Reference no: EM133219674
Primary Admitting Diagnosis: Ulcerative Colitis
Notes: Diagnosed with ulcerative colitis. Follow up with gastrointestinal physician as consulted. Complains of abdominal pain. Decreased appetite and multiple loose stools everyday for the past three days.
Family History: Patient's grandmother diagnosed with ulcerative colitis at age thirty.
Pain Scale:
Pain Location - Abdomen
Frequency- Intermittent
Type of Pain - Chronic
Pain Goal - 0 No Pain
Aggravating Factors - Movement, Coughing
Alleviating Factors - Rest, Medication, Immobility
Pain Scale Used - Wong Baker FACES
Pain Characteristics - Aching
Previous Nursing Notes
1. Admitted to bed 6 in emergency room. Complaints of pain, see flowsheet. MD wishes to admit. Orders provided, will follow.
2. Admitted and transferred to pediatric unit per MD orders. Gastroenterology admitting. Vital signs stable. Transported via stretcher with parent to unit. Care released to Lovett, RN.
3. Admitted to unit per emergency room. Report received from Ross, RN. See flowsheet for details. Parent at bedside. no concerns at present time
4. Mother pulled emergency call light. Xavier in bathroom doubled over in pain and can't get off the toilet. Screaming "Something hurts really bad!." Assisted Xavier back to bed, call light in reach, bed in low position, mother at bedside. Provider notified.
Vital Signs (Last three sets taken)
Blood Pressure - 102/58, Heart Rate - 88, Respiratory Rate - 20, Oxygen Saturation - 100 on room air, temperature 98 oral
Blood pressure - 98/56, Heart Rate - 90, Respiratory Rate- 18, Oxygen Saturation- 100 on room air, temperature 98.2 oral
Blood Pressure - 106/60, Heart Rate - 88, Respiratory Rate- 22, Oxygen Saturation- 100 on room air, temperature 98.2 oral
Intake/Output
Intake - 60mL (ice chips)
Output- 200mL ( two stools and 200mL urine)
Balance= -140mL
MAR
codeine phosphate-acetaminophen 5 milliliters by mouth as needed
(Protocol/Note 12 mg codeine and 120 mg acetaminophen/5 mL As needed for pain)
Orders
Regular Diet
Frequent Vital Signs
Frequent Intake and Output Assessment