Hi Mr. and Mrs. Gomez. This is Rudy, good morning, I will be your nurse today. She's going to be your
nurse from 7:00 a.m. to 7:00 p.m. during the day shift. She's been with us at CHRISTUS Health for
about six months and I actually trained her, so you're in very good hands. We're doing bedside
reporting so that way you are able to be involved in the bedside shift report that way you're at
able to add or help us out with anything that we may or may not have missed okay. So this is
Mr. Edward Gomez if we could check a date of birth date of birth is 10-27-1968 making him
a 45 year old male. Edward Gomez October 27 68. Excellent so he came in last night status post
right hemicolectomy with Dr. Perkins. He had the right hemicolectomy because he does have a
long-standing history of Crohn's disease. He does have two allergies we have the allergy
wristband on him and that is to penicillin's and to sulfus. He came in around 7:45 last
night we do have him on the PCA pump for pain control, he has a history of diabetes type 2,
hypertension and he is a smoker. He is on o2 two liters per nasal cannula according to the C pox
here at the bedside it was between 94 and 96 percent for me all night. Okay I see Mr. Gomez
that you have removed a we need to keep it on okay is it bothering you nose at me yeah it's
making me dry well get our respiratory and let them put a humidifier underneath so it
will help with the dryness okay. So he is up with assistance his fall score was 58 we have applied
the fall wristband okay I see that you did. He is on telly he's currently running sinus rhythm he's
been in the 70s for me read by the ghost monitor and by the tele tech. Okay what were his vitals?
Last set of vitals that I got was at 6 o'clock, okay, blood pressure was 148 over 76 temperature
was 99.1 degrees Fahrenheit respirations was 16 and heart rate was 84. The temperature is
trending up so that will be part of something that we need to monitor today to make sure that there's
no type of infection that's forming today. One thing we do worry about postoperatively is that
sometimes if you're laying around in bed for too long you kind of get some bacteria that can form
at the bottom of the lungs so that's why we want you up and out of bed today as part of our plan
for the day and Brady will also teach you about incentive spirometry today. So he does have two
IVs he has a right wrist that's a 20 gauge and he also has a right AC 20 gauge he hasn't had
any complaints of pain swelling and there's been no redness to it so it Leah both look good they
were just placed yesterday so they're at current we have a point a normal saline running at 100
that one is going into the right wrist and then we have the PCA that is running into the right AC.
Tubing is due to be changed tomorrow on the third but for now they're up to date. We also have to
check the settings for the PCA so here we go we have a fifth one milligram 15-minute walk
out for our lockout 16 milligrams and he used 8 milligrams during the shift he did have a high
blood pressure last night around midnight it was a blood pressure of 208 as you can see over 94 and
I did give him the one-time dose of a Presley and that was 10 milligrams that we had ordered
and it has resolved since then we haven't had any more issues okay. So the incision is closed
with staples we're just going to take a look at it to make sure the dressing is clean dry
and intact here we have the dressing I changed it last night around 4 a.m. and I've marked it there
he also does have a JP approximal to the incision and it is sanguinis as you can see and Dr. Perkins
isn't too worried about it but he will be around to come look at it this morning to make sure it's
okay let me make sure this is to suction. He also does have a Foley we're just gonna check and make
sure that he is secured so we don't we prevent any UTIs from happening okay all right so we have the
stat lock there excellent. He did have about of nausea last night I did get a one-time dose of
4 milligrams of zofran and he hadn't complained about any nausea after the administration Foley
was 20 200 milliliters for me okay and it's a dark amber color so the plan for today take that Foley
catheter out so you're able to get up and ambulate and we do want you to ambulate two to three times
today and have all your meals in the chairs okay and then also we have a CBC ordered for you just
so we can get a blood draw and see how your blood levels are and then nine o'clock meds seems that
you only have 20 units of lantus for your type-2 diabetes and then also 10 milligrams list and a
pearl for your hypertension those are due at nine o'clock correct all right excellent. I'm gonna
go ahead and update the board here and before I go over there I just want to make sure you have
your call light with you call us if you need to get out of bed so we follow some safety measures
and you don't. I don't want to have to bother you or anything my wife can help me I can get up if I
ever okay well it's truly not a bother we're here to make sure that you're safe and you don't fall
and cause any more injuries okay so please do not hesitate to call okay and I see that he has
the fall band on here and that just alerts our staff that you're a high fall risk so we keep a
closer eye on you okay and I'm gonna make sure we have yellow socks for you non-skid very good all
right and we have to side reel's up you can use that to turn and that prevents you from falling
as well if you just in case you fall asleep or anything okay so gonna put my name on the board
and hopefully we can have a great day together. Thanks for including us with your report and so we
remind you my name again is Riddhi and I'm a CNA today her name is Tina in my charge nurse her name
is Amanda and this right here is the pain scale I like to update it just so I know I can keep track
of how your pain is doing so zero being no pain 10 being really really painful. Where would you
say your pain is at I'm about a 4 right now about a 4 okay and is that a charter bill pain for you
yeah that's great well how about we make it a 3 a goal to aim at 3 okay and then we'll try to keep
track of it okay and if you need anything else let me know I'll check on you in a little bit.