Please fill out this entire document based on all information I provide you with.
Page 1: I will fill out top information.
Background info on the patient to help fill in each page:
This patient is a 52 year old female who is 1 1/2 weeks status post panniculectomy and repair of enterocutaneous fistula who presented with an infected abdominal wall wound. She is now 1 day post op abdominal debridement. My patient is African American, speaks English, is religious, and had a stable income. She resides with her husband and has a daughter and a grandson. She does not consume any alcohol or drugs and has never smoked. Her occupation consists of working with the homeless population to provide housing and their meet essential needs.
Concurrent and Past Medical History includes:
Gastric bypass revision x3 – last revision was in 2005
Bariatric surgery (9/13/2018)
Excisional debridement of wound (12/6/2018)
Incision and Drainage (1/3/2019)
Panniculectomy (2/19/2021)
Closure of appendiceal fistula (2/29/2021)
Debridement of wound (3/2/2021)
Pertinent lab findings: Will attach photo of her labs
Concurrent physicians orders:
Activity: As tolerated, with assistance
Wound Care: Surgeon will pack abdominal wounds 2x per day with wet-to-dry Kerlix as well as applying an abdominal binder.
Infection Control: Standard precautions
Diet: Regular diet. No fluid restrictions.
Diagnostic tests: Wound cultures were taken prior to surgery.
Gram stain showed many white blood cells with few
intracellular gram positive cocci in clusters
Rationale: Fill in rationale based on this information
Medications:
Polyethylene Glycol 3350 (Miralax) 17gram/dose Oral Powder
Bisacodyl (Dulcolax) 10 mg Rectal Suppository
Hydrocodone-Acetaminophen (Norco) 5/325 mg Oral tab
Sulfamethoxazole-Trimethoprim (Bactrim/Septra DS) 800-160 mg oral tab
Cephalexin (Keflex) 500 mg Oral Capsule
Pathophysiology of Admitted and/or Related Diagnosis:
Fill this out based on information above
Identify Potential Health Problem Alterations:
Risk for Bleeding and Risk for Infection
Include signs and symptoms of each and two interventions for each
QSEN: Fill out as directed
I will attach a sample paper, the blank template, and the photos of the labs for you to reference. Please let me know if you have any questions.
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