History
Vitals
Labs
Orders
Notes
Client underwent ileostomy creation 8 hours ago for ulcerative colitis. No known allergies. Past medical history unremarkable.個案因潰瘍性結腸炎於8小時前接受迴腸造口術。無已知過敏史。過去病史無特殊。
BP 118/72, HR 88, RR 16, Temp 98.8°F (37.1°C), SpO2 98% on room air血壓118/72，心跳88，呼吸16，體溫98.8°F (37.1°C)，SpO2 98%（室內空氣）
Hgb 11.2 g/dL, WBC 9,500/mm³血紅素11.2 g/dL，白血球9,500/mm³
Vital signs every 4 hours, stoma assessment every 4 hours, advance diet as tolerated, pain management per protocol每4小時測量生命徵象，每4小時評估造口，依耐受度漸進式飲食，依醫囑處理疼痛
Client is drowsy but arousable. Abdomen soft, bowel sounds hypoactive. Stoma appears dusky and purplish with dry surface. No frank bleeding. Dressing has small amount of serosanguineous drainage.個案嗜睡但可喚醒。腹部柔軟，腸音減弱。造口呈暗紫色且表面乾燥。無明顯出血。敷料上有少量漿液血性引流液。