Shift Report
B- Background
Emily Grace, 45 year old femaile admitted to Medical Surgical
unit with a small bowel obstruction. Has a 4 day history of
abdominal pain and vomiting, with up to 12 vomiting episodes per
day. The Mrs Grace has had an uncomfortable night. Her pain has
been from 6-8 on a scale of 0-10. She has had minimal relief with
morphine. The pain seems to be worse this morning. Her husband has
been with her tonight, and he is quite worried and frustrated. Mrs.
Grace says her pain is in the upper abdomen with right side worse
than left. the pain is intermittent and feels like bad labor pains.
Her abdomen is distended and diffusely tender to palpation. her
abdomen seems more distended this morning. There are minimal,
hypoactive bowel sounds present. The NG drained 600 mL dark brown
green drainage this shift. Her urine output was 75mL with dark
yellow, thick urine. Vomitus is blood streaked at times. Medical
history includes hypertension X 8 years, Type 2 diabetes X 12
years.
A- Assessment
Had an uncomfortable night. Her pain has been from 6-8 on a
scale of 0-10. She has had minimal relief with morphine. The pain
seems to be worse this morning. Her husband has been with her
tonight, and he is quite worried and frustrated. Mrs. Grace says
her pain is in the upper abdomen with right side worse than left.
the pain is intermittent and feels like bad labor pains. Her
abdomen is distended and diffusely tender to palpation. her abdomen
seems more distended this morning. There are minimal, hypoactive
bowel sounds present. The NG drained 600 mL dark brown green
drainage this shift. Her urine output was 75mL with dark yellow,
thick urine. Cool pale skin, poor skin turgor, dry
mucous membranes, capillary refill >5 sec. Disoriented to time
and place, tries to get out of bed when alone, answer questions
inconsistently, restless.
R- Recommendation
Review orders and assess
- S Situation Shift Report B Background Emily Grace 45 Year Old Femaile Admitted To Medical Surgical Unit With A Small 1 (57.69 KiB) Viewed 42 times