Placed on Right side after dinner. ------------------------------------------- BS Nursing Notes (Night Shift) Time 2010 Received report; assessment complete. Patient awake Calm; husband remains in room; no restraints in place at this time. Placed in a supine position. Husband plans to Stay the night. ------------------------------------------------ SR Patient crying out; husband believes she is in pain. Administered 2 Percocets.---------------------------------- SR Patient dosing off and on; husband reports the pain medication has been effective. Turned to R side in a supported position--------------------- ----------------------- SR Assessed patient; sleeping; husband at side.------- SR Patient screaming; husband upset; attempting to calm her. Patient completely disoriented; does not appear to Recognize husband. Administered 2mg morphine- SR Patient now calmer; crying softly; husband talking with her. Turned to R side. ------------------------------------ SR Sleeping.--------------------------------------------------- SR 2215 2250 0845 0230 0410 1120 1230 0420 0620 1500 1700 1800 Day Shift: RN signature: Bobby Schofield RN signature: Nursing Tech: Randi Jones Night Shift: RN signature: Sandy Ryder RN signature: Nursing Tech:
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