317 PATIENT WITH SIGNS AND SYMPTOMS OF POSTOP COMPLICATIONS 221 3-17 PATIENT WIT

Question

317 PATIENT WITH SIGNS AND SYMPTOMS OF POSTOP COMPLICATIONS 221 3-17 PATIENT WITH SIGNS AND SYMPTOMS OF POSTOP COMPLICATIONS 1500 Handoff Report SMs. B 23 years old, had an emergency appendectomy yesterday. She has Down syndrome. She has gotten up to the chair twice today. Surgical dressing is clean, dry, and intact. Bowl sounds are hypoactive. Her IV is infusing well; you have 200 mL left Oral intakc is 100 mL and output is 400 mL I gave her mor- phine sulfate 8 mg IVP at noon for complaint of pain at a level of 8. Her roon vital signs are T 100°F P 80, R 20, BP 110/78 ox 9896 The following information is obtained from Ms. P's electronic medical record: Intake and Output Record Patient, p-Age: :23. Sex: T ? 58072; Room: 214 | Drug allergies: fNKDA Focd allergies: None 7-3 shift: 2 .9 Intake Amt Output Tme Amt Void(000 50 (0900 50 (1100) 75 (1200) 50 (1300) 75 (1400) 100 100 Diet: Clear liquid Ambulate with assistanca IV: 1 L D5/0.9% NaCl @ 125 mLhr LFA 22 g engiocath IV: 900 IVPB:50 Emesis: (1200 100 500 Routine Ccfoxitin 1 g IVPB q8h (1000 1800 0200) PRN Morphine sulate 8 mg IVP q4h pm pain Mctcclopramide 10 mg IVP qeh pm NV Scheduled Tima Tctal 1050 180 Collaborative Leaning Activity: Wich a partner, use the clinical situation and the electronic medical record to: 1. Identify the pertinent 2. Identity the pertinent 3. Review the data in patient information made known to you in the handoff report. patient information made known to you from the electronic medical record.needs follow-up. columns 1 and 2 and identity information that Copyight2018, Elsevier Inc. All rights reserved.

Explanation / Answer

1 In this case scenario it is mentioned that patient has a rise in temperature of 100degree celcius and another thing which need to be highlightened is the reduced bowel sounds ,as it is a sign of slowed intestinal activity.Anothe one is where the pain subsided after giving morphine shot.it is not said whether the pain is reduced or not after giving morphine.

2 From the EHR ,the intake and output chart can be visibly observed which shows oral intake is significantly poor and at the same time patient has vomited ,indicates a hypoactive bowel.

3 I think ,bowel sounds need to be observed and temperature be reassesed .It should be monitored frequently,as there might be chances of infection.

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