Order 1103231: Clinical Case study post op

URN O75486

SURNAME Roberts

GIVEN NAME Darren

ADDRESS 25 Happy St

Cairns

DATE OF BIRTH 23/11/1968 DOCTOR Smith

4/03/2018

2230

M R

3 2

4

P R

O G

R E

S S

N O

T E

S

PROGRESS NOTES Including Initial History and Examination

NURSING: O/A: Presented to ED with an acute episode and recent Hx of upper epigastric pain. P’t report pain 7/10 radiating across upper abdomen,and has a positive Murphy's sign. ------------------------- CNS: Pt. is alert and orientated to person place and time, GCS -15, PEARLA. Morphine 5mg administered via 18g IVC inserted in L)hand. NVS: CWMS present in all peripheries, Capillary refill <3sec, and Pedal pulses present. CVS: HR 99bpm/reg, BP, 155/88, Temp - 37.6, Nil Chest pain, Base line ECG attended. Resp: RR 26rpm, minimal increase in WOB, pt. able to speak in full sentences, nil cough or sputum, O2Sats 95% RA, air entry Equal/Bilateral on auscultation, nil adventitious breath sounds, GIT: History of N&V for last few days, nil since admission, Bowel sounds present in all 4 quadrants, Bowels regular and patient continent of bowels and urine, BGL 3.5mmol, increase pain on gentle palpation consistent with positive Murphy's sign. Integ: Braden Score - 18, skin intact, slightly warm and moist. ADLS: Pt. normally attends to all ADLS independently. Safety: provided with call bell and explained how and when to use it, Social: No NOK present, pt.s son lives in Melbourne -pt. is worried about him, Pt owns his own company and is also concerned about how this will run without him on site. Declined pastoral care. MSE: Pt. is anxious regarding needing to be admitted to hospital ....................................................................................Sally Grimm RND1 Medical 0300: Bloods, Ultrasound and CT Scan R/V'd by surgical team and diagnosis of Acute Cholecystitis. Consent gained by patient for a Cholecystectomy +/- Open procedure. Patient prepared for transfer to surgical ward when bed is available. Plan: Theatre at 0800 in the morning. Anaesthetist will see p’t in the AM ...........................................................................................................................................GBrigs RMO Medical 0315: Documentation from emergency admission is incomplete, this will be sent to the ward ASAP .........................................................................................................................................G Brigs RMO Nursing: Darren transferred to surgical ward @ 0400 hours from ED. CNS: GCS 15, alert & oriented, Pain 2/10 at rest, 3/10 on movement, CVS: HR90 reg, BP 110/85, T37.8, nil chest pain, IVC insitu in L) hand, VTE assessment completed, TED stockings insitu Resp: RR 20, nil increase in WOB, able to speak in full sentences, O2Sats 96%RA, GIT: nil N&V, Fasting for procedure in the morning, Safety: Pt, oriented to ward, provided with call bell and instructed when and how to use it. Social: AWS assessment attended, made arrangements for Darren to contact his son and business in the morning prior to surgery...... Di Symes RND1................................................................................................................................................................. Nursing:Darren seen by anaethetist at 0700hrs, Consent signed, Ed documentation has arrived and is in patients file, Pre-operative checklist completed. Awaiting tansfer to theatre.............Rachel Mckenzie RND1 Nursing:Patient transferred to theatre @ 0740hrs.......................................................Rachel Mckenzie RND1

5/3/18 0300

5/3/18 0315 5/3/18 0400

5/3/18, 0715hrs

5/3/18, 0740hrs