Header Boyd Dubois Shift Report The Patient Is Boyd Dubois Who Is 58 Yo Dob Is July 4 1963 Male And Baptist Who Under 1 (72.18 KiB) Viewed 79 times
Header Boyd Dubois Shift Report The Patient Is Boyd Dubois Who Is 58 Yo Dob Is July 4 1963 Male And Baptist Who Under 2 (72.18 KiB) Viewed 79 times
Header Boyd Dubois Shift Report The Patient Is Boyd Dubois Who Is 58 Yo Dob Is July 4 1963 Male And Baptist Who Under 3 (59.28 KiB) Viewed 79 times
Header Boyd Dubois Shift Report The patient is Boyd Dubois who is 58 yo. DOB is July 4, 1963, male and Baptist who underwent a right hip arthroplasty yesterday by Dr. James McCray. He is 74 in/188 cm and 240 lbs./108.9 Kg. He is allergic to Iodine and shellfish, both cause hives. He has a history of GERD, hypothyroidism, and COPD with a 30 pack-year smoking history, he usually does not use oxygen. He has osteoarthritis of the hips for 10 years with increasing difficulty in ambulating and recently started using a cane. He is married to his third wife who is 28 xe and estranged from his 4 children whose ages range from 22-38 se He is a Full Code and does not have and Advanced Directive. He has an order for 02 PRN to maintain SpO2 between 88% and 92%. He reports pain at the R hip incision site as 6 out of 10 and received morphine 2 mg IV 2 hours ago. He also has hydrocodonc ordered, but it has not been given Labs are H & H was 179 & 48% and now 9.9 and 27, WBCs were 7 and are now 10. Na is 135, and K+ is 3.8. He has an IV in the L forcarm with lactated ringers running at 125 ml/hour 0400 VS 99.4 F/37.4 C-78 -19 128/82 89% RA He has a right hip incision with an intact dressing, the dressing has a 2 cm diameter spot of serosanguinous drainage. Surgery will change the first dressing He also has a Jackson Pratt drain in the right hip with 10 mil of serosanguinous drainage for the night shift. He is taking ice chips well and has sipped some water. His diet may be advanced as tolerated. He said something about eating breakfast. He is on Standard Precautions and is on bedrest. Physical Therapy will sce and start ambulation today. He of course is a High Fall Risk Neuro is alert and oriented times 4 and is sleepy with morphine. Cardiac is S1 S2, sinus rhythm, no murmurs, no rubs Respiratory expiratory wheezing and crackles throughout, respirations are labored with movement. Mucous is yellow, copious, and thick & tenacious. GI/GU is active bowel sounds, no reports of heartburn, Voiding OK without difficulty continued Footer Header Integumentary is pale with circumoral cyanosis with any exertion, skin dry, there is a Rhip incision Coccyx is not reddened. Ortho/Mobility is meses all extremities and needs help moving in bed Psychosocial is pleasant and cooperative It is noteworthy that he is worried about mobility postop, he is a golfer ind is afraid he will not get to play now. The plan of care is for him to be in the hospital for 2 or 3 nights and then he will go home where his wife will take care of him. There are no pending tests and the only pending order is PT to see today. continued
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