OBJECTIVE DATA:
Traces of serosanguineous effluent (discharge that contains both blood and clear yellow liquid-blood serum) in ostomy bag upon arrival
Ht: 5'6", Weight: 109 lbs
Temp: 98.8, 97.6, 98.0, 98.2
Pulse: 114, 62, 68, 68
Respirations: 22, 16, 16, 18
BP: 100/60, 94/56, 98/58, 98/60
O2: 95%, 96%, 98%, 98%
Nail beds pink, good capillary refill.
Pt.'s skin is pale, warm, and dry to the touch.
Mouth/throat- pink, dry mucosa, no lesions. Ulva rises on phonation.
Intake: 475, 280 mL
Output: 710, 725 mL
Heart & lung sounds- HR elevated, S1 and S2 normal-breath sounds clear, no adventitious sounds.
Abdomen-soft, flat, no apparent masses. Skin smooth. Hyperactive bowel sounds present. Tympany to percussion in all 4 quadrants. Liver/spleen palpated-no masses. Moderate overall abdominal tenderness. No rebound tenderness or guarding. Ileostomy present on the lower right hand side of the abdomen-draining semi liquid stool with red streaks.
Musculoskeletal/neurologica exams intact.
SUBJECTIVE DATA:
Pt. states her abdomen feels "very sore and crampy," also stating her pain is at a level 6 (0 out of 10 pain scale). She states the pain is at "top of my stomach." Pt. states stress is the aggravating factor of her pain. Pt. states when she's stressed "I don't eat healthy foods and then I get headaches and take Ibuprofen."