General - Patient is a 34-year-old Hispanic female with several comorbidities (DM II, HTN, Anxiety, Depression), admitted on 2/10/18 due to an inability to tolerate a bedside vac change at a SNF. Pleasant, calm, sleeping often. Complains of 6/10 pain on right ankle and left thigh.
Neuro- Pt is A&Ox4. Behavior appropriate to situation. Active ROM in UE bilaterally, limited ROM on LE bilaterally due to right ankle injury and left upper thigh free flap donor site. Denies paresthesia or numbness. Verbalization clear & understandable. Reports no difficulty swallowing. No other sensory alterations noted.
HEENT- PERLA, 3+ pupils. Face symmetrical, no facial drooping, vision intact. Oral mucosa and lips pink and moist. Pt reports no difficulty swallowing. No nasal or oral drainage or reported congestion.
Heart and Lungs- Normal S1 & S2 auscultated at all heart sounds sites, no murmurs noted. All peripheral pulses present, 2+ bilaterally in upper and lower extremities. Cap RF <3 sec. 0654 vitals of BP 153/94, P 80, RR 18, T 98.8 F, O2 sat 96% on RA; 0933 vitals BP 156/90, P 82, RR 12, T 98.0 F, O2 sat 97% RA; 1129 vitals BP 149/87, P 81, RR 16, T 98.3 F, O2 sat 97% RA. Lung sounds clear anteriorly and posteriorly in all lobes, no adventitious sounds auscultated. Pt reports SOB on exertion and uses O2 mask @ 2L prn for comfort, though no O2 orders present except for O2 sat under 92%. 3+ labial and bilateral upper thigh edema.
GU- Pt had Foley removed the day before my date of care (2/19). Pt reports no difficulty or pain with urination, voids per bedpan w/ assistance. Pt voided 350 mL of clear, yellow, non-foul-smelling urine during my shift.
GI – Pt reports a decrease in appetite & only had 1 Ensure shake during my date of care. Patient reported LBM of 2/19, 2 solid BMs & 1 diarrhea. Soft non-tender abdomen. Normoactive bowel sounds present in all 4 quadrants. Carb-control diet, no caffeine, chocolate or tobacco. No N/V.
Mobility/Musculoskeletal- Pt on strict bedrest. Orders for right leg elevation. Wound connected to wound vac on right ankle. Left upper thigh donor site covered w/ mepilex. Active ROM in UE bilaterally. Patient able to reposition upper body, needs assistance w/ leg repositioning. Orders for ambulation w/ PT once bed rest orders are discontinued. Unable to transition or bathe independently.
Integumentary- Wound on right ankle covered in gauze connected to wound vac continuous @ 100 mmHg, 400 mL of serous fluid in canister. Left upper thigh donor site w/ JP drain & mepilex, 60mL serous fluid. Unable to visualize ankle wound because covered, but dressing did not appear saturated with fluid. Left upper thigh donor site clean and dry w/ no S&S of infection. Orders for PT wound care for right ankle.
IV sites- PICC right arm, last cap/dressing change 2/18. PICC connected to PCA. No continuous fluids running. No redness, swelling, or signs of infiltration/phlebitis.
Emotional- Patient pleasant and comfortable but reports of history of depression and anxiety. Compliant with bupropion and sertraline.
Safety issues-Pt on strict bed rest. Pt is a fall-risk because is on opioid analgesia and because of location of injury (ankle). Side rails up X3, bed wheels locked, call device within reach, adequate lighting provided, belongings within reach.
I & O- (0700-1300) I: 500 mL, O: 350 mL
Weight- 90.718 kg, BMI 34.3 (obese)
Pain- Pt reports 6/10 burning pain on right ankle and thigh upper thigh donor site. Pt states movement and dressing/vac changes makes pain worse, but that pain medication and relaxation helps to relieve it. Pain in localized. Pain started after ankle injury and has increased since debridement and free flap reconstruction surgery. Reminded pt of PCA usage and notified nurse of pain. Pt’s pain decreased to 4/10 once she pushed her PCA, denied prn morphine.