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Stonyfield
Tori Merrick
Created on November 16, 2024
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Transcript
Patient admitted two days ago for chronic back pain with numbness and tingling in R leg for 6 months. Neuro: Alert and Oriented x4 Cardiac: NSR Access: L forearm PIV Respiratory: Lung sounds clear and equal bilaterally GI: Positive bowel sounds Vascular: CMS intact Integumentary: Incision CDI, closed with staples covered with ABD pad. Hemovac draining moderate amount of serosanguineous drainage Patient complaining of 5/10 sharp incisional pain You note: bilateral crackles on auscultation Hemovac output: 80ml/4hrs, serosanguineous
POD 1 Laminectomy L2-L5
Surgical History
Summary
HTN, CAD, Chronic back pain
Medical History
Order Kardex
MAR
Labs
Vitals
Full Code Allergies: None
Rebecca Stonyfield 55 yo, Female
Summary
Order Kardex
MAR
Labs
Vitals
Summary
Order Kardex
MAR
Labs
Vitals
VS & CMS Every 4hrs Heart Healthy diet Strict I/Os every 4hrs OOB as tolerated with TSLO brace IS every hour while awake CBC, Chem-7 daily Notify provider for: Temp ≥ 38.5, UOP ≤ 240ml/8hrs, SBP ≥ 120 ≤ 90, DBP ≥90 ≤60, HR ≥120 ≤ 60, RR ≥28≤12, O2 sat <92%
Summary
Order Kardex
MAR
Labs
Vitals
Hydromorphone (10mg/50ml) PCA dose 0.3mg, Lockout interval 10 min, Max 1hr limit 1.8mg, loading dose 0.3 mg
Ondansetron 4mg IVP PRN Q6H nausea
Diphenhydramine 25mg IVP PRH Q6H itching
NS 100ml/hr
Acetaminophen 650mg PO Q6H
Senna 1 tab Daily
Docusate Sodium 100mg PO daily
Atorvastatin 20mg PO Daily
Metoprolol 50mg PO Daily
Summary
Order Kardex
MAR
Labs
Vitals