Download Neighborhood Hospital Physician Progress Notes

Allen, Clifford
MR #7691614449
Neighborhood Hospital
Physician Progress Notes
Mon
1530
S/P TURP POD #1. Procedure without complications; estimated blood loss < 100 cc; stable condition
to recovery room. To be admitted to Urology following PACU. Dan Stein, MD
Mon
1720
S/P TURP. Stable, doing well. Some bladder spasm earlier today; pain well controlled with
morphine & B&O suppository. CV: HRRR; Lungs Cl. Temp 36.4. Hem 15 g/dl; Hct 40%. A few
small clots noted in Foley; CBI running; cherry red. Dan Stein, MD
Tues
0740
S/P TURP POD #2 Stable, doing well. CBI continues, but slowing; no clots, urine light red. Mild
pain. Patient reports sleeping well. Good appetite. Temp 37.3.Hem 14 g/dl; Hct 37%. CV: HRRR;
Lungs Cl; Abd soft. Dan Stein, MD
Tues
1800
Doing well. CBI discontinued; no clots. Occasional mild pain reported well controlled with percocet.
Urine pale red, clearing. Good appetite. Plan discharge in am. Dan Stein, MD
Wed
0640
S/P TURP POD #3. Stable, doing well. No clots or excessive bleeding; no bladder distention; urine
tea colored, output adequate. HRRR; lungs clear, Eating well; Abd soft . Temp 36.6. Hem 14.2 g/dl;
Hct 37%. Will DC Foley to day and discharge after void; follow up in office on Friday.
Dan Stein, MD
Allen, Clifford
MR #7691614449
Neighborhood Hospital
Physician Order Sheet
Drug Allergies: PCN
Date Time
Order
Mon 15:30 Admit to Urology Service S/P TURP
Diet: Cl liq; advance as tolerated to regular
Vitals: every 4 hours x 24 hours; then every 8 hours.
Activity: Up ad lib
Oxygen 2 L n/c as needed to keep O2 Sat >90%
Foley with CBI to gravity drainage
I&O q 8 hours
IV D5 0.45% NaCl rate: 125/hour; DC when taking oral intake adequate.
Meds: cephalexin 500 mg by mouth every 6 hours
oxybutynin chloride 2.5 mg by mouth every day
docusate sodium 100 mg by mouth every day.
morphine sulfate 2-4 mg IV every 1-2 hours as needed for pain
B & O suppository one per rectum every 8 hours as needed for unrelieved bladder spasm.
acetaminophen 650 mg by mouth every 4-6 hours as needed for temp > 38.0 C
promethazine 12.5-25 mg IV every 4-6 hours as needed for nausea.
Labs: H & H now and in AM
Signature: Dan Stein, MD
Print Name: Dan Stein, MD
Drug Allergies: PCN
Date Time
Order
Tues 0730 H & H in AM
DC CBI today at noon.
DC Morphine.
Percocet 1 or 2 tablets by mouth as needed for pain.
Signature: Dan Stein, MD
Print Name: Dan Stein, MD
Drug Allergies: PCN
Date Time
Order
Wed 0640 DC Foley
Discharge home this afternoon after successful voiding.
Make appointment for office visit on Friday.
Rx for cephalexin 250 mg by mouth every 6 hours.
Signature: Dan Stein, MD
Print Name: Dan Stein, MD
Allen, Clifford
Neighborhood Hospital
MR #7691614449
Date: 0700 Monday – 0700 Tuesday
Medication Administration Record
Scheduled Medications
Order Medication Dose, Route, & Frequency
Date
Mon
cephalexin 500 mg by mouth every 6 hours
1530
Mon
1530
Mon
1530
Sched
Times
08
16
24
oxybutynin chloride 2.5 mg by mouth twice a day
08
20
Colace 100 mg by mouth once a day
08
Non-Scheduled and One Time Medications
Order Medication Dose, Route, & Frequency
Date
Mon
Morphine Sulfate 2-4 IV mg every 1-2 hours as
1530 needed for pain
Mon
1530
Mon
1530
Mon
1530
Allergies:
BPH; S/P TURP
Monday
Stein
PCN
16
24 NJ
20 NJ
Administered
B & O suppository one per rectum every 8 hours as
needed for unrelieved bladder spasm.
Tylenol 650 mg by mouth every 4-6 hours as needed
for temp > 38.0 C
Promethazine 12.5-25 mg IV every 4-6 hours as
needed for nausea.
Diagnosis:
Admission Date:
Physician:
Administered
1640, 4 mg
1945 4 mg NJ
0430 2mg NJ.
2030 NJ
Signature
Nishell Jackson, RN
Initial
NJ
Allen, Clifford
Neighborhood Hospital
MR #7691614449
Date: 0700 Tuesday – 0700 Wednesday
Medication Administration Record
Scheduled Medications
Order Medication Dose, Route, & Frequency
Date
Mon
cephalexin 500 mg by mouth every 6 hours
1530
Mon
1530
Mon
1530
oxybutynin chloride 2.5 mg by mouth twice a day
Non-Scheduled and One Time Medications
Order Medication Dose, Route, & Frequency
Date
Mon
Morphine Sulfate 2-4 IV mg every 1-2 hours as
1530 needed for pain
Mon
B & O suppository one per rectum every 8 hours as
1530 needed for unrelieved bladder spasm.
Mon
Tylenol 650 mg by mouth every 4-6 hours as needed
1530 for temp > 38.0 C
Mon
Promethazine 12.5-25 mg IV every 4-6 hours as
1530 needed for nausea.
Tues
Percocet 1 or 2 tablets by mouth as needed for pain
0730
Allergies:
BPH S/P TURP
Monday
Stein
PCN
Administered
08
16
24
0800 BS
1600 BS
08
20
0800 BS
08
20
Colace 100 mg orally every day.
Diagnosis:
Admission Date:
Physician:
Sched
Times
2400
2000
NJ
NJ
0800 BS
2000
NJ
Administered
0800 Percocet 2 tabs BS
1510 Percocet 2 tabs BS
Signature
Initial
Bobby Schofield, RN
BS
Nishell Jackson, RN
NJ
Allen, Clifford
Neighborhood Hospital
MR #7691614449
Date: 0700 Monday – 0700 Tuesday
Nurses Flow Sheet – Medical Surgical Units
Initial Shift Assessment (Day Shift)
Time Assessment Completed: 16:10 pm
Mental Status/Neuro
Orientation: Sleepy; awakens easily. OR x 3
Pupils: 3mm bilaterally
Glasgow: N/A
Psychosocial: calm
Skin
Respiratory:
Cardiovascular
Cardiac Rhythm: HRRR
Heart Sounds: S 1 & 2; no murmurs
Edema: absent
Pulses: 2+ L and R lower extremities
Cap Refill: < 2 seconds L & R LE
IV Sites: Left FA;site without
redness/swelling
Other:
Fall Assessment Score: 4 Low Risk
Respiratory Effort: Even and unlabored
Breath Sounds: Clear all lung fields
Equipment: Oxygen 2 L n/c
Other:
Braden Score: 21 Low risk
Color: pink
Moisture: dry
Temp: warm
Wounds: none
Drains:
Other:
Head/Neck:
Eyes: clear, without drainage
Ears: hearing intact
Nose: clear, without drainage
Mouth: mucous membranes pink, moist, no
lesions noted.
Lymph: deferred
Musculoskeletal:
Movement: moves all extremities;
Sensation: + sensation toes/feet bilaterally
Equipment:
Other:
Equipment:
Other:
Abdomen:
Contour: flat, non-distended
Bowel Sounds: + all quadrants
Palpation: soft, non-tender
Equipment: n/a
GU/Genitalia
Urine: dark red/clots present; CBI infusing
Genitalia: WNL, no breakdown noted
Equipment: Foley; patent
Special Equipment or Additional
Assessment
Other:
Other:
Initial Shift Assessment (Night Shift)
Time Assessment Completed: 1940
Head/Neck:
Eyes: clear, without drainage
Ears: hearing intact
Nose: clear, without drainage
Mouth: mucous membranes pink, moist, no
lesions noted.
Lymph: deferred
Mental Status/Neuro
Orientation: awake
Pupils: 3mm bilaterally
Glasgow: N/A
Psychosocial: calm
Skin
Respiratory:
Cardiovascular
Cardiac Rhythm: HRRR
Heart Sounds: S 1 & 2; no murmurs
Edema: absent
Pulses: 2+ L all extremities
Cap Refill: < 2 seconds all extremities
IV Sites: Left FA; site without
redness/swelling
Musculoskeletal:
Movement: moves all extremities;
ambulatory; steady gait.
Sensation: + sensation all extremities.
GU/Genitalia
Urine: clear, cherry red
Genitalia: WNL, no breakdown noted
Equipment: Foley; patent; CBI infusing
Special Equipment or Additional
Assessment
Other:
Fall Assessment Score: 4 – low risk
Respiratory Effort: Even and unlabored
Breath Sounds: Clear all lung fields
Equipment: Oxygen 2 L n/c
Other:
Braden Score: 21 Low risk
Color: pink
Moisture: dry
Temp: warm
Wounds: none
Drains: none
Other:
Equipment:
Other:
Equipment:
Other:
Abdomen:
Contour: flat, non-distended
Bowel Sounds: + all quadrants
Palpation: soft, non-tender
Equipment: n/a
Other:
Other:
Allen, Clifford
MR #7691614449
Date: 0700 Monday – 0700 Tuesday
Vital Signs (day shift)
Time BP
HR RR T
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
132/88
86
16
Fluid Intake
Time
Type
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
FROM OR
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
Oral
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
IV D51/2 NS
CBI
24 hour intake total
36.2
O2
Sat
98%
Amount
475
125
150
125
150
125
150
320
125
100
125
100
125
100
125
100
125
100
125
100
125
100
125
100
125
100
125
100
125
100
125
100
Pain
BG
Vital Signs (night shift)
Time
BP HR RR T
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
8
2
Running
Total
750
1025
1700
1620
1800
1845
1900
2070
2000
2295
2100
2520
2200
2745
2300
2970
2400
3195
0100
3420
0200
3645
0300
3870
0400
4095
0500
4320
0600
4320
Pain
8
2
130/80
92
18
37.3
96%
126/74
88
16
37.1
95%
122/76
84
16
37.2
96%
Fluid Output
Time
Type
1400
1500
1600
O2
Sat
Amount
5
Running
Total
Foley PACU
660
Foley
740
1400
Foley
900
2300
Foley
840
3140
Foley
880
4020
24 hour output total
BG
4020
Allen, Clifford
MR #7691614449
Date: 0700 Monday – 0700 Tuesday
Nursing Notes (Day Shift)
Time
Time
1610
Arrived to flow post-op TURP in stable condition. Pt
communicates clearly and without difficulty. IV infusing.
L forearm; site patent; Foley patent; CBI infusing; dark red
Drainage with clots noted; patient complaining of spasms in
bladder. Increased CBI flow rate.------------------------ LP
1945
Medicated with morphine 4 mg IVP for pain.---------- LP
Patient verbalizes some pain relief.; pain now rated at 2/10
Ate 100% of dinner meal; reports no nausea. CBI infusing
and patent; no clots noted. ------------------------------------ LP
2150
Patient reports pain nearly gone; states suppository was
0030
Very effective. CBI continues to infuse; slowed rate; urine
Light red color.-------------------------------------------------- NJ
Pt. sleeping soundly; CBI infusion assessed; Foley
1640
1700
1800
Nursing Notes (Night Shift)
2030
0430
0500
0640
Day Shift:
RN signature:
RN signature:
Nursing Tech:
Assumed care; assessment complete. Stable. States is
having more pain 8/10– spasm in bladder Medicated with
morphine.------------------------------------------------------- NJ
Pain has decreased to 6/10, but still experiencing bladder
spasm. B&O suppository administered. -----------------NJ
patent.------------------------------------------------------------NJ
Patient requesting pain medication; rates pain 5/10.
Administered 2 mg morphine.----------------------------- NJ
Pain reassessment; patient asleep.------------------------- NJ
Pt states he slept well through the night; experiencing
minimal discomfort. Foley and CBI patient--------------- NJ
Night Shift:
Linda Paulson LP
RN signature: Nishell
RN signature:
Nursing Tech:
Jackson, RN
Allen, Clifford
Neighborhood Hospital
MR #7691614449
Date: 0700 Tuesday – 0700 Wednesday
Nurses Flow Sheet – Medical Surgical Units
Initial Shift Assessment (Day Shift)
Mental Status/Neuro
Orientation: Awake, alert, fully oriented to
person, time, place
Pupils: 3mm bilaterally
Glasgow: N/A
Psychosocial: calm
Other:
Fall Assessment Score: 4 Low Risk
Respiratory:
Respiratory Effort: Even and unlabored
Breath Sounds: Clear all lung fields
Equipment: Oxygen 2 L n/c
Other:
Skin
Time Assessment Completed: 0730 am
Head/Neck:
Eyes: clear, without drainage
Ears: hearing intact
Nose: clear, without drainage
Mouth: mucous membranes pink, moist, no
lesions noted.
Lymph: deferred
Braden Score: 21 Low risk
Color: pink
Moisture: dry
Temp: warm
Wounds: none
Drains:
Other:
Cardiovascular
Cardiac Rhythm: HRRR
Heart Sounds: S 1 & 2; no murmurs
Edema: absent
Pulses: 2+ L and R lower extremities
Cap Refill: < 2 seconds L & R LE
IV Sites: Left FA;site without
redness/swelling
Musculoskeletal:
Movement: moves all extremities; smooth
even gait.
Sensation: + sensation toes/feet bilaterally
Equipment:
Other:
Equipment:
Other:
Abdomen:
Contour: flat, non-distended
Bowel Sounds: + all quadrants
Palpation: soft, non-tender
Equipment: n/a
GU/Genitalia
Urine: light red, no clots; CBI infusing;
slow rate.
Genitalia: WNL, no breakdown noted
Equipment: Foley; patent
Other:
Other:
Special Equipment or Additional
Assessment
Initial Shift Assessment (Night Shift)
Mental Status/Neuro
Orientation:Fully awake, alert
Pupils: 3mm bilaterally, PEERLA
Glasgow: N/A
Psychosocial: calm
Other:
Fall Assessment Score: 4 Low Risk
Respiratory:
Respiratory Effort: Even and unlabored
Breath Sounds: Clear all lung fields
Equipment:
Other:
Time Assessment Completed: 2030
Skin
Braden Score: 21 Low risk
Head/Neck:
Color: pink
Eyes: clear, without drainage
Moisture: dry
Ears: hearing intact
Temp: warm
Nose: clear, without drainage
Wounds: none
Mouth: mucous membranes pink, moist, no
Drains:
lesions noted.
Other:
Lymph: deferred
Cardiovascular
Cardiac Rhythm: HRRR
Heart Sounds: S 1 & 2; no murmurs
Edema: absent
Pulses: 2+ L and R lower extremities
Cap Refill: < 2 seconds L & R LE
Musculoskeletal:
Movement::smooth even gait; moves all
extremities;
Sensation: full sensation.
Equipment:
Other:
IV Sites:
Equipment:
Other:
Abdomen:
Contour: flat, non-distended
Bowel Sounds: + all quadrants
Palpation: soft, non-tender
Equipment: n/a
Other:
GU/Genitalia
Urine: tea colored/ no clots present
Genitalia: WNL, no breakdown noted
Equipment: Foley; patent
Other:
Special Equipment or Additional
Assessment
Allen, Clifford
MR #7691614449
Date: 0700 Tuesday – 0700 Wednesday
Vital Signs (day shift)
Time BP
HR RR T
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
Pain
120/70
84
16
37.2
96%
6
2
128/74
88
18
36.8
97%
2
122/78
86
18
36.7
98%
4
1
Fluid Intake
Time
Type
0700
O2
Sat
D50.45% NaCl
CBI
D5 0.45%
CBI
Oral
D50.45%NaCl
CBI
CBI
Oral
CBI
CBI
Oral
BG
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
Running
Total
100
50
50
50
380
50
50
50
120
50
50
420
150
0700
630
0800
730
0900
900
1000
950
1420
1100
1200
240
1660
Oral
360
2020
Oral
240
2260
120
2380
2380
120/80
84
16
Fluid Output
Time
Type
Amount
Oral
24 hour intake total
Vital Signs (night shift)
Time
BP HR RR T
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
36.8
O2
Sat
Pain
97%
1
Amount
BG
Running
Total
Foley
800
800
Foley
620
1420
Foley
520
1940
Foley
24 hour output total
590
2530
2530
Allen, Clifford
MR #7691614449
Date: 0700 Tuesday – 0700 Wednesday
Nursing Notes (Day Shift)
Time
0730
0800
0850
1010
1230
1510
1600
1800
Assessment completed. Dr. Stein visiting with patient.---- BS
Pt reports pain – percocet 2 tabs; ate 100 % breakfast. DCd
oxygen; O2 sat = 96% on room air. -------------------------- BS
Pain reassess; pt reports relief.-------------------------------- BS
IV DC’d; cath tip intact.; site without redness/swelling. Pt
Ambulating on unit. ---------------------------------------BS
Ate 100% of lunch; no nausea reported. Urine tea-colored
Encouraged high oral fluids next couple of days to flush
bladder; see Teaching Record--------------------------------- BS
Patient reports pain; percocet 1 tab administered.------ BS
Pain reassessment; reports relief of pain. ------------------ BS
Reports having large BM; states he feels good and will
be ready to go home in the morning. Ate 100% of dinner.
Foley patent with tea colored urine; no clots----------------- BS
Day Shift:
RN signature: Bobby Schofield, RN
RN signature:
Nursing Tech:
Nursing Notes (Night Shift)
Time
2030
2130
0030
0245
0630
Assessment completed. Patient states he feels “really
excellent” and is looking forward to going home in AM NJ
Discharge teaching; see Teaching Record. ----- NJ
Ambulating on unit; denies pain; states can’t sleep. NJ
Pt requested 1 Percocet for slight pain. No clots noted in Foley bag. -------------------------------------------------------NJ
Dr. Stein morning rounds; discussing discharge with pt.
New orders noted. Foley DC’d. Instructed patient to drink
plenty of fluids and save next void in urinal.------------- NJ
Night Shift:
RN signature: Nishell
RN signature:
Nursing Tech:
Jackson, RN