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MedSurg_Careplan_041311_Reformatted.docx{GRADEDA+}

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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 N... aproxen 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 [Show More]

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