ID: Name, Age, Sex, Post-Op Day #, after what kind of surgery?, Abx day #___,
24hr events/subjective complaints: Including presence or absence of nausea, vomiting, flatus, BM, ambulation, pain, chest pain, SOB, and other PERTINENT info.
Vitals: Tmax, Tcurrent, BP (range over 24 hrs), HR(range over 24 hrs) RR (range over 24 hrs), Blood sugars (AM, Afternoon, PM)
Total In/Total Out:
Intake in total over past 24 hrs: ____ cc, of that ______ cc from IV, ______ cc Nasogastric tube, ________ cc PO etc...
Output (Just urine) in total over past 24 hrs: ____ cc total, ____CC/kg/hr
PE: Lungs – CTA bil
Heart – RRR, no M/R/G
Abdomen – soft, ND/NT, normoactive BS
Wound – well-approximated, no erythema or d/c
Stoma – pink, patent, productive of stool
Ext – no edema
Assessment: __ year old man/woman POD#___ after ______________________ progressing well
Plan: (Systems based):
Neuro: Pain control adequate, continue PCA, OOB, ambulate today
CV: Mild tachycardia, will bolus with 500cc isotonic crystalloid and reevaluate
Resp: No issues, continue spirometry
GI: Await return of bowel function, continue NPO, NGT
GU: U/O marginal, continue to monitor closely after volume load, Replete electrolytes
Heme: HCT 27 and stable, continue SQ Heparin
ID: Perioperative abx D/C'd, afebrile, check WBC today
Endocrine: Continue ISS, BS well controlled
Disposition: Whats keeping them from going home?