Day 2

Status-post open (partial) gastrectomy. Client reports abdominal pain 6/10 on the Numerical Rating Scale. Client is still receiving patient-controlled analgesia (PCA) of fentanyl. Abdomen is taut with hypoactive bowel sounds in all quadrants. Reports passing no flatus. Endorses occasional nausea with no vomiting. Incision approximated with moderate serosanguinous drainage. Abnormal laboratory data noted: BUN 19 mg/dL (10 – 20 mg/dL); Creatinine 1.0 mg/dL (0.6 – 1.2 mg/dL); Potassium 3.3 mEq/l (3.5 – 5.0 mEq/l). Not tolerating a clear liquid diet, only consuming 10-15% of meals. No VS abnormalities.

Day 3

Status-post open (partial) gastrectomy. Client reports abdominal pain 4/10 on the Numerical Rating Scale. Client is still receiving patient-controlled analgesia (PCA) of fentanyl. Abdomen is distended, with hypoactive bowel sounds in all quadrants. Reports passing no flatus and is hiccuping during the exam. Endorses persistent nausea and occasional vomiting with no relief from prescribed ondansetron. Incision approximated with scant serosanguinous drainage. Abnormal laboratory data noted: BUN 23 mg/dL (10 – 20 mg/dL); Creatinine 1.3 mg/dL (0.6 – 1.2 mg/dL); Potassium 3.1 mEq/l (3.5 – 5.0 mEq/l). Not tolerating a clear liquid diet, nursing reports 0% consumption of meals. VS showed an oral temperature of 99.5°F (37.5°C).