How To Write A Post-Operative Report

The district nursing team were now to be responsible for the wound care of an ulcer on the sole of her right foot on her impending discharge. She had previously attended the practice nurse and a podiatry service based within her local clinic. Due to a change in circumstances, she was now clearly housebound for the near future due to mobility issues. Prior to an arranged visit, the patient had called the nurse to advise her that she was pyrexial and was experiencing a pain in her right foot that was different from her normal neuropathic pain, which was often problematic. She was also finding it difficult to mobilise and was disinclined for diet but was taking oral fluids.

Shortly the incision made off the weight bearing surface of the posterior heel. Guide wire from the 70 cannulated

I was just two weeks into my internal medicine rotation at Suez Canal University in Egypt, when I encountered a case that I still remember to this day. Ms. Rafat was an elderly diabetic patient that came into our clinic complaining of a persistent wound on the sole of her foot. Upon removing her boots, her complaint turned out to be a foot ulcer with an infection extending to the first and second metatarsal bones .Unfortunately for her, we had to break the news to her and her family that her foot would need amputation. Ms. Rafat was understandably upset but took the news in stride. Following up on her case, I learned that after the surgery, the blood flow to her leg became increasingly poor and she had to return to have a below the knee amputation. Ms. Rafat ended up dying of pulmonary embolism as a complication of her second surgery. This case stayed with me not only because it

Initially we had difficulty obtaining his discharge orders as the hospital care manager replied she had forwarded the documentation, but neither I nor Mrs. Bianco had received a copy. Mrs. Bianco made a visit to Mills Creek and met with Mr. Smith at that time she was made aware of an appointment that Mr. Smith attended. Mr. Smith attended a physician appointment on June 28, 2017 with Dr. Leonard, Orthopedic trauma. Mills Creek assisted with the transportation and a mobile x-ray unit was coordinated to obtain x-rays of the femur at the facility as Mr. Smith didn’t bring his slide board to the appointment and couldn’t get onto the radiology table.

Dorrance Darling an 18 year old college football player, who was injured during a play and was rushed to a small accredited Emergency room, where a general practitioner, Dr Alexander, treated his wounds (Pozgar,2013). Dr. Alexander had not treated a major leg fracture in three years (Pozgar, 2013). An x-ray was performed that showed a tib/fib fracture, followed by Dr. Alexander reducing the fracture and applying a plaster cast from below the groin to the toes (Pozgar, 2013). Shortly after the reduction, the patient complained of pain, the cast was split and staff continued to visit patient (Pozgar, 2013). After two weeks, patient’s care was transferred to an orthopedic physician at a larger hospital, where they discovered considerable amounts of dead tissue requiring eventual leg amputation (Pozgar, 2013).

When she was sent for an X-ray it showed that she had some swelling, but not a fracture. Dr. Scott advised her to think about having reconstructive surgery, which she followed through with. Part

The healthcare team honored the patients’ wishes as best as possible; the only time we bothered the patient was when we changed the dressings on the pressure ulcers located on the anterior portion of the left foot and right buttocks and when we provided the patient with PRN pain medications. Since this is a Medical Surgical floor, we were required to do one assessment, and that occurred during the time the health care team went in as a group to clump all of the care up and do it at one time. The only negative experience that had occurred was when the patient was expressing non-verbal signs of pain – and from that point, we worked quickly to give him his PRN pain medications to manage it.

I met Mr. Eigner at the office of Dr. Taha. Mr. Eigner reports he is not taking any pain medications at this time. He reports he has a jolting shooting pain to the right and left legs only occasionally. He denied any pain to his right forearm. X-rays taken showed good alignment and healing of the fracture. The incisions are all healed except for a couple small spots on the right ankle. There is some swelling to the right ankle which Dr. Taha said is to be expected. The range of motion to the left ankle and toes was good. The range of motion to the right stores was limited. Dr. Taha said there is scar tissue at times from this type of repair and he would like physical therapy to start working on that. He is still going to be non-weight bearing for another 6 to 8 weeks on the right leg. He is now allowed full weight bearing as tolerated to the left leg. Dr. Taha ordered a rolling scooter to aid with ambulation and stop using the wheelchair. I have contacted Reverence physical therapy and faxed the new orders so the service can begin. I will process the rolled scooter with directions from the adjuster. The attendant care and replacement services will continue through to the next appointment.

It would certainly be standard care to watch extremities for lack of circulation yet this was not done. When cutting the cast not only did the Dr. cut him the first time but then to continue without any precautions and cut the other side too is certainly misconduct. While reading other court documents in this case it was also stated that because of the swelling of the leg, the cast should not have been put on until some of the swelling went down. Dr. Alexander didn't take this in to account either. Clearly an expertise should have been called in for this

May 18th 2014 Mr. Beaird fell and broke his hip. This followed hip surgery performed by Dr. Baker and 21 day rehabilitation form Cordova NH. Before his 21 days was up Mr. Beaird tried to break out of NH by running his scooter though the front door at the NH. When the scooter hit the door, the door opened and Mr. Beaird rolled onto the front porch during this altercation, his foot was injured and the ambulance was called. Mr. Beaird was admitted to Senior Care and diagnosed with a

Waters, Renita Apr 4 2017 12:21PM Waters, Renita April 4,2017 10:05 AM TC Beth Orrick RN nurse from Bent Wood Nursing for information on Mr.Allen Union who was in Bent Wood for a wound on his feet. Ms. Beth explained Allen was getting OT, and PT and was on a walker. Beth stated Mr. Allen wanted to leave and go pay his rent and other bills yesterday he didn't return back. Beth stated she TC Mr. Allen at home and he refuse to come back for any more therapy. Beth explained to Allen he must have more treatment on the wound on his feet to heal and he did take Bent Wood walker back he took. I asked Beth was Allen on any medicine she commented he left all his medication. Beth stated Allen is a diabetic and has high blood pressure including a open

During the home health observation day, there were several opportunities to observe a variety of patients with varying levels of functioning ability, different illnesses, and different needs and levels of interaction with the nurse. The first patient seen was a seventy-three year old Caucasian female with an ulcer on her right heel. Several weeks prior, she had scratched her left leg and she also had several small wounds on her left leg. The orders were to clean and redress the ulcer. She has a history of end stage renal disease, pneumonia, weakness, diabetes, dialysis, and right hip fracture. Upon entering the home, the patient was found to be sitting in a wheel chair in the living room watching television with her husband close by her side. She greeted the nurse with a smile and began to update her on her current condition. Her heel was “hurting” and she rated her pain an 8 on a scale of 1 to 10. She also had some “swelling” that she could not “get to go away; because, she could not get up and walk. They need to fix my foot so that I can get up and get around.” She told the nurse that she had been to see the doctor “yesterday” and the doctor had given her a written order that she wanted her to see. The order was written for an evaluation for a soft pressure shoe fitting. The nurse read the order to

S: TM is here for follow up of her Right Knee Contusion. Tm reports her current pain is 6/10, sore ness that is localized to her right patella area. TM report she did ice her right knee at home last night and she took her ibuprofen this am. She may go see per PCP. TM was informed, if she goes and sees her PCP, it becomes personal condition and TM would not be treated by HMMA Medical Clinic. TM reported that wasn’t a problem with her since she only had one body. Her personal feeling is she needs to go home today and return to work tomorrow since she is still sore from the contusion that had occurred yesterday. Explained to the TM, there is difference between the soreness and

A twenty-one year old female, basketball player experienced an ankle sprain by accidentally stepping on another player’s foot. The player was going up to make a shot landed on the opponents foot when she came back down, which made her ankle invert. The head athletic trainer evaluated her then taped her ankle to provide support and keep the swelling to a minimum at that time, so the player could return to play. Immediately after the game, the player’s ankle was iced down to control the swelling and was receiving NSAID’s to help with the pain or discomfort she was feeling. The player was referred to the team physician for x-rays and MRI to help rule out fractures. Treatment was started to help relieving the swelling and pain.

“There wasn’t a tear in her eye. On the contrary, she was consoling me”, I overheard my father say in Gujarati. Never having witnessed him cry before, I saw his eyes water up for the first time. In that moment I sensed something had gone awry. I will never forget the day my parents delivered the dreadful news to us. “I have a brain tumor that has been causing me to suffer severe headaches,” my mom said. At the age of nine, I didn’t know what a tumor was but I understood that it was making her ill. I was dismal at the thought of my seeing mother suffering but never had I imagined the possibility of losing her. After many assurances from my mother that she would be better in no time, she was admitted to the hospital for the surgical removal of her tumor. Post-surgery, dad announced that the physician had extracted the lime-sized tumor out of her brain. Consequently, I believed I would have my healthy, courageous, caring, and joyous mother back from the hospital. On the contrary, she came home glum and debilitated with surgical staples on her scalp. After days of refusing to allow us to see her in that condition, her health improved and she began to interact with us. Not long after, her days were filled with frequent hospital appointments for radiation. Then came the chemotherapy. With the passing of time, I started to realize she would never completely be her prior self again. The unknown future had her constantly stressed for us children. Due to the changes it had brought to