t is now day 1 following surgery for Mrs Romano, following handover at 0700, you have been allocated to care for her, handover information is contained in Appendix 5: Handover sheet.  At the commencement of your care, you undertake a systems assessment.  These are your assessment findings: CNS: conscious and responding to verbal instructions.  .  Temp 37.6C CVS: Peripherally warm and dry.  No peripheral oedema.  HR = 76 regular.  BP = 145/68. Resp: RR = 18 resps/min.  Sa02 = 93% NP 3LPM Renal: IDC removed 0600 HNPU GIT: Bowel sounds present.  No abdo swelling. Endocrine: BGL = 4.2mmol/L Musculoskeletal: NAD.  Has not been out of bed a yet Post op. Complaining of leg pain, TED stocking removed, slightly reddened areas noted on both heels (signs of DVT, compartment syndrome). Left calf noted to be swollen, red and warm to touch. Integumentary: Dressing to abdominal wound, intact with no further ooze since marked the evening before. Laparoscopic incision dressings clean and dry. Bellovac drain, minimal further drainage since midnight/   2.     (i)  from your assessment can you formulate a potential diagnosis         (ii) what is your next course of action?

Comprehensive Medical Terminology
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ISBN:9781133478850
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Chapter24: Gerontology
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It is now day 1 following surgery for Mrs Romano, following handover at 0700, you have been allocated to care for her, handover information is contained in Appendix 5: Handover sheet.  At the commencement of your care, you undertake a systems assessment.  These are your assessment findings:

CNS: conscious and responding to verbal instructions.  .  Temp 37.6C

CVS: Peripherally warm and dry.  No peripheral oedema.  HR = 76 regular.  BP = 145/68.

Resp: RR = 18 resps/min.  Sa02 = 93% NP 3LPM

Renal: IDC removed 0600 HNPU

GIT: Bowel sounds present.  No abdo swelling.

Endocrine: BGL = 4.2mmol/L

Musculoskeletal: NAD.  Has not been out of bed a yet Post op. Complaining of leg pain, TED stocking removed, slightly reddened areas noted on both heels (signs of DVT, compartment syndrome). Left calf noted to be swollen, red and warm to touch.

Integumentary: Dressing to abdominal wound, intact with no further ooze since marked the evening before. Laparoscopic incision dressings clean and dry. Bellovac drain, minimal further drainage since midnight/

 

2.     (i)  from your assessment can you formulate a potential diagnosis

        (ii) what is your next course of action?

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