General Appearance - Speech

Affect and facial expression appropriate to situation. Patient not observed

OOB. Speech clear.
Skin-Color, texture, hygiene, moisture
Skin mostly warm and dry. Braden score- 20. Catheter insertion site found
with dried sanguineous urine around meatus. Area cleaned thoroughly. R
midline dressing covered with Telfa cloth adhesive dressing soaked with dried
blood inferior to incision, gauze covering changed, JP drain intact. Midline
and 2 groin incisions at top of each leg clean, dry and well approximated with
derma bond. No other skin lesions or breakdown
Room and equipment - IV fluids, IV access - Tube feedings - Drains,
Foley
D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. R wrist PIV
medlocked. Foley catheter. JP drain from R midline incision drained 19 ml
sanguineous fluid, drain reactivated. (Drain later removed by MD, incision
left clean, dry and intact).
Neuro - LOC, pupils - Hand grips - Feet flexion, extension
Oriented x4. Grips, flexion, extension strong bilaterally.
C-V: pulses Heart: rhythm, S1, S2, extra sounds Capillary refill JVD, bruits
Edema
S1, S2 auscultated over aortic, pulmonic, erbs point, tricuspid
and mitral areas. Pulse rate 70. Radial 3+, R dorsalis pedis 2+ . Cap refill <3
sec. No JVD. Or bruit. No edema.
Resp: rate, rhythm, depth, effort Accessory muscle use Chest expansion
Breath sounds
Rate 20, even, unlabored respirations. No accessory
muscles used. Breath sounds clear in all areas.
GI: abdominal shape, appearance bowel sounds x 4 tenderness last BM,
usual pattern
Abdomen round and soft. Bowel sounds x 4.Tenderness
only in compromised areas. No BM since the day before operation (3/4/08).
G-U: voiding pattern Amount, color, clarity, Urgency, frequency, pain on
voiding Bladder tenderness or distention
180 ml clear amber urine
drained from Foley catheter. No pain or bladder tenderness reported. No
distention.
Psy/ Soc - Family/ support systems
Lives with wife, who will be caregiver as needed upon discharge

Pain - Intensity (specify tool)- Location, character - Associated signs/

symptoms - Pain interventions and effectiveness
Pain noted at 6 on the number scale. Pain medication administered and pain
noted at 3 on same scale 30 minutes later.
Rest/ Sleep - Usual pattern/ changes since hospitalized - Sleeping
aids used
Pt reported no sleep problems other than hospital required interruptions.
Other: specific to your patient, incl. Dressings/ treatments
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General Appearance - Affect, facial expression, posture, gait Speech

Flat affect. Posture stupped. Gait unsteady and weak. Speech clear.
Affect
and facial expression appropriate to situation. Posture erect. Gait weak.
Speech clear.
Skin - Color, texture, hygiene, moisture - Braden score - Intactness,
lesions, breakdown
Skin pink, cool and dry. Braden score- 18. Abdominal sagittal midline well
approximated incision with packed wound at inferior and superior ends, both
approx 1 cm in circumference and 11-12 mm in depth, no site redness or
swelling, scant sanguiness drainage. Three puncture wounds from
laparoscopic nephrectomy, well approximated, covered with steri-strips
located right medial midline, inferior and superior left lateral abdominal area,
no site swelling or redness. No other skin lesions or breakdown found. Skin
pink, cool and dry. Braden score- 17. Abdominal sagittal midline well
approximated incision with packed wound at inferior and superior ends, both
approx 1 cm in circumference and 11-12 mm in depth, no site redness or
swelling, scant serosanguiness drainage. Three puncture wounds from
laparoscopic nephrectomy, well approximated, covered with steri-strips
located right medial midline, inferior and superior left lateral abdominal area,
no site swelling or redness. No other skin lesions or breakdown found.
Room and equipment - IV fluids, IV access - Tube feedings - Drains,
Foley
NS at 50 ml/hr in 22 gauge LFA IVAD, insertion date 6/1/08. Dressing clean,
dry, intact and reinforced with . No other tubes, drains, or Foley. 22 gauge

LFA S/L, insertion date 6/1/08. Dressing clean, dry intact, and reinforced with .
No other tubes, drains, or Foley.
Neuro - LOC, pupils- - Hand grips - Feet flexion, extension
Oriented x4. Grips, flexion, extension strong bilaterally.
PERRL. Grips, flexion, extension strong bilaterally.

Oriented x4.

C-V: pulses Heart: rhythm, S1, S2, extra sounds Capillary refill
JVD, bruits

Edema
S1, S2 auscultated over aortic, pulmonic, erbs point, tricuspid and mitral
areas. Pulse rate 72. Radial pulse 2+, dorsalis pedis and posterior tibial
pulses 1+ bilaterally. Cap refill <2 sec. No JVD or bruit. Non-pitting edema in
hands and feet bilaterally. S1, S2 auscultated over aortic, pulmonic, erbs
point, tricuspid and mitral areas. Pulse rate 76. Radial pulse 2+, dorsalis
pedis and posterior tibial pulses 1+ bilaterally. Cap refill <2 sec. No JVD or
bruit.
Resp: rate, rhythm, depth, effort Accessory muscle use Chest
expansion - Breath sounds
Rate 20, even, unlabored respirations. No accessory muscles used. RLL wet,
all other breath sounds clear.
Rate 20, even, unlabored respirations. No
accessory muscles used. Breath sounds clear in all areas.
GI: abdominal shape, appearance bowel sounds x 4 tenderness last BM, usual pattern
Abdomen firm and round. Bowel sounds x 4. General abdominal tenderness
reported. Reported last BM was formed 5/31/08.
Abdomen firm and round.
Bowel sounds hyperactive x 4. Soft stool at approx 10:00 after administration
of Ducolax suppository.
G-U: voiding pattern Amount, color, clarity, Urgency, frequency, pain
on voiding - Bladder tenderness or distention
230 ml clear, yellow urine. No pain, urgency, frequency or tenderness with
voiding reported. No bladder distention reported. Reported voiding x 2 this
morning. No pain, urgency, frequency or tenderness with voiding reported.
No bladder distention reported.
Psy/ Soc - Feelings or concerns r/t hospitalization, illness. Recent

stressors, anxiety or depression. Family/ support systems

Pt transferred from rehab facility and expects to go back to another facility
prior to going back home where wife is caregiver. Wife has arthritis and back
problems, so in-home assistance may be needed for a period of time. Pt
concerned about pet (Beauty) and not being able to take her on long walks
which they both enjoy. Not being able to do this and anticipating never being
able to do this along with unrelieved pain and lack of sleep caused pt to say
if I had a gun, I would shoot myself. Daughter (who is able to give some
support for pt and caregiver) and wife are arranging placement for pt into a
rehab facility upon expected discharge today. Pt is please that he has been
able to self ambulate today, but has concern of repeated evisceration.
Pain - Intensity (specify tool) - Location, character - Associated
signs/ symptoms - Pain interventions and effectiveness
Pain noted at 5 on the number scale at incision site and radiating to right
side. PRN Oxycodone pain medication administered with no relief within 30
minutes. PRN acetaminophen administered with pain decreased to a 3 with
30 minutes. Patients report of consistent lack of pain relief reported to his
nurse. Pain noted at 5 on the number scale at incision site and radiating to
right side. PRN Oxycodone pain medication administered with pain decrease
to 3 within 30 minutes.
Rest/ Sleep - Usual pattern/ changes since hospitalized - Sleeping
aids used
Pt reported not being able to get any sleep due to unrelieved pain.
reported reduced pain and was able to get rest during the night.

Pt

Other: specific to your patient, incl. Dressings/ treatments

Abdominal incision site packed with NuGauze, covered with (2) 44, left
untapped, then covered with binder. Two abdominal pads placed underneath
top edge on binder to prevent chaffing. Dressing changed by Dr. during
rounds this morning. Dressing found clean and intact with scant amount of
sanguiness drainage during assessment. Order for dressing change TID.
Abdominal incision site dressed with approx. 4 inches NuGauze (both
superiorly and inferiorly), covered with (2) 44, tapped, then covered with
binder. Two abdominal pads placed underneath top edge on binder to prevent
chaffing. Dressing changed 11:00 and found scant amt of serosanguiness
drainage on the both pieces of NuGauze. Order for dressing change TID.