patient report (report from nurse ending shift)diet: resume 1800 ada diet as tolerated patient name:...

Chart Materials Eugene Shaw Simulation 3 © National League for Nursing, 2013

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Patient Report (Report from nurse ending shift) Current time: 1530 on Wednesday afternoon Situation: Mr. Eugene Shaw, age 82, is in his second postoperative day. He came to the ER on Saturday at 2100 with complaints of pain and a burning sensation in his right leg. He had some small ulcerations of the skin, especially on the heel, with bluish discoloration of his right foot and some ankle edema. He was admitted to our unit Sunday morning at 0600. The surgeon evaluated him and said his angiogram revealed a clot in the artery just below the right knee. He had femoral-popliteal bypass surgery on Monday morning. Background: Mr. Shaw has a 30-year history of hypertension, osteoarthritis of the knee and foot, fallen arches and chronic cold sensitization. For the past 40 years he has had nocturnal pain in lower limbs and hands. He was diagnosed with Type 2 Diabetes 20 years ago. He admits that he does not stick to his diet and the doctor put him on Simvastatin to prevent his cholesterol from going up. Mr. Shaw insists that he takes his medications regularly. He says he stopped smoking at home over 50 years ago when his son was born, but still sneaks a few cigarettes when out with friends at the local bar. Assessment: Gene is alert and orientated to person, place and time. His vital signs have been stable with temperature of 98.6 F (37 C), BP 128/70, heart rate 88, respirations 16, SpO2 96% on room air. Mr. Shaw’s blood glucose was 115 mg/dL at 0600. His neurovascular checks have greatly improved. There is some swelling in his leg. He has been eating well and voiding. He had a bowel movement this morning. He continues to complain of some pain, but says it is not as bad as before surgery and he no longer has the aching and burning in his leg. His last dose of Vicodin was at 1300. The incision site is healing well. Gene has had some difficulty ambulating and needs a lot of assistance. He has complained of some tooth pain and bleeding from his gums but reports this has been ongoing for many months. Recommendation: He is due for vitals and a pain assessment, along with a dressing change. His wife is visiting. Encourage him to ambulate. He may be discharged in 2 days so we need to assess how he will manage at home.

Provider’s Orders Allergies: NKA

Date/Time: Monday

1100 Post-Operative Medical Orders Condition of patient: Good 1. DIET: resume 1800 ADA diet as tolerated

Patient Name: Eugene Shaw

MRN: 09625

Room: 120 Doctor Name: Dr. Ian Stein DOB: 05/21/xx Date Admitted: Age: 82 Diagnosis: Peripheral Vascular Disease; Surgery:

Femoral-popliteal graft - RIGHT


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2. FLUIDS: discontinue IV fluids as soon as able to tolerate oral fluids 3. VITAL SIGNS: q. 4h. If temperature > 101 F (38.33 C) notify resident 4. ACTIVITY:

a. Up in chair with leg elevated b. Ambulate with assistance

5. NEUROVASCULAR CHECKS: Q 2 h for first 24 hours, then every shift 6. LABS: Call abnormal results to orthopedic resident or attending surgeon

a. Electrolytes, CBC 7. MEDICATIONS:

a. Vicodin 5/500 mg q2h PRN for pain b. Lasix 10mg daily c. Plavix 75mh PO daily

8. CHECK THE BLOOD SUGAR (BS): before every meal & before bedtime a. with regular insulin coverage as follows:

0-150: no insulin 150-199: 2 units 200-249: 4 units 250-299: 7 units 300-349: 10 units Over 350: 12 units and notify MD

b. Docusate (Colace) 100 mg PO daily, may repeat X1 PRN for constipation

c. Ferrous Sulfate 325 mg PO daily d. Zocor (Simvastatin) 20 mg PO daily e. Zestril (Lisinopril) 5 mg PO daily f. Glucotrol 30mg 1 tab PO bid g. Citracal 180 mg 1 tab PO daily h. Enoxaparin (Lovenox) 30 mg subcutaneous q.12h i. Bactrim DS one tab bid j. Penicillin VK 500mg PO Q6H

Robert Moses, MD

Stat Order Form

Date/Time: STAT PHYSICIAN ORDER

Lab Data

Date/Time: Test: Result: Reference range: Monday 1600 Chemistries Sodium 137 mEq/L 135-145 mEq/L

Potassium 4.0 mEq/L 3.5-5.2 mEq/L


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Chloride 103 mEq/L 96-106 mEq/L Bicarbonate 21 MEq/L 19-25 mEq/L Calcium 8.6 mg/dl 8.5 – 10.2 mg/dl

Phosphorus 2.8 mg/dl 2.4-4.7 mg/dl Magnesium 1.9 mg/dl 1.8-3.0 mg/dl Glucose 99 mg/dl 74 -106 mg/dl Bun 15 mg/dl 7-20 mg/dl Creatinine 1.0 mg/dl 0.8 – 1.4 mg/dl Hematology Hematocrit 39% 38 – 43% Hemoglobin 15 g/dl 12 – 16 mg/dl Red blood cells 4.8 million/mm3 4.6-6.2 million/mm3

Erythrocyte sedimentation

rate

19 mm/hr < 20 mm/hr

Leukocytes 9,000/mm3 5000-10,000/mm3

Platelets 325,000/mm3 150,000-450,000/mm3

Prothrombin time (PT)

10.2 sec 9.6-11.8 sec

Partial thromboplastin

time (PTT)

32 30-40 sec

HgbA1C 5.8% 4-5.6% Renal BUN 7 mg/dl 6-20 mg/dl

Creatinine 1.2 mg/dl 0.6-1.3 mg/dl Urine Test pH 4.4 4.5-8.0 Specific gravity 1.018 1.010-1.025


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Medication Administration Record Allergies: NKA Scheduled & Routine Drugs

Date of

Order:

Medication: Dosage: Route: Frequency: Hours to be

Given:

Dates/Times Given/Initials:

Colace (Docusate)

100mg PO daily 0900 - Sunday/ 0900 NN

- Monday/ hold

- Tuesday/ 0900 NN

- Wednesday/ 0900 NN

Plavix 75mg PO daily 0900 - Sunday/ 0900 NN

- Monday/ hold

- Tuesday/ 0900 NN


Ferrous Sulfate

325 mg PO daily 0900 - Sunday/ 0900 NN

- Monday/ hold

- Tuesday/ 0900 NN



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Zocor (Simvastatin)


- Monday/ hold

- Tuesday/ 0900 NN


Lovenox (Enoxaparin)

30 mg Subcutaneous q.12h 0900 2100

- Sunday/ 0900 NN

- Sunday/ 2100 CR

- Monday/ 0600 NN

- Monday/ 2100 CR

- Tuesday/ 0600 NN

- Tuesday/ 2100 CR


- Wednesday/ 2100 CR

Zestril (Lisinopril)


- Monday/ hold

- Tuesday/ 0900 NN


Lasix (Furosemide)


- Monday/ hold

- Tuesday/ 0900 NN



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Citracal 180 mg 1 tab

PO daily 0900 - Sunday/ 0900 NN

- Monday/ hold

- Tuesday/ 0900 NN


Glucotrol 30mg 1 tab

PO bid 0900 2100

- Sunday/ 0700 NN

- Sunday 2100 CR

- Monday/ hold

- Tuesday/ 0900 NN

- Tuesday/ 2100 CR



Cephazolin Injection (Ancef)

1 g IVPB 1 hour prior to surgery

1 hour prior to surgery

- Monday/ 0700

Bactrim DS one tab bid 0900 2100

- Tuesday/ 0900 NN

- Tuesday/ 2100 CR




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Penicillin VK 500mg PO Q6H 0900 1500 2100 0300

- Tuesday/ 0900 NN

- Tuesday/ 1500 NN

- Tuesday/ 2100 CR

- Tuesday/ 0300 CR





Nurse Signatures

Date/Time Initial Nurse Signature AB Ann Brennan, RN NN Nancy Nurse, RN CR Carol Reynolds, RN

PRN Medications

Date of

Order:

Medication: Dosage: Route: Frequency: Hours to be

Given:

Dates/Times Given/Initials:

Vicodin (hydrocodone bitartrate/acetaminophen

5/500)

1 tab PO Q2h prn for pain

- Sunday/ 0100 AB

- Sunday/ 0430 AB

- Sunday/ 0730 NN

- Sunday/ 1100 NN

- Sunday/ 1300 NN


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- Sunday/ 1600 NN

- Sunday/ 1900 CR

- Sunday/ 2200 CR

- Monday/ 0130 CR

- Monday/ 0500 CR

- Monday/ 1800 CR

- Monday/ 2300 CR

- Tuesday/ 0600 NN

- Tuesday/ 1630 CR

- Tuesday/ 2200 CR




Xanax

0.5mg PO 0800 q. 8h prn

anxiety

- Sunday/ 1530 NN

Nurse Signatures

Date/Time Initial Nurse Signature AB Ann Brennan, RN NN Nancy Nurse, RN CR Carol Reynolds, RN


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Physician: Robert Moses, MD

Diagnosis: Peripheral Vascular Disease

Age: 82 Gender: Male Height: 5’7” Weight: 195 lbs Major Support: Wife Phone: 648-888-0002 Robert (son) 555-720-0953

Type of Operation: Femoral-popliteal graft - RIGHT History: hypertension, and Type 2 Diabetic Advanced Directives: No

Allergies: None known Fall Precautions: High Isolation Precautions: Standard Restraints: No Diet: 1800 ADA Regular

Monitoring Vital signs – Q shift Neurovascular checks - Q shift Bedside Glucose Monitoring

Medication IV access – 1 peripheral IV in right antecubital placed Saturday – DISCONTINUED ON TUESDAY

Oral medications

Respiratory Incentive spirometer 10 times

every hour while awake – deep breath and cough

Social History - Lives with wife in own home

Son lives out of state Race/religion: Catholic Medication brought from home: None

Consults - Physical therapy - Rehabilitation medicine

Treatments - Foley removed on Tuesday

Diagnostic Studies

Activities of Daily Living Up in chair with pillow Assist with ambulation

Discharge Planning - Referral for inpatient

rehabilitation


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Medical Reconciliation Form Source of medication list (check all that apply) patient medication list, patient/family recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility Allergies: NKA

Medication Name Dose Route Frequency Last Dose

Continue/DC

Colace (Docusate) 100 mg PO BID Saturday AM

C DC

Plavix (Clopidogrel)

75mg PO Daily Saturday AM

C DC

Ferrous Sulfate 325 mg PO Daily Saturday AM

C DC

Zocor (Simvastatin)

20 mg PO Daily Saturday AM

C DC

Zestril (Lisinopril)

5mg PO Daily Saturday AM

C DC

Citracal 180mg PO Daily Saturday AM

C DC

Glucotrol 30mg PO Twice Daily Saturday AM

C DC

Lasix 10 mg PO Daily Saturday AM

C DC

Provider Signatures

Date/Time Initial Provider Signature Saturday 2330 IS Ian Stein, MD

Nurse Signatures

Date/Time Initial Nurse Signature Saturday 2330 AB Ann Brennan, RN

Reviewed on Transfer by: Nancy Nurse, RN Date: Sunday 0600

Scan to Pharmacy Time: Date:


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Downtime Documentation 24-hour Abbreviated Neurovascular Assessment Flowsheet

Date/Time: Monday 0600


Nurse Signature: Nancy Nurse, RN

Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT

Extremity to be assessed: Right leg

Pallor (Color): Polar (Temp):

Pedal Pulse:

Popliteal Pulse:

Pain (passive, motion)

Paresthesia (numbness, tingling):

Movement:

Pink Pale Dusky Cyanotic

Warm Cool Cold

Present Faint Absent


None Moderate Severe

Present Moderate Severe Absent

Present Decreased Absent

Post- Op Recovery Room



Nurse Signature: Jennifer Williams, RN




Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold







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Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold












Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold








Nurse Signature: Carol Reynolds, RN




Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold







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Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold












Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold












Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold







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Date/Time: Tuesday 0130






Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold












Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold












Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold







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Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold












Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold












Pedal Pulse:

Popliteal Pulse:



Movement:


Warm Cool Cold







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Date: Sunday Time: 900 Patient Name: Eugene Shaw Impression: Normal

Date: Sunday Time: 1100 Patient Name: Eugene Shaw Impression: Normal

patient report (report from nurse ending shift)diet: resume 1800 ada diet as tolerated patient name:...

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