NURSING HANDOFF REPORT

Patient: SC Age: 52-year-old Gender: Male Room: Ht: 160 cm Weight: 76 Kg

Date of Admission: 10/23/2020 LOS: Code Status: Full
Allergies: Demerol Advance Directives:
Isolation: Standard T: 99
Diagnosis: Rule out Preoperative bowel obstruction HR; 128
Pertinent History: complaints of severe abdominal pain, nausea, RR: 29
and vomiting over the last few days O2 Sat: 90%

Neuro: Alert and oriented x 3 dizzy and weak B/P: 107/77

CV: Normal heart sounds Pain: Pain is a 4 in his stomach
Telemetry Status/Changes: Sinus tachycardia Pain Meds: Buprenorphine
Edema: None Time of last Dose: 1351
Pulses: present and Strong, 130 bpm
Resp: beathing 28 breaths per minute. Chest is moving normally on Blood Glucose Results: None
both sides
O2: after SBAR conversation: 2 L /min Nasal cannula, 91% O2 sat
Chest Tube: None
GI: Hyperactive bowel sounds Activity/Safety: No activity
Diet: Morse Fall Risk Score: none
G tube: None Equipment: none
NGT placed on intermittent suction
Restraints: none
GU: Abdomen distended, has not urinated since yesterday IV/PICC/Central Line: Peripheral IV
dry and intact
Foley Cath: None
NS IV bolus 500 mL over 30 min
Date Inserted/Removed: None
Insertion Date: 10/23/2020
Dressing Change: none
Labs: Hematocrit test, Potassium level, serum, Chloride level, Skin: cold and decreased skin turgor
serum
Dry mucous membrane
Venous blood sample: Hb high 20, high HCT 60, high WBC 17 Braden Scale Score: None
high Na+ 150, high Cl- 108, high BUN 42, high creatinine 1.9
Incisions/wounds: None
metabolic alkalosis later upon drawing up labs

Meds: Buprenorphine, Ondansetron

Diagnostics: Abdominal x-ray Psychosocial: Appropriate and calm
Planned Procedures: Discharge Plan: Medication
management