8/25/2016
DocEngage print layout
PHYCACPAssessmentPLAN Details Dr. Hitesh Chauhan
Apollo Home Healthcare Ltd, 8th Floor Health Street Building Apollo Health City Campus Jubilee Hills
18605008585
[email protected] www.apollohomecare.com
Hyderabad India, 500033
Sunil Verma 55 Years Old Male 9897337443
19 Aug 16, 5:31pm UID: AHCDL100218 Encounter Id: 319372
CLINICAL ASSESSMENT (PART 1) Primary Diagnosis
Carcinoma Lower Oesophagus,Post Oesophagectomy Now With Anastomatic Leak
Secondary Diagnosis
HTN,DM,OTHERS
If OTHERS
RCC Post Nephrectomy Feb 2016
PRIMARY PHYSICIAN
Dr.Zaidi Zuaib
HOSPITAL
Apollo
Surgical History
Oesophagectomy With Feeding Jejunostomy On 08/07/16,CXR S hows Right Hydropneumothorax
GENERAL EXAMINATION Condition
Non Critical
Ambulatory Status
Ambulatory
Bed Sore
No
Conscious
Coherent
Yes
Comfortable
Yes
GCSScore
15
TEMP(F):
Afebrile
PULSE(MIN)
102
REGULAR
122/80
BP(MM OFHG):
OXYGEN SAT (R/A)
NON OBESE
94
1/5
8/25/2016
DocEngage print layout
Specific Attachments
ORAL,IV,PEG,OTHERS
IN HOSPITAL/NURSING SERVICES (A) 1. Nursing Category
SPECIALIST
PEG,ICD,End Of Life /Palliative Timings Of Nursing Services
24 HOURS
Specific Care Requirements
GENERAL CARE,NO BED SORE,NO FALL,PEG TUBE
Remarks
General Condition Sick ,Pt.Got Admitted To Apollo Hospital With C/O Chest Pain ,Shortness Of Breath,Now
AT HOME OTHER SERVICES (B) 2. PHYSICIAN
Yes
FREQUENCY
Daily
3. PHYSIOTHERAPIST
Yes
FREQUENCY
Daily
4. DIETICIAN
Yes
FREQUENCY
Once In 15 Days
5. RESPIRATORY THERAPIST
No
6. SPEECH THERAPIST
7. SPECIALIST PHYSICIAN
Yes
FREQUENCY
On Call
NIMBUS OR ALPHA BED
Yes
WHEEL CHAIR
No
ADJUSTABLE BED
Yes
WALKER
No
OXYGEN CYLINDERS SMALL
Yes
OXYGEN CYLINDERS LARGE
No
OXYGEN CONCENTRATOR
Yes
SUCTION APPARATUS
No
AMBU BAG
Yes
BAINS CIRCUIT
No
SYRINGEPUMP
No
EQUIPMENTS
2/5
8/25/2016
DocEngage print layout
VENTILATOR
No
CPAP OR BIPAP MACHINE
No
FOLEYS SET
No
ANTI DVT STOCKINGS
No
DRESSING SETS SMALL
Yes
DRESSING SETS LARGE
No
TRACHEOSTOMY SET
No
RYLES TUBE SET
No
IV FLUID SET INCLUDING STAND
Yes
BACK REST
NO
NEBULIZER
YES
LAB INVESTIGATION
As Per Discharge Summary
NUTRITIONAL PLAN
Oral
PHYSIOTHERAPY PLAN
Yes
SPECIFIC CARE REQUIREMENTS
BED SORE,NO FALL,PEG TUBE,DM MANAGEMENT,FLUID MAN AGEMENT
CARE PLAN CATEGORY
RESPIRATORY/COPD,PALLIATIVE
COMMENTS
Air Entry Decreased On Right Side Than Left Side. Spo2 88% On NP 3 Days Back.On Inj.Human Actrapid Now As Per Sliding Scale, Be Watch Ful For Spo2/Tachypnoea
PHYSICIAN NAME
Dr.Hitesh
MLC
NO
HISTORY OF PRESENT ILLNESS
Admitted With Chief C/O Dysphaghia To Both Solid & Liquid Food Since March 2016, Diagnosed As Adenocarcinoma . Developed P E
PAST MEDICAL HISTORY
HTN,DM
FAMILY HISTORY
Na
SURGICAL HISTORY
CARE PLAN (PART 2)
3/5
8/25/2016
DocEngage print layout
ALLERGIES
Na
NUTRITIONAL STATUS
PEG
CONDITION
GOOD
BED SORE
NO
SKIN TURGOR
NORMAL
EDEMA
NO
ULCERATION
No
CVS
S1,S2
CNS GCS SCORE E
4
V
5
M
6
OVER ALL SCORE
15
POWER
5/5
RESPIRATORY
Right Side Air Entry Decreased
PER ABDOMEN
BS+
SYSTEMIC EXAMINATION
MODIFIED FALL RISK ASSESSMENT
LOW RISK (024)
BRADEN PRESSURE ULCER RISKSCORE
None(1923)
PAIN SCORE
1
AMBULATORY FIM SCORE
Independent(67)
DYSPNEA SCORE
No Dyspnea
SURGICAL WOUND STATUS
No Wound
PRESSURE ULCER GRADE
0
ADMISSION SCALES
GOALS DAILY MAINTAINANCE
1. Maintain Airway And Patency,2. Maintain Fluid Balance,3. Reli eve Pain And Discomfort,4. Maintain Good Nutritional Status,5. Pre vent Infection,6. Maintain Skin Integrity,7. Ensure Safety,8. Improve Activity Tolerance,9. Maintain Personal Hygiene,10. Meet Eliminati on Needs,11. Reduce Anxiety,13. Patient And Family Education
SHORT TERM GOALS
Jejunostomy Feeding As Per Protocols,Decrease In Out Put Of Ch est Drainage, Prevent Further Episodes Of Hydropneumo Thorax A s Per Protocols & Measures To Be Taken To Prevent Infection.Feve r.
4/5
8/25/2016
DocEngage print layout
r.
LONG TERM GOALS
Weaning Of From All Tubes
UNACHEIVABLE PARAMETERS
To Be Discussed After Follow Up With Primary Consultant
UNTOWARD OUTCOMES
INFORMATION ON ORGAN DONATION
PHYSICIAN NAME:
Dr.Hitesh
Signature
5/5
