MEDICAL/SURGICAL
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
Student Name: Melthres Johnson Clinical Date:06/30/2018 Admission
Date:06/27/2018
Patient Initials: L.E Allergies/Reactions to: Aleve Naproxen Sodium
Age:
...
MEDICAL/SURGICAL
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
Student Name: Melthres Johnson Clinical Date:06/30/2018 Admission
Date:06/27/2018
Patient Initials: L.E Allergies/Reactions to: Aleve Naproxen Sodium
Age: 68 LMP: Patient states can’t remember
(Mark NA if not applicable)
Pain: scale used- 1-10 (Advised 2) Gravida:
1
Height: 5’6”
Location: Abdomen
Characteristics: Dull Para:
1
Weight:
Rating: 2 110.7Kg (244lb)
Duration: intermittent AB: 0 BMI:39.38
Non-verbal: n/a
Religion:
How does it affect their care? No specified
Cultural
Considerations: N/A
CHIEF COMPLAINT: Patient advised that she was feeling pretty good and this surgery was due to her ovarian cancer
diagnoses and that she feels positive out a full recovery.
HISTORY OF PRESENT ILLNESS: Patient diagnosed with ovarian cancer in 2017 chemotherapy,
and radiation have not been successful. Patient had total hysterectomy total bilateral with
general anesthesia abdominal with
PAST MEDICAL HISTORY: Urinary incontinence mixed, Post op nausea and vomiting, Ovarian Cancer, Osteopenia,
OSA(Obstructive Sleep Apnea), Muscle pain, Morbid obesity, Hiatus Hernia Syndrome, Fatigue, Esophageal reflux, Drug
induced thrombocytopenia, Drug induced neutropenia (HCC), Deficiency anemia , Asthma, Arthropathy, anxiety, Acid Reflux.
CURRENT ORDERS:
Diet: Was clear liquid changed to regular after
morning physician rounds
IVF: Order was NS, Lasix, Cephalexin
discontinued PRN oxytocin for pain,
Albuterol
Activity: To walk 4x with assist Treatments: Breathing treatment done
by respiratory team
1 MCIVB DDS 4/11
Vital Signs: BP 132/89 pulse 67 O2 94 temp 98.5
reps 16
O2: 2L discontinues @0815
Other: Patient chewing gum to aid in flatulence
and to promote Bowel Movement.
Isolation: N/A
Risks: FALL yes SKIN intact MRSA+ Neg VRE+ Neg
VITAL SIGNS:
TIME BP TEMP HR RESP O2 SAT
0800
132/89
98.5 67 16 94
1100 136/92 98.5 70 18 95
1400
129/85
98.5 65 18 95
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