Admission Info Natasha Featherstone 10/15/1958

Bybnagra

Admission History

Admit DateDischarge DateLocationReason for Visit
TodayGoal is 3 days post-opTRU Simulation HospitalGynecological surgery

Health History

Source of InformationPatient
Reason for VisitScheduled for a Total Abdominal Hysterectomy and Bilateral Salpingo-oopherectomy
Approximately 6 months ago Natasha reported experiencing irregular vaginal bleeding, fatigue, changes in digestion and an increased urgency to urinate. Upon an internal pelvic exam, a mass was felt around her right ovary and her uterus was enlarged. An ultrasound located a large solid tumour (approx. 8cm in diameter ) which had grown into the fallopian tube and the uterus thus is regarded as a stage 2A.
Health HistoryStage 2A Ovarian Cancer
Height162 cmWeight68.37kg
Allergies NKAReaction type:Severity:
Language SpokenEnglishReading/WritingEnglish
Family History
Previous Illnesses
ARO ScreeningMRSA:CPO:Close contact with someone positive:
Isolation PrecautionsType:
Surgical Historynone
Wounds
Aggressive Behavior ScreeningHistory of Violence:noPhysically violent:noVerbally Aggressive:noAGG FORM
Dietary HistoryDiet Type:Consistency:
Substance UseType:noLast Used:
Substance UseType:noLast Used:
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Pre Admission Health Assessment

HEENT:
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Gynecology/Urology:
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Pre Hospital Level of Functioning Summary

Pain Management:IndependentY NComments:
Medication Management:IndependentY NComments:
Cognitive Functioning:IndependentY NComments:
Psychosocial:IndependentY NComments:
Nutrition/Swallowing:IndependentY NComments:
Bowel/Bladder Management:IndependentY NComments:
Functional Mobility:IndependentY NComments:
Discharge Considerations
Patient/Family Goals:Discharge home when able to manage post-operative recovery independentlyDate:Today

Plan of Care

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Patient Demographics

Last Name:First Name:Middle Name:Age:DOB:Gender:Marital Status:Ethnicity:Religion:
FeatherstoneNatasha6610/15/1958F
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