Post Hemicolectomy Case Study
Vital Signs. Mr. S is 1.96 meters tall and weighs 141.6 kg. Body mass index (BMI) is 37.0. Post hemicolectomy, blood pressure 120/55 mm Hg, heart rate 96 bpm, SaO2 96%, temperature 99.1 °F, and respiratory rate 20 breaths per minute.
Ventilator setting. Synchronized intermittent mandatory ventilation plus pressure support ventilation (SIMV + PSV) mode, tidal volume 650 mL, RR 16 per minute, Positive end-expiratory pressure (PEEP) five centimeter of water, FiO2 50%
General Appearance. Mr. S appears tall, well-nourished and critically ill. Signs of discomfort were unnoticed. He has 7.1 kg fluid weight gain since admission.
Head, Eyes, Ears, Nose, Throat (HEENT).Head: normocephalic and normal facies symmetric without involuntary movements. Eyes: pupils are equal, round and reactive to light. Ears: there was no discharge or lesion. Nose: NGT was in placed and secured with tape. Throat: endotracheal tubes (ETT) was in …show more content…
ABD pad dressing is covering mid-abdominal incision. The incision was not visualized since general surgery team will like to do the first dressing change. Stoma was located at RLQ and appears moist and beefy red. Approximately five mL serous drain is present in the ileostomy bag. No flatus noticed in the ileostomy bag. General surgery team will change the first dressing. The abdomen appears soft and nondistended. Hypoactive bowel sound is appreciated in all quadrants. Mr. S has increased NGT output which was 750 mL. The drainage color was dark green. Upon assessment, the findings are negative for ascites, masses, organomegaly, or hernia.
Genitourinary. Foley catheter is in place with clear yellow urine. Urine output was more than 3.5 L in 24 hours.
Neurology. Mr. S is sedated but withdrew on painful stimuli. He moves all his extremities. Mr. S’s cough reflex is intact.
Lines and Drains. Mr. S has the following lines: foley catheter, left radial arterial line, two peripheral IVs, and right internal jugular central venous catheter
Ventilator setting. Synchronized intermittent mandatory ventilation plus pressure support ventilation (SIMV + PSV) mode, tidal volume 650 mL, RR 16 per minute, Positive end-expiratory pressure (PEEP) five centimeter of water, FiO2 50%
General Appearance. Mr. S appears tall, well-nourished and critically ill. Signs of discomfort were unnoticed. He has 7.1 kg fluid weight gain since admission.
Head, Eyes, Ears, Nose, Throat (HEENT).Head: normocephalic and normal facies symmetric without involuntary movements. Eyes: pupils are equal, round and reactive to light. Ears: there was no discharge or lesion. Nose: NGT was in placed and secured with tape. Throat: endotracheal tubes (ETT) was in …show more content…
ABD pad dressing is covering mid-abdominal incision. The incision was not visualized since general surgery team will like to do the first dressing change. Stoma was located at RLQ and appears moist and beefy red. Approximately five mL serous drain is present in the ileostomy bag. No flatus noticed in the ileostomy bag. General surgery team will change the first dressing. The abdomen appears soft and nondistended. Hypoactive bowel sound is appreciated in all quadrants. Mr. S has increased NGT output which was 750 mL. The drainage color was dark green. Upon assessment, the findings are negative for ascites, masses, organomegaly, or hernia.
Genitourinary. Foley catheter is in place with clear yellow urine. Urine output was more than 3.5 L in 24 hours.
Neurology. Mr. S is sedated but withdrew on painful stimuli. He moves all his extremities. Mr. S’s cough reflex is intact.
Lines and Drains. Mr. S has the following lines: foley catheter, left radial arterial line, two peripheral IVs, and right internal jugular central venous catheter