Stan Checketts

Male; 52
Allergies: Demerol
Pt admitted for: Abdominal pain and vomiting began 1-2 days ago
- Noted some "swelling" in abdomen and "feels bloated"
- Poor intake of food and fluids d/t "upset stomach"
- Bowel movement 3 days ago contained blood and mucous
- Vitals, I/O and procedures (NG tube, IV placement) done in my care would be reported.
- Pt. needs to be assessed by physician to determine if surgery is necessary for bowel
obstruction.
Continue to monitor:
Monitor vitals q4h
Assess oral cavity for any dryness or furrows on the tongue
Monitor I/O q4h, note color and odor of urine
Administer fluids as ordered
Monitor patient's level of pain
Assess IV access
Asses NG tube for proper placement and monitor output of NG tube

Pt has distended abdomen, poor skin turgor, dry mucous membranes, and has not urinated since
yesterday.

Patient is a watcher
He’s 52 years old, admitted for severe abdominal pain and vomiting that began 1-2 days ago.
His abdomen is distended, he has poor skin turgor and dry mucous membranes, and he has not
urinated since yesterday.

Vitals:
- ECG: sinus tachycardia
- HR: 120
- BP: 105/75
- RR: 28
- SpO2: 93%
- Temp: 99

Per order, IV has been started, administered NS fluid bolus 500 mL over 30 mins, NG tube on
low intermittent suction, gave 0.3 mg of buprenorphine for pain and 4 mg ondansetron for
nausea. has orders for 0.3 mg buprenorphine PRN every 6 hours for pain, and 4-8 mg ondansetron
PRN every 6 hours for nausea.

Continue ECG monitoring, assessing his vitals, and supplementing O2 to keep his SpO2 above 92%