Admission Information Billie Rubin DOB 06/15/1965

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Admission History

Admit DateDischarge DateLocationReason for Visit
2 days agoanticipated discharge 4 days post opTRU simulation hospitalsurgery

Health history

Source of Informationpatient
Reason for Visitbowel surgery
Health History6 weeks ago noticed blood in stool. 30 pound unintentional weight lost over 3 months. suspected bowel cancer. Type 2 diabetes for 7 years
Height180cmWeight79kg
AllergiesReaction type: ASA Sulfa – rashSeverity:mild
Language SpokenEnglishReading/WritingEnglish
Family Historyfamily history of cancer. grandmother died of pancreatic cancer. One brother colon cancer at 43 years old.
Previous Illnessesnone
ARO ScreeningMRSA:negativeCPO:n/aClose contact with someone positive:no
Isolation PrecautionsType: n/a
Surgical Historynone
Woundsnone
Aggressive Behavior ScreeningHistory of Violence: noPhysically violent:noVerbally Aggressive:noAGG FORM
Dietary HistoryCDA (Canadian Diabetic Association) dietDiet Type:Consistency:Regular
Substance UseType: Alcohol (beer, cider)Last Used:7 days ago
Substance UseType: n/aLast Used:n/a
Housingindependent in 2 bedroom condoBarriers:none identifiedCommunity Support:none at present
Current MedicationsDrugDoseRouteFreqComments
Metformin500 mgPOBID

Pre Admission Health Assessment

HEENT (head, eyes, ears, nose, throat): reading glasses. No hearing aids. no difficulty swallowing
Integument: denies rashes or wounds
Respiratory: work of breathing easy. Chest clear. Equal air entry bilaterally. Denies cough. Denies smoking. RR 12 SpO2 97% room air
Cardiovascular: Heart rate: 78 regular BP: 134/86 . Brisk cap refill all extremities. denies cardiovascular health issues
Gastrointestinal: blood in stool x 6 weeks. Change in bowel habits. 30 pound weight loss- unintentional. States appetite ‘normal’
Genitourinary: no change in urinary habits. describes urine as clear amber
Musculoskeletal: states no issues with mobility. No previous musculoskeletal injury. Does not use mobility aids. Independent with walking mobility
Neurologic: alert and oriented x 3. denies headaches. no history stroke / brain injury
Endocrine: type 2 diabetes x 7 years
Lymphatic: denies lymphatic health issues
Pain: denies pain
Developmental: Adult male. Lives independently. 2 grown children live out of town.
Assessment completed by: TAbout RN Date: pre op

Pre Hospital Level of Functioning Summary

Pain Management: Independentn/aComments:denies pain
Medication Management:IndependentY Comments:
Cognitive Functioning:IndependentY Comments:
Psychosocial:IndependentY Comments:2 grown children live out of town
Nutrition/Swallowing:IndependentY Comments:
Bowel/Bladder Management:IndependentY Comments:
Functional Mobility:IndependentY Comments:
Discharge Considerations: reassess post op re ADLs/ pain management. Nursing to assess diabetes management including blood glucose monitoring prior to discharge
Patient/Family Goals:discharge home day 4 as stated by surgeonDate: 2 days pre op
Patient/Family Goals:Date:

Plan of Care

SMART GOAL: Patient’s goal is ‘To be discharged home post op by day 4 post op ‘
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Patient Demographics

Last Name:First Name:Middle Name:Age:DOB:Gender:Marital Status:Ethnicity:Religion:
RubinBillie—5906/15/1965—singleCanadiannone
Address:Street 123 Apple StreetApt. #CityProvincePostal CodeMRP
102KamloopsBCB2D 8S4Spot
Home Phone:123 456 7890Cell Phone:123 456 7890
Guarantor/Legal Guardian of Minor (If different from patient)
Last Name:First Name:Middle Name:Age:DOB:Gender:Relation:
Address:StreetApt. #CityProvince:Postal Code
Home PhoneCell Phone
Employer Information – currently unemployed
Name
AddressStreetSuite #CityProvince:Postal Code
Primary Insurance Information
Name of Insurance Company:MedicarePhone:
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Emergency Contact
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