SAMPLE ADMITTING CHART FOR MALE PATIENT WITH ACUTE APPENDICITIS

Patient Information:
Name: Pablo Munzon
Sex: Male
Address: Dasmarinas, Cavite

Admission Details:
Date and Time of Admission: August 24, 2020 / 9:35am
Reason for Admission: Abdominal Pain

Primary Diagnosis
Diagnosis: Acute Appendicitis
Symptoms: Severe abdominal pain, nausea, vomiting

Vital Signs on Admission

BP: 130/90
CR: 88bpm
RR: 19bpm
T: 36.5
Wt.: 60kg

Medical History
Past Medical History: N/A
Medications: N/A
Allergies: N/A
Social History: smoke and alcohol seldom

Chief Complaint and Present Illness

The patient presented with a chief complaint of severe abdominal pain, which started around the navel
and migrated to the right lower quadrant over 24 hours. The patient reports associated symptoms of
nausea, and vomiting.

Physical Examination Findings

Abdominal examination revealed tenderness, guarding, and rebound tenderness in the right lower
quadrant.
No other significant findings on physical examination.

Treatment Plan
Treatment: Surgical intervention with laparoscopic appendectomy.
Preoperative Medications: (refer to the doctors order)
NPO Status: Patient to remain NPO (nothing by mouth) for surgery.

Nursing Care Plan

Pain Management: Administer pain medications as ordered to alleviate severe abdominal pain.
Fluid Management: Initiate IV fluids to correct dehydration and maintain hydration.
Antibiotics: Administer antibiotics (e.g., cefoxitin) as ordered to control infection.
Vital Signs Monitoring: Continuously monitor vital signs and report any abnormalities promptly.
Nausea Control: Administer antiemetic medications as needed.
Patient Education: Provide information about the surgical procedure, postoperative care, and discharge
instructions.

Consultations
Surgical Consultation: Consulted (Surgeon's Name), who recommends appendectomy.
Anesthesia Consultation: Consulted (Anesthesiologist's Name) for anesthesia assessment.

Patient and Family Education

The patient and family were educated about the surgical procedure, potential risks, and benefits.
Information on postoperative care, including wound care and pain management, was provided.
Instructions on when to seek medical attention post-discharge were given.

Admitting Physician: ___________

Date and Time: _______________
Nurse’s Signature: ____________
Date and Time: _______________

Some info were gathered from google sites