Briefly describe assessment finding in the areas outlined below. Include any additional abnormal findings that are not listed below. Physical Assessment Data?RANGE OF FINDINGS (ESPECIALLY IF UNSTABLE)

Date of Care:
Patient Initials: G M Age: 75 Gender: FEMALE

Reason for Hospitalization:
Abdominal pain, Perforated Diverticulitis
Surgical Procedures with dates: post day 4 Exploratory laparotomy, with sigmoidectomy, colostomy on the left abdomen, and Hartmann’s procedure/end colostomy. 3/8/15, Post menopausal hormone replacement at the age of sixty.
Admitting Medical Diagnosis: Abdominal pain, Perforated Diverticulitis Vitamin –D deficiency

Current Medical Diagnosis: Abdominal pain, Perforated Diverticulitis. Vitamin-D deficiency, vertigo,

Past Medical & Surgical History: CVA, 3 years ago, post menopausal hormone replacement at the age of sixty one 14 years ago. vertigo
Smoking History: Formal smoker, quit more than one year ago

Allergies: Patient stated no drug or food allergies known.

Psychosocial and Cultural Assessment

Marital Status: 0 married 0 single 0 divorced 0 partnered 0 widowed
Occupation (if retired, list previous): Was Elementary school teacher for 36 years. Retired 15 years ago.
Mood/Affect: calm but looks drowsy.
Ethnicity: African American.
Other relevant psychosocial and cultural data: Has two children, one is a medical doctor, (OBGYN), with one daughter that is in pre med school. Another is a collage chemistry professor, also has one daughter and two grand children. Her husband died of colon cancer 5 years ago at the age of 77 years old, also was a retired social worker and a deken at the church. Her both parents died at the earlier age. has one brother with the hx of CVA, HTN, Never use any ETOH/substance abuse.

Advance Directives (Nursing Admission Assessments)

Do not resuscitate (DNR) order: 0 yes 0 no Living will: 0 yes 0 no

Physical Assessment Data?RANGE OF FINDINGS (ESPECIALLY IF UNSTABLE)
ASSESSMENT PARAMETER FINDINGS
Temp:
7:30am 99.9
10:00am 98.7 (3/11/15)
12:00am 98.3
HR
7:30am 76
10:00am 84 (3/11/15)
12:00am 86
RR:
7:30am 18
10:00am 18 (3/11/15)
12:00pm 20
SpO2 (pulse oximetry):
7:30am 97% room air
10:00am 98% room air (3/11/15)
12:00am 98% room air.
BP:
7:30am 136/67 position lying l/arm
10:00am 128/ 59 position sitting l/arm (3/11/15)
12:00pm 124/60, position lying l/arm
PAIN Assessment:
TYPE OF PAIN SCALE: (Note location, intensity etc.) At the time of assessment patient verbalized no pain round the stoma and surgical site pain 0/10. patient stated the “nurse gave me Percocet an about one and half to two house ago this am ok for now”

Height 66.0 method wing span. Weight: 166lbs 11 oz (75.60kg) lying down bed scale. 3/11/15
BMI: 26.8
CHANGE from BASELINE? How much? + or –Mrs GM is overweight. Normal weight range would be from 115to 150 pounds.
Hemodynamic Monitoring
(IF APPLICABLE) n/a
Swan Ganz catheter:
location, waveform, dressing, readings: n/a
Arterial line:
location, waveform, dressing, Allen’s sign: n/a
Balloon pump:
location, dressings, settings, distal pulses n/a
REVIEW OF SYSTEMS
Briefly describe assessment finding in the areas outlined below.
Include any additional abnormal findings that are not listed below.
Physical Assessment Data?RANGE OF FINDINGS (ESPECIALLY IF UNSTABLE)