#1 Concept: Oxygenation/Perfusion
Related Data: Pt has peripheral artery
disease, hypertension, and Hx of TIA
(transient ischemic attack) and stroke
Intervention:
-Meds: Heparin (subcutaneous): 5,000
unit, 1mL, SUBCUT, Q12H
Atorvastatin 20mg oral tablet:
20mg, 1 tab, PO. DAILY, tab 0 Refill(s)
-Monitor Labs: Monitor H&H, RBC,
Platelets daily
-Weight pt daily
-Monitor VS q 1hr
#4 Concept: Elimination
Related Data: Fecal
incontinence and Rectal pain
Intervention:
-Colonoscopy
-Anorectal ultrasonography
-Monitor fecal output
-suggest Pt to take dietary
supplements and fibre
supplements
#2 Concept: Nutrition
REASON FOR ADMISSION/MEDICAL SURGICAL Related Data: Pt has Diabetes, Gout,
DIAGNOSES:
Fecal Incontinence and Rectal Pain on 03/04/2019
and Hypertension
FOCUSED ASSESSMENT: Intervention:
-63 y/o male with Hx of: Colon cancer, Rectal cancer, -Meds: NovoLog Mix 70/30 FlexPen
Chemotherapy follow-up examination,OM w/o complication subcutaneous suspension: 10 unit, 0
type II, Heart disease, Essential hypertension, History of
colonic polyps, Cerebral occlusion with cerebral infarction,
Refill(s)
Stroke, Incisional hernia, Bleed easily, Constipation, Acetaminophen Oxycodone
Diarrhea, Rectal pain, Fecal incontinence, and Abdominal 325mg-10 mg oral tablet: 2 tab PO,
pain. PRN, for 3 day, PRN: for pain:
-Pt has Gout, Hypertension, Diabetes, and Peripheral artery moderate/severe
disease. Pt is also a smoker.
-Weigh pt daily
-Pt is AOx3, well hydrated, in no distress, well developed,
well nourished. -Monitor blood sugar, FPS
-PERRLA, extraocular movement full and smooth. Skin is -Encourage pt to restrict in eating high-
warm and dry with no rashes purine foods, fructose, and sweetened
-RR is 21. Lungs are clear to auscultation and percussion, beverages
no costochondral tenderness, no gross rib deformity, normal
shape and expansion
-BP131/66, cardiovascular functions are within normal limits,
S1 & S2 normal, no murmurs and no jugular venous
distention
-Rectal exams shows no melena output, digital rectal exam
shows poor resting tone, poor anal squeeze, and no sensory
loss around the anal orifice
-Ano-rectum inspection shows multiple scars in the perineal #3 Concept: Comfort
region
-IV catheter still intact with Sodium Chloride 0.9%, to Related Data: Pt has fecal
discontinue on 06/27/29
incontinence and Rectal pain. Pt has
GOALS: Hx of colon cancer and rectal cancer
Short Term: Pt will have decreased rectal pain and improved
bowel movement by the end of care Intervention:
Long Term: Pt will have no rectal pain and normal bowel -Monitor: VS
movement and by discharge
-Asses pain
Treatment -Asses bowel movement
Fecal incontinence - R15.9 (Primary) -Meds: Norco, Stadol (IV Push),
Rectal stricture - K62.4 hydromorphone, morphine (IV push),
Change in bowel habits - R19.4 phantephrazole
Rectal pain - K62.89
-Detect if Pt has polyps
 Medication Map
Chloraseptic spray
Antiseptic

1 spray, topical, Q2H

Assess for rash, itching, redness of skin

Rash/itching/Redness of skin
Benadryl
s s
Antihistamine

Morphine zz
ine 25 mg, 0.5 mL, IV, Q4H

di
Opiod Analgesic
ach
e/
Assess for dizziness, headache,
ad
2 mg or 4 mg, 1 mL, I.V., Q2H
Na
He upset stomach
Assess for us

ch
ea

ma
/v
nausea, vomiting, constipation, om

to
iti
ng

ts
se
Up
Vomiting
Norco
ch
set
sto
ma 325 mg-7.5 mg, PO, Q4H

Up
Assess for vomiting, upset
stomach, constipation,

dr
red y
nes m
ou
s th
re
ssu
pre
blo
od
high dycard
a
ia Stadol
x br
Phenylephrine  refle Analgesic

Decongestant
2 mg, 1 mL, IV, Q4H

in
pa

50 mg, IV
Assess for dry mouth/warmth or
ch
ma

Monitor heartrate redness under the skin

sto

n
ai
tp
and blood pressure
br

in
uis

jo
ing

bl
uis
h
co
lo
re
d
sk
in
Heparin
Anticoagulant

Pantoprazole 5,000 unit, 1 mL, SUBCUT, Q12H

Proton pump inhibitor

Assess for bleeding and bruising

40 mg, 10 mL, IV, QD

Assess for fever symptoms