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Student Name: Date(s): 12/07/2025 Unit___________________________ Doctor: Dr Admission Date: 05/16/2025 Patient initials: __RL____________ Date of Birth: Allergies: Almond Diet/Restrictions Regular Diet, Regular/Thin Consistency, Please do not serve chicken noodle soup. Patient likes boneless chicken, honey mustard, bananas, tomato soup, salad with caesar dressing, grilled cheese with single cheese slide and milk for tea. Diagnosis: Significant Past History: Chronic Kidney Disease, Muscle Weakness (Generalized), Sarcopena, Unspecified Secondary Hypertension, Deficiency Of Other B Group Vitamins, Acute Embolism And Thrombosis Of Unspecified Deep Veins Of Right Lower Extremity, Localized Edema, Unspecified Anemia, Pyridoxine Deficiency, Methymalonic Acidemia, Homocystinuria, Adjustment Disorder With Anxiety, Bilateral Complex Regional Pain Syndrome 1 Of Limb, Metabolic Encephalopathy, Other Nonrheumatic Mitral Valve Disorders, Unspecified Supraventricular Tachycardia, Unspecified Dysphagia, Not Elsewhere Classified Difficulty Walking, Cognitive Communication Deficit, Unspecified Quadriplegia_ Current information (what brought the patient to the hospital/nursing home for this admission)? What is the patient’s status today (trend)? RL is a 57-year old right hand-dominant lady with a past medical history of cobalamin C deficiency/defect, combined methylmalonic acidemia and homocystinuria, who was BIBA, on 4/14/2025 for altered mental status after police were called for wellness check, Pt was found laying on the couch awakened easily, confused, and reported that she had not been off the couch in 1-2 days. She is supposed to take hydroxcobalamin 10,000mcg every week, she usually gets it from compounded pharmacy. However, family is concerned that the patient has not been administering her medication. Course complicated by low-grade fever, vacillating mental and neurologic status, RLE DVT with diffuse cerebral volume loss and chronic small vessel ischemie change. Started on IV Rocephin tor UTI. Started on cyanocobalamin 1000 mcg IM daily. Genetics consulted, agree with high doses of b12 IM necessary for treatment. Pt’s family has been supplying home hydroxycobalamin. Course further complicated by SVT for which cardiology was consulted, started on beta-blocker and TTE revealed systolic anterior motion of the mitral valve. Recommend adequate hydration and start metoprolol succinate 25 mg twice daily. Patient was previously independent with functional mobility ADL despite bilateral lower extremity weakness (right worse than left). After evaluation by occupational, physical and speech therapy, intensive inpatient rehabilitation with close medical follow-up was recommended. _____________________________________________________________________________________________________________ ADL’s/Restrictions: Height & Weight:
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Last Recorded Date:12/07/2025 Vital Signs: Time:2:30pm
Date 12/14/2025
Dat e:
Date: Date:
Evaluation of Vital Signs. Is there a trend? Evaluation of Fluid Needs. Does the patient take in enough fluid during clinical time? (Fluid need divided by 24 gives mL amount needed per hour)
Lab values within the last three months. Are these
values/results normal or abnormal?
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T:96.9 97.3
P:68 70
R:19 16
B/P:119/65 105/69
Estimated Fluid Requirements: Estimated Kcal Requirements: Date of Last Bowel Movement:
Other special needs/items such as PEG-tube care, Trach care, suctions, dressings, wound care, etc.
Medication order (Generic/Brand name, dose to be given, frequency to be given, times to be given)
Classification
Action
Normal actions Why is your patient taking
this medication? What diagnoses is this
medication treating for this patient?
Normal Dosage and available
routes
Major Side
effects
Major
Complications/ Drug Interactions/Food
Interactions/Herbal Interactions
Nursing Implications/ Interventions
Patient Teaching Lab values needed
Eliquis (apixaban)
Generic name: Apixaban
Dose: Commonly 2.5 mg or 5 mg
Route: Oral (PO)
Frequency: Twice daily (BID)
Time: As ordered
Hydroxocobalamin Acetate
Generic name: Hydroxocobalamin
Anticoagulant Factor Xa inhibitor
Vitamin Antianemic agent Vitamin B12 replacement
Loop diuretic Antihypertensive
Eliquis inhibits Factor Xa, which decreases thrombin generation and prevents the formation of blood clots.
Why is your patient taking this medication?
To prevent or treat blood clots
What diagnoses is this medication treating for this patient?
● Atrial fibrillation (stroke prevention)
● Deep vein thrombosis (DVT)
● Pulmonary embolism (PE)
2.5 mg PO BID 5 mg PO BID (most common dose) Oral tablets only Dose adjustments may be required for: Older adults Renal impairment Low body weigh
1,000 mcg IM Daily for 1 week Weekly for 1 month Monthly for maintenance Route: Intramuscular
Bleeding (most common)
● Bruising
● Anemia
● Nausea
● Dizziness
● Injection site pain or redness
Complications:
● Major bleeding
● Hemorrhagic stroke
● GI bleeding
Drug Interactions:
● Other anticoagulants
● NSAIDs (ibuprofen, naproxen)
● Antiplatelets (aspirin,
Nursing Implications & Interventions:
● Monitor for signs of bleeding (bruising, hematuria, melena, epistaxis)
● Implement fall precautions
● Assess renal function
● Hold medication before procedures as ordered
Patient Teaching:
Take medication exactly as prescribed Do NOT stop medication abruptly Report any signs of bleeding
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Dose: Commonly 1,000 mcg
Route: Intramuscular (IM)
Frequency: Daily, weekly, then monthly (varies by protocol)
Time: As ordered
Lasix (furosemide)
Generic name: Furosemide
Dose: 40 mg
Route: Oral (PO)
Frequency: Daily or BID (as ordered)
Time: As ordered (preferably in the morning)
● Beta-a drener gic blocke r
● Antihy perten sive
● Antian ginal
● Analge sic
● Antipy retic
● Post–hip or knee replacement clot prevention
Hydroxocobalamin is a form of vitamin B12 that supports red blood cell formation, DNA synthesis, and neurologic function.
Why is your patient taking this medication?
● To treat vitamin B12 deficiency when oral absorption is impaired
What diagnoses is this medication treating for this patient?
● Vitamin B12 deficiency
● Pernicious anemia
● Megaloblastic anemia
● Neuropathy related to B12 deficiency
injection only
● 20–80 mg PO daily or BID
● Tablet or oral solution
● IV form available (hospital use)
● Dose may be adjusted based on response and renal function
● 25–100 mg PO once daily (extended
● Headache
● Nausea
● Dizziness
● Diarrhea
● Hypokale mia
● Dehydrati on
● Dizziness
● Hypotensi on
● Increased urination
● Bradycard ia
● Hypotensi on
clopidogrel)
● Certain antifungals and antibiotics
Herbal Interactions:
● St. John’s Wort (decreases effectiveness)
● Ginkgo, garlic, ginseng (increase bleeding risk)
Food Interactions:
● No specific dietary restrictions (unlike warfarin)
Complications:
immediately
● Avoid NSAIDs unless approved by provider
● Inform all healthcare providers of Eliquis use
Lab Values Needed:
● No routine INR monitoring required
● Monitor: ● CBC (hemoglobin,
hematocrit) ● Renal function (BUN,
creatinine) ● Liver function tests if
indicated
Nursing Implications & Interventions:
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Toprol-XL (metoprolol succinate extended-release)
Generic name: Metoprolol succinate
Dose: 50 mg
Route: Oral (PO)
Frequency: Once daily
Time: As ordered
Hold parameters: Hold for SBP < 110 mmHg or HR < 60 bpm
Tylenol (acetaminophen)
Generic name: Acetaminophen
Dose: 325 mg tablets (650 mg per dose)
Route: Oral (PO)
● Vitami n
● Antian emic agent
● Dietar y supple ment
● Osmoti c laxativ e
● Malabsorption syndromes (e.g., gastric surgery)
Furosemide inhibits sodium and chloride reabsorption in the loop of Henle, increasing urine output and reducing fluid volume.
Why is your patient taking this medication?
● To reduce excess fluid retention
What diagnoses is this medication treating for this patient?
● Edema
● Heart failure–related fluid overload
● Renal disease–related edema
-release)
● Tablets must be swallowe d whole or may be split, do not crush or chew
● Oral route only
Normal Dosage and Available Routes
● 325–650 mg PO every 4–6 hours PRN
● Maximum daily dose: 3,000 mg/day
● Fatigue
● Dizziness
● Depressio n
● Shortness of breath (less common)
● Nausea
● Rash (rare)
● Headache
● Nausea
● Abdomina l bloating
● Hypokalemia during initial therapy
● Rare allergic reactions
Drug Interactions:
● Chloramphenicol (may reduce response)
● Metformin (can decrease B12 absorption with oral forms)
Food Interactions:
● None significant with IM administration
Herbal Interactions:
● Administer deep IM injection (deltoid or ventrogluteal)
● Rotate injection sites
● Monitor for signs of allergic reaction
● Assess neurologic status (numbness, tingling)
● Monitor potassium levels during initial therapy
Patient Teaching:
● Explain importance of lifelong therapy if pernicious anemia
● Report tingling, muscle weakness, or palpitations
● Injection schedule may decrease over time
● Improvement in energy may take several weeks
Lab Values Needed:
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Frequency: Every 6 hours as needed (PRN)
Maximum dose: Do not exceed 3 grams/day
Indication: Mild to moderate pain
Folic Acid
Generic name: Folic acid (Vitamin B9)
Dose: 1 mg
Route: Oral (PO)
Frequency: Once daily
Indication: Nutritional supplement
● Liver disease–related ascites
Metoprolol selectively blocks beta-1 adrenergic receptors, decreasing heart rate, myocardial contractility, and cardiac output, which lowers blood pressure.
Why is your patient taking this medication?
● To control elevated blood pressure
What diagnoses is this medication treating for this patient?
● Hypertension
● May also be used for heart failure, angina, or rate control (if applicable)
● Routes available
● Oral tablet or liquid
● Rectal supposito ry IV (hospital setting)
● 0.4–1 mg PO daily
● Oral tablets or liquid
● May be administe red IM or IV in severe deficiency (less common)
● Flatulence
● Bitter taste (rare)
● Bloating
● Abdomina l cramping
● Flatulence
● Nausea
● Diarrhea (with overuse)
● No major known interactions
Complications:
● Electrolyte imbalance (↓ potassium, sodium, magnesium)
● Acute kidney injury
● Ototoxicity (high doses or rapid IV use)
Drug Interactions:
● Digoxin (↑ risk of toxicity with low potassium)
● Lithium (↑ lithium levels)
● Vitamin B12 levels
● CBC (hemoglobin, hematocrit, MCV)
● Potassium levels during early treatment
Nursing Implications & Interventions:
● Monitor intake and output
● Daily weights (same time each day)
● Assess edema and lung sounds
● Monitor blood pressure
● Administer early in the day to prevent nocturia
Patient Teaching:
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MiraLax (polyethylene glycol 3350)
Generic name: Polyethylene glycol 3350
Dose: 17 g (1 scoop)
Route: Oral (PO)
Frequency: Once daily or as ordered
Indication: Constipation
Acetaminophen works by inhibiting prostaglandin synthesis in the central nervous system, reducing pain and fever.
Why is your patient taking this medication?
● To relieve pain
What diagnoses is this medication treating for this patient?
● Mild to moderate pain
● Fever
Folic acid is essential for DNA synthesis, red blood cell formation, and cell growth.
Why is your patient taking this medication?
● 17 g PO once daily
● Powder dissolved in 4–8 oz of water, juice, coffee, or tea
● Oral route only
● NSAIDs (↓ diuretic effect)
● Other antihypertensives (↑ hypotension)
Food Interactions:
● May take with food to reduce GI upset
● Encourage potassium-rich foods if not contraindicated
Herbal Interactions:
● Licorice (increase potassium loss)
● Stimulant laxatives (increase electrolyte imbalance)
● Rise slowly to prevent dizziness
● Report muscle cramps, weakness, or palpitations
● Take medication as prescribed
● Do not skip doses or double doses
Lab Values Needed:
● Potassium
● Sodium
● Magnesium
● BUN and creatinine
Nursing Implications & Interventions:
● Check blood pressure and heart rate before
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● To prevent or treat folate deficiency
What diagnoses is this medication treating for this patient?
● Folate deficiency
● Megaloblastic anemia
● Nutritional deficiency
Polyethylene glycol 3350 retains water in the stool, increasing stool frequency and improving stool consistency.
Why is your patient taking this medication?
Complications:
● Severe bradycardia
● Heart block
● Worsening heart failure
● Masking signs of hypoglycemia
Drug Interactions:
● Other antihypertensives (↑ hypotension)
● Digoxin (↑ bradycardia risk)
● Calcium channel blockers (verapamil, diltiazem)
● Insulin/oral hypoglycemics (masks
administration
● Hold medication if SBP < 110 mmHg or HR < 60 bpm
● Monitor for dizziness, fatigue, and hypotension
● Assess for signs of heart failure (edema, SOB)
Patient Teaching:
● Do not stop medication abruptly
● Rise slowly from sitting or lying positions
● Report dizziness, fainting, or shortness of breath
● Monitor blood pressure and pulse at home if instructed
Lab Values Needed:
● No routine labs required
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● To relieve constipation
What diagnoses is this medication treating for this patient?
● Constipation
● Decreased bowel motility
hypoglycemia)
Food Interactions:
● Take with or immediately after meals for better absorption
Herbal Interactions:
● Hawthorn (increase hypotensive effect)
Complications:
● Hepatotoxicity with overdose or chronic use
● Monitor:
○ Blood pressure
○ Heart rate
○ Blood glucose in diabetic patients
○
Nursing Implications & Interventions:
● Assess pain level before and after administration
● Monitor total daily acetaminophen intake
● Assess liver function if long-term use
● Use caution in patients with liver disease
Patient Teaching:
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● Acute liver failure (serious)
Drug Interactions:
● Alcohol (↑ liver toxicity risk)
● Other acetaminophen-c ontaining products (overdose risk)
● Warfarin (↑ bleeding risk with long-term use)
Food Interactions:
● May take with or without food
Herbal Interactions:
● St. John’s Wort
● Do not exceed 3 grams per day
● Avoid alcohol while taking this medication
● Read labels to avoid duplicate acetaminophen products
● Report right upper quadrant pain, dark urine, or jaundice
Lab Values Needed:
● Liver function tests (AST, ALT) with prolonged use
● Acetaminophen level if overdose suspected
Nursing Implications & Interventions:
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● Kava (increase liver toxicity risk)
Complications:
● May mask vitamin B12 deficiency if used alone
● Rare hypersensitivity reactions
Drug Interactions:
● Phenytoin (↓ anticonvulsant levels)
● Methotrexate (interferes with action)
● Sulfasalazine (decrease
● Assess nutritional status
● Monitor CBC if treating anemia
● Evaluate for concurrent vitamin B12 deficiency
Patient Teaching:
● Take as prescribed
● Maintain a balanced diet with folate-rich foods (leafy greens, citrus, beans)
● Do not exceed recommended dose unless instructed
Lab Values Needed:
● Folate levels
● CBC (hemoglobin, hematocrit, MCV)
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absorption)
Food Interactions:
● No significant interactions
● Best absorbed on an empty stomach but may take with food if GI upset occurs
Herbal Interactions:
● No significant known interactions
Complications:
● Electrolyte imbalance with prolonged or
● Vitamin B12 level (if anemia present)
Nursing Implications & Interventions:
● Assess bowel pattern and abdominal status
● Monitor stool frequency and consistency
● Ensure adequate fluid intake
● Hold if patient develops diarrhea
Patient Teaching:
● Mix powder completely before drinking
● May take 1–3 days for effect
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excessive use
● Dehydration
● Severe diarrhea
Drug Interactions:
● Minimal significant drug interactions
Food Interactions:
● May mix with most liquids
● Adequate fluid intake is important
Herbal Interactions:
● Use caution with stimulant laxatives or herbal laxatives
● Do not use long term unless directed
● Increase fiber and fluids
Lab Values Needed:
● No routine labs required
● Monitor electrolytes if prolonged use or diarrhea occurs
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(senna, cascara)
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ASSESSMENT DATA IN MEETING HUMAN NEEDS
Neurosensory: Hygiene/ADL Pt. alert & oriented - A+Ox4 ADL’s (assistance needed?) - Responsive to verbal & tactile stimuli - Yes Toileting - Independent Follows commands - Yes Feeding - Independent Speech comprehensible - Normal, Clear Speech Bathing - Setup/ Cleanup Assistance Eyes: PERRLA - Yes Glasses - Drainage - Oral Care - Setup/Cleanup Assistance Hearing Deficits - None Devices? - None Pericare - Independent Numbness/Tingling -Resident denies Ambulation - With Aid Of A Cane Hand Grips -Left Hand Dominant Repositioning - Independent Gait - Steady with Cane/Walker ROM - Tolerated, With Staff Assistance Dizziness w/ standing or ambulation - Mental Status Assessment (MMSE Score) - Geriatric Depression Screening/Score -
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Cellular Nutrition/Circulation Safety Skin - Call Light - Within Reach And working well Quality of Pulse - Rhythm - Bed Rails - No bed rails on bed Pulse Deficit - Fall Risk Assessment: Pedal/Post tibial pulse - Safety education - Resident educated on the safe use of walker/cane to prevent
falls Capillary Refill - Reposition - Independent Tenting present - Dizziness - Resident denies any dizziness Hx of Heart problems - Assistive Devices - Walker/Cane Oral Mucosa - Moist, No redness or sores Medications of concern - Lymph nodes - Restraints (physical and/or chemical) Sequential Compression Devices - Fall Prevention Audit: Oxygenation / Respiration
Activity / Rest
Oxygen saturation - 98% on room air Daily activity involvement - Respirations - 19 Related medications - Oxygen - Setting - Delivery - Sleep - Resident reports not being able to sleep well at night due to roommate
being cared for and playing the television all night Food / Fluid Sexuality / Family Diet - Regular Diet, Regular Texture, Thin Liquids. Please DO NOT SERVE CHICKEN NOODLE SOUP. Patient like boneless chicken, honey mustard, bananas, tomato soup, salad with Caesar dressing, grilled cheese with single cheese slide, milk for tea Consistency - Regular
Appropriate apparel - Resident wear house gowns instead of casual clothes
Fluids: Oral - IV - No Ivs Support system - Sister and Daughter Teeth - Natural Teeth Intact Dentures - None Body image issues - “Big Legs” Throat - Swallowing Intact - Yes Nausea/vomiting - Elimination / GU / GI Cultural / Spiritual / Psychosocial Urine output - Amount - 350 Color - Amber Resides - Inspection - Bowel sounds: Hypo - Hyper- Normal - In all 4 quads Work (current or Hx) - Palpation - Stools: Color - Brown Odor- no foul odor Consistency- Soft Culture (not race) Hinduism Continent/Incontinent: Bowel - Continent Bladder - Continent Hobbies - Drawing,
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Odor - No foul odor Flatus - Concerns - Catheter - N/A Type - N/A Visitors/Support Systems - Daughter And Sister Emesis - None Amount - N/A Social limitations due to disease process - Resident report not being able to go
outside with other resident due to her not being able to wear shoes Drains - None Affect - NG - None Amount - N/A Color - N/A Spirituality - Skin Integrity / Musculoskeletal Growth / Development / Erikson Stage Incisions - None Where - N/A Why - What stage of development - Generativity vs. Stagnation (Middle
Adulthood, ages 40–65 Drains - None Type - N/A Location - N/A Rationale - At this stage, adults focus on contributing to society, guiding
younger generations, maintaining productivity, and finding meaning in life. Success leads to feelings of usefulness and fulfillment; failure may result in stagnation, self-absorption, or lack of purpose
Conditions of surrounding skin - Intact Dressings - None Why - S/S of infections - None Noted Repositioning - Bony Prominence - Tenting - Edema - +4 Pitting To Both Legs Muscle Strength - Right Sided Weakness Ambulation - Ambulatory With Aid Frequency - Daily Distance - Skin conditions - Skin is warm and dry Braden Scale - Recommendations for this score –
Bruising/breakdown/rashes/lesions - None where - N/A Related Lab values (PT, PTT, INR) Wound status - None Where - N/A Protocol – N/A
Pain / Comfort Teaching / Learning / Discharge Planning Pain Assessment: Assessment / Knowledge - Pain scale - Type - Location - Disease Process - Alleviating factors - Medications - Exacerbating factors - Safety - Grimacing/guarding - Ambulation -
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Comfort in room - ADL’s - Repositioning - Self-care - Pain on palpation - Where - Pain medications - Evaluation of efficacy of medications given – Pain score - Other:
Nursing Diagnosis (Minimum of 3; one of which needs to be a psychosocial nursing diagnosis) PRIORITIZE your nursing diagnosis
Goals 2-3 goals per nursing diagnosis
Interventions 2-3 nursing interventions per
goal
Rationale for intervention with
reference
Evaluation Relating directly back to your patient as to: Goal met, Goal
partially met, Goal not met (explain how assessment data demonstrates patient outcomes were met). If the
goals were not met, provide the reasoning and explain how to
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change the NI to meet the patient's need.
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Reference: (APA Format)
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