Pt. name:  Dale Mayman                        Admitting Physician:   Dr. S Phillips       
Age:
51                                           DOB: 11/13/xx                             Bed: ER Bed 2
Admitting diagnosis:
Confusion bleeding gums
Pt. ID # 542768
                                                Med Rec #:  78543
Wt. lbs: 172  kg: 78                 Ht.: 71 inches                                 Race:Caucasian
Major Support:
 Wife                                                                      Religion:
Not stated

Immunizations: current
Allergies:
Ace inhibitors (angioedema)

 

Nursing Map of Care
Complete Patient Assessment

Paracentesis performed in the ER under local Anesthesia Rt lowerl abd with removed 1200 mL of yellow slightly cloudy fluid. Patient tolerated the procedure well with no distress noted Small dry dressing over the site. No bleeding noted. Six 10 mL vials obtain and hand carried to lab. The paracentesis results revealed a spontaneous bacterial peritonitis.