S Victoria
Smith is a 55 year old female who is second post-op day for a right
mastectomy.
B Diagnosed
with right breast adenocarcinoma, positive family
history for breast cancer. Now day 2 s/p
mastectomy.
A She is
alert and oriented. She tends to desat to 87% when she is sleeping
so she wore O2 @ 2L during the night. She received pain meds twice
last shift. She is up ad lib in the room. She is doing her
incentive spirometry to 1500. Her JP drain had 40 mL in it this
shift. She is tolerating a regular diet. Her IV came out during the
night, but it has been restarted. She is complaining some of it
hurting. She refuses to look at her breast wound. Incision is 12 cm
long, approximated, slightly red, dressing dry and intact; JP
draining 40 mL of serosanguinous fluid per shift.
R Change
dressing q shift and PRN, monitor IV, assess and treat
pain as ordered.
T 100.7 – P 88
– R 20
– B/P 126/84
– SpO2 95% on RA
– Pain 3 at incisional
site Lung sounds - crackles
Set up: No
ID band
IV fluid set correctly but should be
d/c’d today.
IV
infiltrated.
JP
drain to right mastectomy < 40 mL
Dressing
to right mastectomy.
Incentive
spirometer at bedside.
Nasal
cannula attached to wall.
- Nursing Report S Victoria Smith Is A 55 Year Old Female Who Is Second Post Op Day For A Right Mastectomy B 1 (70.42 KiB) Viewed 26 times