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Ramona Stukes med-surg Room 304 Comprehensive Evaluation

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Ramona Stukes Room 304 Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Non-significant past medical history. No known allergies (NKA). Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Neuro WNL, a ...

Ramona Stukes Room 304 Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Non-significant past medical history. No known allergies (NKA). Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Neuro WNL, alert, and cooperative. Skin warm and dry, daily dressing changes, T-tube without drainage. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. NPO with small amount of ice chips only. Today's weight 226. IV D5 1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). Ambulates with assistance. Dr. Levine You responded correctly to 6 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status assessment reports NG tube possibly D/C'd, NPO with ice chips only. Fall Risk Increased acuity Status assessment reports NG tube, Today's weight 226, IV left forearm, Pain medicine 2hrs ago at 1300, Ambulates with assistance. Health Change Increased acuity Status assessment reports patient is 3rd day post-op resection. NG tube possibly D/C'd. Today's incentive spirometry Tidal Volume is 1250ml…, NPO. Pain Level Increased acuity Patient is receiving Demerol for pain Psychological Needs Normal acuity Status assessment reports indication of increased psychological acuity Sensorium Normal acuity Status assessment reports no indication of increased LOC acuity You correctly diagnosed 10 out of 10 options: Physiological Description Your Response Explanation Bleeding, Risk for True Status assessment reports surgical site Description Your Response Explanation Constipation False Patient would be "at Risk" for nursing concern. Deficient Fluid Volume, Risk for True Status assessment reports patient is receiving treatment for this possible nursing concern. Dysfunctional Gastrointestinal Motility False Patient would be "at Risk" for nursing concern. Imbalanced Fluid Volume False Patient would be "at Risk" for nursing concern. Impaired Mobility True Status assessment reports patient's surgical site and abdominal movement.

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