Patient Introduction Location Emergency Department Time 04 00 Situation Stan Checketts A 52 Year Old Widower Arrive 1 (42.55 KiB) Viewed 64 times
Patient Introduction Location Emergency Department Time 04 00 Situation Stan Checketts A 52 Year Old Widower Arrive 2 (38.1 KiB) Viewed 64 times
Patient Introduction Location: Emergency Department Time: 04:00 Situation: Stan Checketts, a 52-year-old widower, arrived in the Emergency Department 30 minutes ago with severe abdominal pain. A small bowel obstruction is suspected. Background: He has experienced worsening abdominal pain, nausea, and vomiting for 1-2 days with inability to eat or drink much over the last few days. His past surgical history includes a cholecystectomy, appendectomy. and right inguinal hemia repair, all more than 5 years ago. Assessment: Mr. Checketts is awake and states he has felt "dizzy" and "weak all evening. His vital signs upon arrival were: BP: 108/73; temperature: 100.9 °F (38.3 °C), pulse: 110; respiratory rate: 22, and SpO2: 95% on room air. He has poor skin turgor, dry mucous membranes, and has not urinated since yesterday. His abdomen is distended. He signed an informed consent for treatment. A right forearm saline lock was placed, and labs, a CBC, and BMP were drawn. Recommendation: You will need to check the provider's orders just written and see if the lab results are back.
Provider's Orders Feb 7 03:30 Administer normal saline 500 mL IV bolus wide open Oxygen to maintain SpO2 greater than 92% ECG monitoring Diet: NPO Insert nasogastric (NqXtube to low intermittent suction Confirm NG tube placement with radiology of kidneys, ureters, and urinary bladder (KUB) Labs: Complete blood count Chemistry profile Diagnostic CT of abdomen Meds: Ondansetron 4 mg IV push every 6 hours PRN for nausea/vomiting Morphine 2 mg IV push every 4 hours PRN for moderate pain level 4-7 Morphine 4 mg IV push every 4 hours PRN for severe pain level 8-10
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