#1 Concept: Oxygenation/Perfusion #2 Concept: Nutrition

Related Data: Pt has peripheral artery REASON FOR ADMISSION/MEDICAL SURGICAL Related Data: Pt has Diabetes, Gout,
DIAGNOSES:
disease, hypertension, and Hx of TIA Fecal Incontinence and Rectal Pain on 03/04/2019
and Hypertension
(transient ischemic attack) and stroke
FOCUSED ASSESSMENT: Intervention:
Intervention: -63 y/o male with Hx of: Colon cancer, Rectal cancer, -Meds: NovoLog Mix 70/30 FlexPen
-Meds: Heparin (subcutaneous): 5,000 Chemotherapy follow-up examination,OM w/o complication subcutaneous suspension: 10 unit, 0
type II, Heart disease, Essential hypertension, History of
unit, 1mL, SUBCUT, Q12H colonic polyps, Cerebral occlusion with cerebral infarction,
Refill(s)
Atorvastatin 20mg oral tablet: Stroke, Incisional hernia, Bleed easily, Constipation, Acetaminophen Oxycodone
20mg, 1 tab, PO. DAILY, tab 0 Refill(s) Diarrhea, Rectal pain, Fecal incontinence, and Abdominal 325mg-10 mg oral tablet: 2 tab PO,
-Monitor Labs: Monitor H&H, RBC, pain. PRN, for 3 day, PRN: for pain:
Platelets daily -Pt has Gout, Hypertension, Diabetes, and Peripheral artery moderate/severe
disease. Pt is also a smoker.
-Weight pt daily -Weigh pt daily
-Pt is AOx3, well hydrated, in no distress, well developed,
-Monitor VS q 1hr well nourished. -Monitor blood sugar, FPS
-PERRLA, extraocular movement full and smooth. Skin is -Encourage pt to restrict in eating high-
warm and dry with no rashes purine foods, fructose, and sweetened
-RR is 21. Lungs are clear to auscultation and percussion, beverages
no costochondral tenderness, no gross rib deformity, normal
shape and expansion
-BP131/66, cardiovascular functions are within normal limits,
S1 & S2 normal, no murmurs and no jugular venous
distention
-Rectal exams shows no melena output, digital rectal exam
shows poor resting tone, poor anal squeeze, and no sensory
loss around the anal orifice
-Ano-rectum inspection shows multiple scars in the perineal #3 Concept: Comfort
region
#4 Concept: Elimination -IV catheter still intact with Sodium Chloride 0.9%, to Related Data: Pt has fecal
discontinue on 06/27/29
incontinence and Rectal pain. Pt has
Related Data: Fecal GOALS: Hx of colon cancer and rectal cancer
Short Term: Pt will have decreased rectal pain and improved
incontinence and Rectal pain bowel movement by the end of care Intervention:
Long Term: Pt will have no rectal pain and normal bowel -Monitor: VS
Intervention: movement and by discharge
-Asses pain
-Colonoscopy Treatment -Asses bowel movement
-Anorectal ultrasonography Fecal incontinence - R15.9 (Primary) -Meds: Norco, Stadol (IV Push),
-Monitor fecal output Rectal stricture - K62.4 hydromorphone, morphine (IV push),
Change in bowel habits - R19.4 phantephrazole
-suggest Pt to take dietary Rectal pain - K62.89
-Detect if Pt has polyps
supplements and fibre
supplements
 Medication Map
Chloraseptic spray
Antiseptic

1 spray, topical, Q2H

Assess for rash, itching, redness of skin

Rash/itching/Redness of skin
Benadryl
s s
Antihistamine

Morphine zz
ine 25 mg, 0.5 mL, IV, Q4H

di
Opiod Analgesic
ach
e/
Assess for dizziness, headache,
ad
2 mg or 4 mg, 1 mL, I.V., Q2H
Na
He upset stomach
Assess for us

ch
ea

ma
/v
nausea, vomiting, constipation, om

to
iti
ng

ts
se
Up
Vomiting
Norco
ch
set
sto
ma 325 mg-7.5 mg, PO, Q4H

Up
Assess for vomiting, upset
stomach, constipation,

dr
red y
nes m
ou
s th
re
ssu
pre
blo
od
high dycard
a
ia Stadol
x br
Phenylephrine  refle Analgesic

Decongestant
2 mg, 1 mL, IV, Q4H

in
pa

50 mg, IV
Assess for dry mouth/warmth or
ch
ma

Monitor heartrate redness under the skin

sto

n
ai
tp
and blood pressure
br

in
uis

jo
ing

bl
uis
h
co
lo
re
d
sk
in
Heparin
Anticoagulant

Pantoprazole 5,000 unit, 1 mL, SUBCUT, Q12H

Proton pump inhibitor

Assess for bleeding and bruising

40 mg, 10 mL, IV, QD

Assess for fever symptoms