Choose the relevant data in Admission Notes
- Medical Center Brisbane (April 11)
- Colon polypectomy (April 13)
- Post-op complications at the recovery room, experienced respiratory distress, metabolic acidosis.
- Transferred to ICU and moved to regular ward on April 15
- Hooked to oxygen support at 3-5L NP as needed
- Patient uncooperative at times and requires encouragement to take medications.
- Difficulty sitting; Cannot walk around the room.
- Pain meds given as prn: Paracetamol 1g IV and Endone 2.5mg PRN for intolerable pain
- On laxative, Senna, OD at bedtime.
- Was on Foley’s Catheter; Now with adult diapers due to incontinence.
- Stable vital signs at regular ward
- O2 sat at 96-97% at 2-3L
- Wean if able to tolerate 1L
- Moderate post op pain, wound with no exudates.
- Covid19 test negative
Answer the most essential questions
|1||Patient||Ms Sydney Loten|
|2||Recipient||Ms Jane Hall, Transition Care|
|3||Request||Transfer the patient to home|
Help with transfer
|4||Admission||April 11, (this year)|
|5||Admitting Condition||Multiple polyps|
|6||Current Condition (Prognosis)||Post polypectomy|
|8||Discharge Status||Will be discharged when Oxygen availability is arranged at home.|
|9||Writer||Nurse Practitioner, current facility|
Get Ready! Decide if the following information are relevant or irrelevant!