Summary – Mel LaFleur
Patient Summary
| MRP | Dr. B. Geeze | |||||
| Admit Date | Day of admission | |||||
| Primary Diagnosis | #Rt Hip, Respiratory distress, Confusion? | |||||
| SECONDARY DIAGNOSES | COPD, Hypertension, Osteoarthritis, Diabetes | |||||
| Implanted Device | ||||||
| Blood Consent | Blood Type: | |||||
| Aggression | History of Violence: No | Physically Aggresive: | No | |||
| Behaviour | Verbally Aggresive: No | Violence Prevention Toolkit: | ||||
| Religion | 2 worlds: Indigenous elements and member of the Protestant Church | |||||
| OXYGEN | SUCTION | |||||
| SURGERY | Awaiting consult | |||||
| DRAIN | ||||||
| WOUND | ||||||
| Isolation | Code Status: | Link to MOST | ||||
| Substance Use | Last Use: | |||||
| Alcohol Use | occasional | 2 drinks a month | Last Use: | 3 months ago | ||
| Tabacco Dependence: | Last Use: | |||||
| ALLERGIES | Reaction type: | Severity: | ||||
| Reaction type: | Severity: | |||||
| Reaction type: | Severity: | |||||
| DIET | Diabetic, low sodium | |||||
Patient Monitoring
| DIET | Diabetic, no difficulty, tolerating 80% meal tray | |||||
| V S | Temp (F): 36.9 | Pulse: 86 | Resp Rate: 18 | BP: 148/68 | O2: 95% RA | |
| I & O | Day: | 1500 | Night: | 1200 | ||
| FOLEY | Day | Night | DC date: | |||
| TUBES | Type: | Type: | ||||
| IV Lines: | NS@75 | Pain: | Morphine regular | Pain Level: | 6/10 | |
| Collection: | Urine C&S | |||||
| Pending Tests & Diagnostics: | ||||||
| Appointments: | Social Worker | |||||
| Blood Glucose (Time/ Reading) | 0730 8.9 | 1130 9.9 | 1630 11.2 | 2030 12.6 | ||
