17TH CASE SCENARIO. (NURSING)APPENDICITIS/ TREATMENT.

Age 56years Sex Male.Unit Q000099977

Admitted Date 02/15/2013

Attending doctor: Dr. Robert Hate.

Medical record number :Q00009594963.

Medical/Surgical Floor. Room: 42066.

CODE STATUS: Full Code. GCS 15

Alert and Oriented × 4.

Lungs clear. RA.

Diagnosis: Acute Appendicitis.

PSH: Bowel Resection 09/20/2011.

PMH: Diverticulitis, RLQ Abdominal pain(unbearable pain),Nausea/Vomiting.

Consultation: Dr. Nor Smile.

Lap Appy and Lysis Adhesion 02/15/13.Abdominal incisions × 3 sites with demoband.

Activity: As tolerated. SCD while in bed.

Incentive Spirometry 10times Q1hour while awake.

Abdomen: Hypoactive Bowel sounds.

DIET : Clear liquid diet. Allergy: NKDA.

Home Medications reviewed and reconciled.

Medications:

Zosyn 3.375gm IV Q8hrs.

Flagyl 500mg IV Q8hrs.

Morphine 2mg IV Q3 prn breakthrough pain.

Zofran 4mg IV Q4hours prn nausea/Vomiting

Narco 5/325mg 2tablets po Q4hours prn pain.

PLAN:

Discharge home with daughter.

Discharge in two days if:

No temperature 24hours.

Labs in am CBC WITH DIFFERENTIAL. CHEMISTRY 7.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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