M.C. is a 36-year-old female who had a Laparoscopic cholecystectomy. She was under general anesthesia and required a fluid bolus during the intraoperative phase. Post -Op Vitals- 98.8 Temp 86 HR 16 RR 104/65 BP O2 Sat 94% on 4 liters NC Surgical Incisions - 4 small incisions on her abdomen with glue and steri-strips Allergies – none Home medications- Aspirin Metformin Omeprazole Medical History - DM HTN GERD M.C. lives at home with her husband and 3 children between the ages of 6-12. M.C. is a stay at home mom and her husband runs his own business at the home.
Develop a care plan for this patient which will include:
1. what are two nursing diagnoses for the patient
2.. what are two things the pt is at risk for with supporting evidence related to
1. Following are the two important Nursing diadnosis which is very essential for Mrs. M.C due to her condition.
2. Following are certain Risk that may be noticed in the given case;
M.C. is a 36-year-old female who had a Laparoscopic cholecystectomy. She was under general anesthesia and...
M.C. is a 36-year-old female who had a Laparoscopic cholecystectomy. She was under general anesthesia and required a fluid bolus during the intraoperative phase. Post -Op Vitals- 98.8 Temp 86 HR 16 RR 104/65 BP O2 Sat 94% on 4 liters NC Surgical Incisions - 4 small incisions on her abdomen with glue and steri-strips Allergies – none Home medications- Aspirin Metformin Omeprazole Medical History - DM HTN GERD M.C. lives at home with her husband and 3 children between...
M.C. is a 36-year-old female who had a Laparoscopic cholecystectomy. She was under general anesthesia and required a fluid bolus during the intraoperative phase. Post -Op Vitals- 98.8 Temp 86 HR 16 RR 104/65 BP O2 Sat 94% on 4 liters NC Surgical Incisions - 4 small incisions on her abdomen with glue and steri-strips Allergies – none Home medications- Aspirin Metformin Omeprazole Medical History - DM HTN GERD M.C. lives at home with her husband and 3 children between...
48 year old female patient in post-anesthesia recovery room she just had a cholecystectomy you will be doing her assessment and plumbing team physician orders and nursing care is needed
The following documentation is from the health record of an 86-year-old female patient. Preoperative Diagnosis: Paraesophageal hernia Postoperative Diagnosis: Paraesophageal hernia Procedure: Laparoscopic reduction of paraesophageal hernia 256Indication The patient, a pleasant, 86-year-old female, previously presented with an acute onset of hematemesis. During this previous encounter an endoscopy was performed, which revealed a large portion of the patient’s stomach in her chest. The condition was discussed with the patient and her family. The options of open versus laparoscopic repair of...
M.H. is an 80-year-old Caucasian female who is married and lives with her spouse. She presents to your office today with her spouse, feeling “coocoo, I just don’t feel right.” Currently she is taking rosuvastatin prescribed by her cardiologist for hyperlipidemia and a daily 325 mg aspirin. She drinks 3-6 hard liquor drinks a day, 3-4 times a week in the evening, and has a 65-year smoking habit, currently smoking two packs per day (ppd). She has no known allergies....
Background: An 86-year-old lady was admitted to the hospital 2 days ago with a suspected bowel obstruction. She is now postoperative day 1 following laparoscopic-assisted right hemicolectomy. Surgery was done under general and spinal anesthetic with the epidural cannula at T10. Intra-operative blood loss estimated at 1.3 L. Past Medical History The patient denies past medical history, but she takes medications for HTN, CHF, arthritis, and osteoporosis. She lives alone but her son lives nearby and visits frequently. Vision is...
Susan Lee is a 60 year old female admitted to the medical surgical floor complaining of abdominal pain on and off for 4 months. Her complaints were constipation, bloating, abdominal pain and indigestion. Her CT scan diagnosed an abdominal mass. Susan’s past medical history includes COPD, Diabetes type 1, and vascular issues. Her medications include the following: Prednisone 10 mg daily Insulin glargine (lantus) 20 units at bedtime ASA 81 mg daily. Her assessment includes the following: Objective: Height :...
Code the first operative report, include any CPT surgery code(s), anesthesia code(s), and any modifiers applicable. (20 points) Code the E&M code for the second office visit. 1. Description: Bilateral open Achilles lengthening with placement of short leg walking cast. PREOPERATIVE DIAGNOSIS: Idiopathic toe walker. POSTOPERATIVE DIAGNOSIS: Idiopathic toe walker. PROCEDURE: Bilateral open Achilles lengthening with placement of short leg walking cast. ANESTHESIA: Surgery performed under general anesthesia. A total of 10 mL of 0.5% Marcaine local anesthetic was used....
Health Record Face Sheet Record Number: 79-50-77 Age: 36 Gender: Female Length of Stay: 5 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Insulin reaction Renal failure Diabetes Mellitus, Type II, long term insulin dependence Permanent catheter right internal jugular Removal peritoneal dialysis catheter DISCHARGE SUMMARY PATIENT: RAINEY INPATIENT RECORD NUMBER: 79-50-77 ADMITTED: 12-19-XX DISCHARGED: 12-24-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSES: 1. Insulin reaction. 2. Renal failure. 3. Diabetes mellitus, Type II. OPERATIONS/ PROCEDURES: 1. Permanent catheter right...