Completes reflective journal a. 150 word minimum reflection. b. Summarize new information learned by completing this assignment. c. Reflects on how the new knowledge will impact future behavior as a healthcare professional.
d. Logical reflective flow which follows standard grammatical rules with minimal (1-2) misspellings and APA where applicable.
Patient Information Nursing notes and assessment 5/12 Nursing Note: Client is working toward completing requirements needed for insurance payment for bariatric surgery.
● 12/06- Initial visit with weight management ● 01/06 – Dietician visit ● 02/12 – Visit with physician assistant for weight management ● 03/19 – Appointment with bariatric surgeon ● 04/10 – Appointment with a psychologist for clearance
Today, 05/12, the client is here for an endoscopy for approval of pre-bariatric surgery. The gastrointestinal provider will clear the client anatomically for surgery as well and a biopsy taken to rule out h-pylori.
6/12
The client was admitted this morning for Roux-en-Y gastric bypass surgery. The client has been working with weight management since December and has completed the requirements for insurance authorization. The client has met with the surgeon and signed consent on file. Anesthesia will meet with the client before the procedure. The client reported that she is “ready for the procedure but anxious.” The client has completed two-week liquid diet as prescribed by the surgeon. Has had nothing by mouth since midnight.
Neurologic: Alert, oriented x 4.
Cardiac: Regular, S1&S2 present, +1 edema in bilateral lower extremities, +2 pulses in radial and pedal pulses.
Respiratory: Lungs clear bilaterally, diminished in bases.
Gastrointestinal: positive bowel sounds x4 quadrants. Rounded, soft, non-tender to palpation
Genitourinary: indwelling catheter draining clear yellow urine
Integumentary: Intact, dry, warm, red discoloration to bilateral lower extremities
6/22
: Client post-op day 1. The client’s indwelling urinary catheter was removed at 0500 this morning. The client has not voided on her own. The client has a morse fall risk of 35. Ambulating independently in the room. Upon rising this morning, the client started her oral water intake of 15mL per hour.
Neurologic: Alert, oriented x 4. Drowsy
Cardiac: Apical rate 110, S1&S2 present. +1 edema in bilateral lower extremities, +2 bilateral radial and pedal pulses.
Respiratory: Diminished in bilateral lower lobes. Right upper lobes clear. Left upper lobes with mild wheezing
Gastrointestinal: Abdomen tender in all quadrants. Positive bowel sounds in all 4 quadrants, mild distention, rounded,
Genitourinary: Indwelling urinary catheter removed at 0500. No post-catheter void.
Integumentary: Four surgical incisions on the abdomen closed with surgical glue. Edges well-approximated
Pain: 4/10 in abdomen.
Date & Time Temp HR RR BP SpO2 O2
05/12 0730 98.6°F (37.0°C) 98 24 165/92 95% RA
06/21 0645 97.6°F (36.4°C) 112 20 168/96 96% RA
06/22 1000 99.8°F (37.7°C) 98 12 116/58 92% RA
Date & Time Weight BMI
06/21 0645 380 lbs. (172.4 kg) 58
06/21 1000 381 lbs. (173.2 kg) 58
Date Result
06/21 0645 147
05/12 0730 Client Information:
Medical History:
● Hypertension ● Osteoarthritis in bilateral knees and bilateral hips ● Obstructive Sleep Apnea ● Prediabetes (HA1c of 5.7 or higher) ● Morbid Obesity ● Polycystic Ovarian Syndrome ● Uncomplicated Varicella ● Urinary Tract Infection ● Depression
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