Age/ Sex :65years old female.

Account number : V 0056343723.

MR #: V000588675442.

Admission date: 07/29/2021@ 05am.

Status: Inpatient admission.

Attending doctor: Tommy Johnjus.

Patient name: Bikinis Woodwater.

Location: General Surgery.

Room 62104.

Resuscitation Status: Full code.

Primary diagnosis :Right Abdominal pain/ Nausea/Vomiting. R/O SBO.

Secondary diagnosis: Hypertension, Diabetes..

Height : 5feet 6inches.

Weight: 145lbs.

Allergy: Titus Fish.

Isolation Status: Standard Precautions.

Patient at risk for fall: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Strict NPO.

Skin intergrity impaired: No.

Suicidal risk: No.

Transportation method: Bed.

02 at 2liter NC.

Doctor orders:

Morphine sulfate 4mg IV Q4hours prn pain. Zofran 4mg IV Q4hours prn nausea.

Reglan 10mg IV Q8hours x3 first dose now.

Hctz 12.5mg ngt daily.

Tylenol 650mg ngt Q4hours prn fever. Phenergan 12.5mg IM Q8hours nausea/Vomiting.

Metoprolol 10mg ngt daily.Hold with SBP<160.

Ngt to low intermittent Suction. Flush with 30ml of normal saline Q4hours prn.

Humalog insulin per sliding scale:

BS: 60- 100 = zero insulin.

200 to 250= 2units.

251 to 300 =3units.

301 to 350 give 4units.

>351 call the doctor.

Alert and oriented ×4.

Bedside commode within reach.

D545ns@100ml/hour IV right forearm 20guage clean/ Patent/Intact.

Accucheck Q6hours while NPO.

Gastroenterology consult.

CT scan revealed small bowel Obstruction.

CBC with differential.

Bmp and magnesium in am.

K:3.4 replaced.

WBC : 7.5.

H/H 13/39.9.

Discharge plans.

Discharge patient home with daughter when medically stable.

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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