Patient Care Dorel McAllister DOB 01/02/ 1939

Bybnagra

Daily Assessment Record

Legend:X= YesDate: yesterday
SystemNormal CriteriaFormNotes
Safety:QPA xBedside Safety xFalls Risk Assessment xminimum 60 minute checks x
Neurological/ Cognition:Alert & orientated x 3, speech clear and understandable, memory intact, active ROM, sensation intact, no paresthesia x see notespain management flowsheet x
Cardiovascular:Regular apical/peripheral pulse, no chest pain, peripheral pulses palpable, no calf redness, extremities pink and warm, no edema xn/a
Respiratory:Resting respirations quiet & regular, symmetrical chest wall movement, pink nail beds and mucous membranes, air entry clear to bases on L&R lobe ☐ -see notes n/a
GastrointestinalAbdomen soft and non distended, tolerates diet without nausea, no difficulty swallowing, bowel pattern normal for pt, bowel sounds present ☐ – see notesLast BM preop
Genitourinary:Urinates without pain, voiding pattern is usual, urine clear, yellow ☐ – see note
Foley x
Gynecology/UrologyPerineal skin intact x, no lesions or discharge x no itch or odor xn/a
Musculoskeletal:Steady gait, no fractures/sprains/strains ☐ – see notes
1Person Assist x
Psychosocial:Interacts and communicates in an appropriate manner with others, demonstrates effective coping skills xMSE x
Integumentary:Color normal, warm, dry and intact, moist mucus membranes ☐ see notesBraden x
Wound Care ☐
Drain – JP abdomen
Pain:Denies pain ☐ – see notes
pain management flow sheet x
Other:—-—-
IV:Free of inflammation, patent, no pain, dressing intact, flushes well xType: PVAD short
Gauge: 22
Location: right forearm
Lumen #: 1
DateNurses Notes (Data/Action/Response/Notes)Provider
2 days prior @1930Admitted from PAR. Alert & oriented x3. Epidural infusion bupivacaine / fentanyl @ 6cc/hr. See flowsheet. Abdominal pain 6/10. Sharp. Abdominal splint provided. Sensory block present T10-T12 bilaterally. No evidence of motor block. Decreased air entry bilateral bases. DB&C instructed & encouraged hourly while awake. O2@ 5L / NP. SpO2 93%. RR 14. Abdomen soft, flat. no bowel sounds. denies flatus. Foley insitu. Clear amber urine. Abdominal dressing dry & intact. JP drain emerging from dressing. Scant sanguineous drainage present. All limbs warm. Brisk cap refill. 128/68 HR 70 regular ———————————————————————————————————–DG RN
yesterday @ 0740Dr. James aware of abnormal bloodwork. No orders received. No evidence of active bleeding. RA RN
last night @ 2200Epidural infusion bupivacaine / fentanyl @ 6 mL/hr. Describes abdominal pain4/10. Diminished air entry bilateral bases. Reports DB&C hourly while awake. Patient able to demonstrate effective use of incentive inspirometer. SPO2 92% 4L/ nasal prongs. RR 12. Foley insitu. Clear amber urine. 1person assist to bathroom. Gait strong bilaterally. Requires assurance. Declines offer of walker. Abdominal dressing scant shadowing. JP scant sanguineous. Tolerating clear fluids. Denies nausea.SL RN
today 0600Weight 105 kg. Increase of 5 kg since admission. Abdominal pain sharp, central lower abdomen. 8/10. Non radiating. Epidural bupivacaine fentanyl increased 8cc/ hr.SL RN

Vital Signs

DAYyesterday @ 1930 – today @ 0730 (night shift)
TIME220002000600
TEMPERATURE36.2 —-36.9
PULSE64 —-74
RESPIRATION121214
BLOOD
PRESSURE		118—-118
66—-64
SpO2 / supplemental oxygen92% 4L—-92%5L
Weight
Initials		—-
SL		—-
SL		105 kg
SL
DAYyesterday 0730-1930 (day shift)
TIME100014001800
TEMPERATURE37.537.536.0
PULSE707068
RESPIRATION161614
BLOOD PRESSURE122120120
687068
SpO2 / supplemental oxygen95% 3L95% 3L92% 2L
Weight
Initials
101kg
RA
—-
RA		—-
RA
DAY2 days ago – admission to nursing unit from PAR 1930-0730 (night shift)
TIME193020302130230002000600
TEMPERATURE36.5—-—-37.0—-36.5
PULSE70—-7274—-70
RESPIRATION141414161416
BLOOD PRESSURE128—-124126—-124
68—-6670—-68
SpO2 / supplemental O293% / 5L —-—-93% / 5L—-—-
Weight100kg—-—-—-—-—-
InitialsDGDGDGDGDGDG

Pain Management Flowsheet

In/Out Record

INTAKEDATEyesterday24 Hr Total
SHIFT:Day shift 0730-1930 *yesterdaynight shift 1930-0730 *last night
TIME:13001500193001000700
ORALsips100100100125
IV360120240330360
TUBE FEED—-—-
BLOOD—-—-
TPN—-—-
LIPIDS—-—-
Other—-—-
TOTAL3602203404304851835
OUTPUTDATEDay shift 0730-1930 *yesterday
TIME:13001500193001000700
VOID—-—-—-—-—-
FOLEY16575130165180
EMESIS00000
Other: JPscant0000
STOOL00000
TOTAL16575130165180715
24 hr
Balance		Note: Today @ 0730: + 645 mL carried from previous shift PLUS 1120 mL today = +1765mL SL RN+1120
INTAKEDATE2 days prior24 Hr Total
SHIFT:Days Nights 1930 – 0730 * admitted from PAR@1930
TIME:—-—-—-—-from OR/ PAR01300700
ORAL—-—-—-NPOsipssips
IV—-—-—-300mL360360
TUBE FEED—-—-—-—-—-—-
BLOOD—-—-—-—-—-—-
TPN—-—-—-—-—-—-
LIPIDS—-—-—-—-—-—-
Other—-—-—-—-—-—-
TOTAL—-—-—-3003603601020
OUTPUTDATEDays Nights 1930 – 0730 *admitted from PAR@1930
TIME:OR/ PAR01300730
VOID—-—-—-—-—-—-—-
FOLEY—-—-—-—-30180165
EMESIS—-—-—-—-000
Other: JP—-—-—-—-scant00
STOOL—-—-—-—-—-—-—-—-
TOTAL—-—-—-—-30180165375
24 hr
Balance		+645
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