Physician Progress Notes Time Mon S/P HoLEP Procedure without complications; estimated blood loss < 100 ml; stable condition to recovery room. 1530 To be admitted to Urology following PACU. Dan Stein, MD Mon S/P HoLEP. Stable, doing well. Denies pain CV: HRRR; Lungs Cl. Temp 36.4. A few small clots noted in Foley; 2200 CBI running; cherry red. Plan to D/C CBI at midnight. Dan Stein, MD Tues S/P HoLEP POD #1 Stable, doing well. CBI D/C last midnight, Voided 200 ml of dark urine overnight no clots, urine 0740 light red. Mild discomfort. Patient reports sleeping well. Good appetite. CV: HRRR; Lungs Cl; Abd soft. Plan: Discharge home with instructions for follow up in 1 month. Dan Stein, MD
Drug Allergies: PCN Neighborhood Hospital Physician Order Sheet Date Time Order Mon 1530 Admit to Urology Service S/P HoLEP Diet: Cl liq; advance as tolerated to regular Vitals: every 4 hours x 24 hours; then every 8 hours. Activity: Up ad lib SCDs to legs until ambulating independently Oxygen: 2 L n/c as needed to keep O2 Sat >90% Foley with CBI to gravity drainage, discontinue (DC) at midnight Check PVR in am. If > 150 ml contact surgeon. Do not insert Foley catheter; call surgeon. I&O q 8 hours IV D5W 0.45% NaCl rate: 125 ml/hour; DC when taking oral intake adequate. Maintain IV Reseal Meds: Ciprofloxacin 500 mg by mouth every 12 hours x 2 doses, start on arrival to unit oxybutynin chloride 2.5 mg by mouth every day Tylenol #3 for moderate pain one tab by mouth every 4 hours as needed morphine sulfate 2-4 mg IV every 1-2 hours as needed for severe pain acetaminophen with codeine 650 mg by mouth every 4-6 hours as needed for temp > 38.0 C ondansetron 4 mg IV every 4-6 hours as needed for nausea. Drug Allergies: PCN Date Time Order Tues 0730 Discharge home with follow-up instructions Continue home meds except for Proscar Signature: Dan Stein, MD Print Name: Dan Stein, MD
Medication Administration Record Drug Allergies: PCN Scheduled Medications Order Date Medication Dose, Route, and Frequency Sched Time Administered Mon ciprofloxacin 500 mg by mouth every 12 hours 1600 1600 BS 0400 0400 NJ Mon oxybutynin chloride 2.5 mg by mouth twice a day 0800 2000 2000 NJ Non-Scheduled Medications Order Date Medication Dose, Route, and Frequency Mon Tylenol #3 for moderate pain 1 to 2 tabs by mouth every 4 hours as needed administration 2000 1530 Mon morphine sulfate 2-4 mg IV every 1-2 hours as needed for pain 1530 Mon morphine sulfate 2-4 mg IV every 1-2 hours as needed for pain 1530 Mon ondansetron 4 mg IV every 4-6 hours as needed for nausea. 0530 Signature: Dan Stein, MD Print Name: Dan Stein, MD
Nurses Flow Sheet Medical Surgical Units Initial Shift Assessment (Day Shift) Time Assessment Completed: 1610 Mental Status/Neuro Orientation: Sleepy; awakens easily. OR x 3 Pupils: 3 mm bilaterally Glasgow: N/A Psychosocial: calm Fall Assessment Score: 4 Low Risk Respiratory Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Oxygen 2 L n/c Abdomen Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender n/a Skin Braden Score: 21 Low risk Color: pink Moisture: dry Temp: warm Wounds: none Drains: Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S1S2; no murmurs Edema: absent Pulses: 2+ L and R lower extremities Cap Refill: <2 secs L & R LE IV Sites: Left forearm (FA); site without redness/swelling, fluid infusing GU/Genitalia Urine: dark red, clots present; CBI infusing Genitalia: WNL, no breakdown noted Foley; patent Head/Neck Eyes: clear, without drainage Ears: hearing intact Nose: clear, without drainage Mouth: mucous membranes pink, moist, no lesions noted. Lymph: deferred Musculoskeletal Movement: moves all extremities Sensation: + sensation, toes/feet bilaterally Special Equipment or Additional Assessment: Initial Shift Assessment (Night Shift) Time Assessment Completed: 1940 Mental Status/Neuro Orientation: awake Pupils: 3 mm bilaterally Glasgow: N/A Psychosocial: calm Fall Assessment Score: 4 Low Risk Respiratory Respiratory Effort: Even and unlabored Breath Sounds: Clear all lung fields Oxygen 2 L n/c Abdomen Contour: flat, non-distended Bowel Sounds: + all quandrants Palpation: soft, non-tender n/a Skin Braden Score: 21 Low risk Color: pink Moisture: dry Temp: warm Wounds: none Drains: none Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S1S2; no murmurs Edema: absent Pulses: 2+ L all extremities Cap Refill: <2 secs all extremities IV Sites: Left FA; site without redness/ swelling GU/Genitalia Urine: clear, cherry red Genitalia: WNL, no breakdown noted Foley; patent; CBI infusing Head/Neck Eyes: clear, without drainage Ears: hearing intact Nose: clear, without drainage Mouth: mucous membranes pink, moist, no lesions noted. Lymph: deferred Musculoskeletal Movement: moves all extremities; ambulatory; steady gait Sensation: + sensation all extremities Special Equipment or Additional Assessment:
Vital Signs (day shift) Time BP HR RR T O 2 Pain BG Sat 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 132/88 86 16 36.2 98% 4 1700 1800 Fluid Intake Time Type Amount Running Total 0700 0800 0900 1000 1100 1200 1300 1400 1500 From OR 475 1600 IV D51/2 NS CBI 125 150 750 1700 IV D51/2 NS CBI 125 150 1025 1800 IV D/C d CBI Oral 125 150 1620 320 1900 CBI 100 1720 2000 CBI 100 1820 2100 CBI 100 1920 2200 CBI 100 2020 2300 CBI 100 2120 0000 DC CBI 50 2170 24 hour intake total 2170 Vital Signs (night shift) Time BP HR RR T O 2 Pain BG Sat 1900 2000 130/80 92 18 37.3 96% 6 2100 2 2200 2300 2400 126/74 88 16 37.1 95% 0100 0200 0300 0400 122/76 84 16 37.2 96% 2 0500 0600 Fluid Output Time Type Amount Running Total 0700 0800 0900 1000 1100 1200 1300 1400 1500 Foley PACU 660 660 1600 1700 1800 Foley 740 1400 1900 2000 2100 2200 Foley 900 2300 2300 2400 DC d Foley 500 2800 0100 0200 0300 0400 voided 200 3000 0500 0600 24 hour output total 3000
Nursing Notes (Day Shift) Time 1610 Arrived to floor post-op HoLEP in stable condition. Pt communicates clearly and without difficulty. IV infusing. L forearm; site patent; Foley patent; CBI infusing; dark red drainage with clots noted; patient complaining of spasms in bladder. Increased CBI flow rate.- LP 1800 Ate 100% of dinner meal; reports no nausea. CBI infusing and patent; no clots noted. Taking PO, IV D/C d. LP Nursing Notes (Night Shift) Time 1945 Assumed care; assessment complete. Stable. CBI fluid slowed. NJ 2000 Pt complaint of mod discomf. Medicated for pain. NJ 2100 Pt states pain 2/10. NJ 0300 Pt. sleeping soundly; CBI discontinued. NJ 0430 Patient voided 200 ml of dark red urine. NJ 0500 Denies pain; patient asleep. NJ 0640 Pt.states he slept well through the night; experiencing minimal discomfort- NJ 0730 Report off to day shift Day Shift: RN signature/initials: Linda Paulson / LP Night Shift: RN signature/initials: Nishell Jackson / NJ Nursing Tech:
Nurses Flow Sheet Medical Surgical Units 0700 Tuesday 0700 Wednesday Initial Shift Assessment (Day Shift) Time Assessment Completed: 0730 Mental Status/Neuro Orientation: Awake, alert, fully oriented to person, time, place Pupils: 3 mm bilaterally Glasgow: NA Psychosocial: calm Fall Assessment Score: 4 Low risk Respiratory Respiratory Effort: even and unlabored Breath Sounds: Clear all lung fields Oxygen 2 L n/c Abdomen Contour: flat, non-distended Bowel Sounds: + all quadrants Palpation: soft, non-tender n/a Special Equipment or Additional Assessment: Skin Braden Score: 21 Low risk Color: pink Moisture: dry Temp: warm Wounds: none Drains: none Cardiovascular Cardiac Rhythm: HRRR Heart Sounds: S1S2; no murmurs Edema: absent Pulses: 2+ L all extremities Cap Refill: <2 secs all extremities IV Sites: GU/Genitalia Urine: clear, cherry red Genitalia: WNL, no breakdown noted Void via urinal Head/Neck Eyes: clear, without drainage Ears: hearing intact Nose: clear, without drainage Mouth: mucous membranes pink, moist, no lesions noted. Lymph: deferred Musculoskeletal Movement: moves all extremities; ambulatory; steady gait Sensation: + sensation all extremities Special Equipment or Additional Assessment:
0700 Tuesday 0700 Wednesday Vital Signs (day shift) Time BP HR RR T O 2 Pain BG Sat 0700 0800 120/70 84 16 37.2 96% 1 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 Nursing Notes (Day Shift) Time 0730 Assessment completed. PVR < 70 ml. MD notified. Dr. Stein visiting with patient. Per MD discharge home today. BS 0800 Ate 100% of breakfast tray. Reports having large BM; states he feels good and feels ready to go home.. BS Day Shift: RN signature/initials: Bobby Schofield / BS RN signature/initials: Nishelle Jackson / NJ Nursing Tech: