Professional Documents
Culture Documents
Room: 616
DOB: 01/23/1926
Age: 84
MRN: 000-555-000
Doctor Name: Dr. Eric Lund
Date Admitted:
PATIENT CHART
Chart for Millie Larsen
Physicians Orders
Allergies: NKA
Date/Tim
e:
Day 1, 0900
Nursing Notes
Date/Tim
e:
Chart Materials Millie Larsen Simulation 1
National League for Nursing, 2015
0200
0900
Liz Townsend, RN
Medication:
Dosag
e:
Rout
e:
Frequenc
y:
Hours to be
Given:
Captopril
25 mg
po
three
times a
day
Metoprolol
Furosemide
100 mg
40 mg
po
Lipitor
Pilocarpine eye
50 mg
2 drops
each
eye
0800, T.M.
1200 T.M. ,
1600 T.M.
0800 JL
0800 T.M.1
600 T.M.
0800 T.M.
0800, T.M.1200
T.M.,1600
T.M.,2000 L.T.
0800 T.M.
1600 T.M.
drops
Fosamax
Tramodol
10 mg
50 mg
Ciprofloxacin
250 mg
Acetaminophen
Celebrex
325 mg
200 mg
Po
po
po
every day
twice per
day
once daily
four times
a day
every day
for
arthritis
pain/prn
every 12
hours
prn
once a
day
Date
s
Give
n:
Day 2
Day 2
Day 2
Day 2
Day 2
Day 2
Day 2
Day 2
L.T.
1400 T.M.
0800 T.M.
Day 2
Day 2
Intravenous Therapy
Date of
Order:
Day 2
IV Solution
Rate Ordered:
60ml/hr
Intramuscular legend:
A=RUOQ ventrogluteal
B=LUOQ ventrogluteal
C=R Deltoid
D=L Deltoid
E=R Thigh Lateral
F=L Thigh Lateral
Date/Time Hung:
Day 2, 1400 T.M.
Nurse Signatures
Initial
Nurse Signature
Initial
Nurse Signature
T.M.
L.T.
Liz Townsend
Day
2
0800
37.3
Day 2
Day 2
Day 2
Day
2
0000
37.2
Day
2
0400
37.1
1200
37.2
1600
37.2
2000
37.3
148/8
2
78
96
134/76
142/86
146/90
76
96
138/8
0
78
96
136/7
8
72
94
80
94
80
96
14
12
16
14
14
14
Nurse
Initials:
T.M.
T.M.
T.M.
L.T.
L.T.
L.T.
IVPB
OTHER
URINE
OUTPUT
Emesis
NG
Drains
Type:
Other
500
750
650
250
2100-0900
ORAL
240
INTAKE
TUBE
FEED
IV
OUTPUT
IVPB
720
OTHER
URINE
Emesis
NG
Drains
Type:
Other
200
400
400
(This is a worksheet to be used at the bedside to keep track of each intake or output. The totals
will then be recorded on the 24 hour Fluid Balance sheet.)
Fluid Measurements:
Sample Measurements:
1 ml = 1 cc
1 ounce = 30 cc
8 ounces = 240 cc
RESPIRATORY:
sleeping
lethargic
calm
agitated
anxious
combative
RESPIRATIONS:
RATE: 14
O2: RA
SPO2:94%
regular
even
irregular
labored
uses accessory muscles
cough
BREATH SOUNDS:
SKIN:
notes
see nursing
risk skin
TURGOR:
<3 sec
> 3 sec
LEFT:
clear
crackles
wheezes
decreased
RIG
absent
THORAX:
even expansion
uneven expansion
TEMP:
warm/dry
hot
cool
cold/clammy
diaphoretic
NEUROLOGICAL:
ORIENTATION:
person
place
time
RESPONDS TO:
name
stimuli
SPEECH:
clear
garbled
slurred
FACE:
symmetrical
drooping
EYES:
PERRLA
unequal
drooping lid
HEARING:
WNL
HOH
HX:
seizures
CVA
brain injury
HAIR:
shiny
dry/flaking
balding
lesions
lice
see nursing notes
SMOKING:
cigarettes pk/day ____________
cigars
marijuana
cocaine
GASTROINTESTINAL/NUTRITION:
notes
disoriented
confused
impaired memory
APPEARANCE:
flat
round
obese
non-responsive
BOWEL SOUNDS:
active
hypoactive
aphasic
inappropriate
cannot follow
conversation
drooling
SIGHT:
no correction
glasses
contacts
blind
hearing aid
spinal injury
other
PALPATION:
non-tender
see nursing
soft
gravid
hyperactive
absent
mass (location)
_______
tender
(location)______
LAST BM yesterday
incontinent
stoma- _______
constipation
diarrhea
mucous
blood
DIET: normal
impaired swallowing
choking
NG tube
color drainage:______________
feeding tube
tube feeding
type: ______________ rate:_________
MUSCULOSKELETAL:
GAIT:
steady
GENITOURINARY:
voids
unsteady
ACTIVITY:
up ad lib
walker
cane
crutches
wheelchair
HAND GRIPS:
AMPUTATION:
left
LOCATION:____________
LEFT:
strong
weak
flaccid
contractures
ROM:
ARMS:
full
weak
flaccid
contractures
AMPUTATION:
right
left
SPINE:
kyphosis
scoliosis
catheter
APPEARANCE OF URINE:
clear
light yellow
amber
brown
BLADDER:
soft
firm/distended
right
RIGHT:
strong
weak
flaccid
contractures
LEGS:
full
weak
flaccid
contractures
TED hose
cloudy
sediment
red/wine
clots
incontinent
dysmenorrheal
BSE monthly
menopause
taking estrogen
safe sex
MED HX:
urinary retention
BPH
Frequent UTI
BKA
AKA
other
osteoporosis
OTHER:
CAST LOCATION:___________
TRACTION:_____________
Chart Materials Millie Larsen Simulation 1
National League for Nursing, 2015
CARDIOVASCULAR:
HEART SOUNDS:
normal S1abnormal S3S2
S4
PULSE:
APICAL:
regular
irregular
strong
faint
murmur
PEDALIS:
regular
irregular
strong
faint
nonpalpable
nonpalpable
generalized (anasarca)
SITE #1:____________
pitting
1+
2+
3+
4+
non-pitting
pitting
1+
2+
3+
4+
non-pitting
CAPILLARY REFILL:
FINGERS:
brisk
slow
HX:
Pacemaker
HTN
CAD
RADIAL:
regular
irregular
strong
faint
PAIN ASSESSMENT:
SEVERITY (0-10/10): 3
NOW: 3
AT WORST: 6
AT BEST: 1
TIMING:_________________________________________
SAFETY:
PRECAUTIONS:
side rails x 2
bed down
call light
nightlight
DISCHARGE/TEACHING:
NEEDS:___________________________________________
____________________________________________________
____________________________________________________
__________________________________
TYPE OF LEARNER:
visual
auditory
kinesthetic
TOES:
brisk
slow
CHF
PVD
Other: _________
FAMILY PRESENT:
yes
no
FLUID BALANCE:
INTAKE:
PO
NURSE SIGNATURE:
IV
REASSESSMENT:
SOLUTION: D5 .45 RATE: 60 ml/hr
TIME: 1200
SITE LOCATION: L FA
clean
patent
redness
swelling
cool
hot
MUCOUS MEMBRANES:
moist
sticky
pink
coated
TODAYS WT: 48
kg
no
change
pain
tubing change
dressing
change
see nurses
notes
Initials TM
see nurses
notes
Initials
see nurses
notes
Initials SH
TIME: 1600
no
change
dry
TIME: 2000
no
change
YESTERDAYS
WT:_______
Time
PAIN ASSESSMENT
Intensity (1-10/10)
Pain Type (see
legend)
Intervention (see
legend)
PATIENT POSITION
TM
Date:
Braden Scale Score:
20
Morse Fall Risk Score: 70
2 2 0 0 0 0
0 2 0 2 4 6
2
A
1
A
2
A
5
M
5
M
2
A
1
A
1
A
1
A
1
A
1
A
1
A
10
PO FLUIDS (ml)
IV SITE/RATE
CHECKED
PATIENT HYGIENE
WOUND
ASSESSMENT
WOUND BED
WOUND DRAINAGE
WOUND CARE
Nurse Initials
240
480
240
240
240
480
240
240
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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n/a
n/a
n/a
n/a
n/a
n/a
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n/a
n/a
n/a
n/a
TM
TM
TM
TM
TM
TM
K.C
K.C
K.C
K.C
K.C
K.C
Initial
Nurse Signature
Initial
Nurse Signature
T.M.
L.T.
Liz Townsend
LEGEND:
PAIN TYPE:
A- aching
T- throbbing
ST- stabbing
B- burning
SH- shooting P- pressure
PAIN INTERVENTIONS:
1- Relaxation/Imagery 2 - Distraction
3- Reposition
4-Medication
WOUND ASSESSMENT
# 1-4 Pressure Ulcer stage
I Incision
R Rash
SK skin tear
E Echymosis
A Abrasion
POSTIONING:
B- back
R- right
L- left
C- chair
A- ambulatory
WOUND BED:
D Dry & intact
S Sutures/ staples
G Granulation tissue
P Pale
Y Yellow
B- Black
PT. HYGIENE:
b- bedbath
p- partial bath
g- grooming
f- foot care
WOUND DRAINAGE:
0 none
S Serous
P Purlulent
S Serosanguinous
B Bright red blood
D Dark old blood
a- assist bath
sh- shower
m mouth care
n- nail care
WOUND CARE:
C Cleaned with NS
G Gauze dressing
W Gauze wrap
A ABD pad
M Medication
O other **
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