Clinical

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PATIENT CHART Chart for Edith Jacobson

STUDENT NAME:

PATIENT INITIALS:

CLINICAL DATE(S):

INSTRUCTOR:

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Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No

Demographics

Marital Status: Widow Primary Language: English

Next of Kin: Eldest child Occupation: Retired teacher

History of Chief Concern: 85 year-old female with a history of osteoporosis. Lives at home by herself and fell and broke her left hip during the night. She is scheduled for hip surgery tomorrow morning.

Past Medical History

Surgical Procedure: Year: Disease/Condition: Date Diagnosed:

Hysterectomy 20 years ago • Osteoporosis. Home medications: raloxifene, calcium, and vitamin D

10 years ago

Notes:

Pain History: Yes

Notes: Piercing pain with movement in left hip

Transfusion History:

Notes:

Allergies: No known allergies Substance: Category: Reaction:

Immunizations: Up to date

Social History

Living situation: Home Lives with: Herself

Education: College

Nicotine Use: Non-smoker

Alcohol Use: User Notes: Occasional glass of wine

Drug Use: Non-user

Violence Screening: Yes, no current issues

Nutritional Screening: Yes, no current issues

Exercise Screening: Yes, no current issues

Mental Health Screening: Yes, no current issues

Sexual Activity: No

PATIENT INFORMATION

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� No prior surgical history � Denies prior medical problems

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NURSING ASSESSMENT FLOWSHEET

TIME OF ASSESSMENT: Done at 1400

RESPIRATORY OXYGEN DELIVERY METHOD: Q Room Air  Nasal Cannula  Simple Face mask  Non-Rebreather Mask  CPAP  BiPAP  Other SPUTUM: RESPIRATORY SYMPTOMS:  Cough  Shortness of Breath  Difficulty Breathing at Rest  Difficulty Breathing with Activity  Use of Accessory Muscles  Cyanosis  Other BREATH SOUNDS: Right: Q Clear  Crackles  Rhonchi  Wheeze  Coarse  Stridor  Inspiratory  Expiratory  Decreased  Absent Left: Q Clear  Crackles  Rhonchi  Wheeze  Coarse  Stridor  Inspiratory  Expiratory  Decreased  Absent RESPIRATIONS: Q Regular  Irregular  Labored  Gasping  Grunting  Retraction  Nasal Flaring THORAX: Q Even expansion  Uneven expansion

NEUROLOGICAL ORIENTATION: Q Person Q Time Q Place Q Situation  Disoriented PUPILS: Q PEERLA Left: Size: Reaction: Right: Size: Reaction: STRENGTH: BEHAVIORAL/EMOTIONAL: Q Calm  Cooperative  Restless  Combative  Confused  Agitated  Untestable GLASGOW COMA SCALE: Eye Opening: Q Spontaneous Q Speech Q Pain  Non-responsive Verbal Response: Q Oriented times 3  Confused  Inappropriate  Incomprehensible  No Sounds Motor Response: Q Obeys commands  Localizes pain  Flexion/Withdrawal to Pain  Abnormal Flexion  Extension  No movement SIGHT: Q No Correction  Glasses  Contacts  Blind HEARING: Q WNL  Hard of Hearing  Hearing Aid  Deaf

GASTROINTESTINAL ABDOMINAL DESCRIPTION: Q Soft  Flat  Non-Distended  Distended  Firm  Round  Sunken  Rigid  Guarding  Rebound  Scars  Hernia PALPATION: Q Non-Tender  Tender Location: GI SYMPTOMS:  Anorexia  Belching  Vomiting  Heartburn  Nausea  Epigastric Pain  Cramping  Constipation  Diarrhea  Abdominal Pain  Flatulence  Hiccup  Early Satiety  Dysphagia  Encopresis  Bloody Stools  Weight Loss  Weight Gain  Other BOWEL SOUNDS: Q Present  Hypoactive  Hyperactive  Absent DIET TOLERANCE:  Excellent Q Adequate  Inadequate  NPO  Other Diet Type:  Impaired swallowing  Choking DEVICES:  NG Tube  Feeding Tube NOTES:

Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No

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CARDIOVASCULAR HEART TONES: Q S1, S2 Q Regular ¨ Irregular ¨ Murmur ¨ S3 ̈ S4 ̈ Gallop ̈ Muffled ̈ Distant ̈ Radiating PULSES: All: ¨ Absent ̈ Intermittent ¨ +1 ̈ +2 ̈ +3 ¨ Bounding ¨ Doppler LUE: ¨ Absent ¨ Intermittent ¨ +1 ¨ +2 Q +3 ¨ Bounding ¨ Doppler RUE: ¨ Absent ¨ Intermittent ¨ +1 ¨ +2 Q +3 ¨ Bounding ¨ Doppler LLE: ¨ Absent ¨ Intermittent ¨ +1 Q +2 ¨ +3 ¨ Bounding ¨ Doppler RLE: ¨ Absent ¨ Intermittent ¨ +1 ¨ +2 Q +3 ¨ Bounding ¨ Doppler EDEMA: Q None ¨ Generalized Site #1: ¨ Absent ̈ Trace ¨ 1 + ̈ 2 + ̈ 3 + ̈ 4 + ̈ Non-Pitting ̈ Pitting Site #2: ¨ Absent ̈ Trace ¨ 1 + ̈ 2 + ̈ 3 + ̈ 4 + ̈ Non-Pitting ̈ Pitting CAPILLARY REFILL: LUE: Q < 3 sec ̈ > 3 sec ̈ Absent RUE: Q < 3 sec ̈ > 3 sec ̈ Absent LLE: Q < 3 sec ̈ > 3 sec ̈ Absent RLE: Q < 3 sec ̈ > 3 sec ̈ Absent SKIN COLOR AND DESCRIPTION: Q Appropriate for ethnicity Q Warm Q Dry Q Intact ¨ Cool ¨ Clammy ¨ Cyanotic ̈ Diaphoretic ¨ Blotchy ̈ Dusky ¨ Flushed ¨ Fragile ̈ Jaundiced ̈ Moist ¨ Mottled ̈ Pale ¨ Ashen ̈ Other DEVICES: ¨ Pacer ̈ IABP ̈ CVP ̈ Pulmonary Artery Monitoring ¨ Cardiac Monitor ¨ Arterial line

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NURSING ASSESSMENT FLOWSHEET – CONTINUED

GENITOURINARY URINARY SYMPTOMS: ¨ Dysuria ¨ Oliguria ¨ Polyuria ¨ Anuria ¨ Hematuria ¨ Nocturia ¨ Urinary Retention ¨ Difficulty Starting Stream ¨ Hesitancy Q None

INCONTINENCE: ¨ Frequency ¨ Urgency ¨ Stress ¨ Complete ¨ Daytime ¨ Nighttime

URINE COLOR: Q Yellow ¨ Amber ¨ Orange ¨ Red ¨ Brown ¨ Pink ¨ Green ¨ Blue ¨ Not Visualized

URINE CHARACTER: Q Clear ¨ Cloudy ¨ Concentrated ¨ Diluted ¨ Sediment ¨ Bloody ¨ Clots ¨ Frothy ¨ Purulent

URINE ODOR:

DEVICE:

CATHETER: Size: Volume in Balloon:

SITE DESCRIPTION:

GENITALIA EXAM:

SANE EXAM:

OTHER/NOTES:

MENTAL HEALTH

PAIN SCALE

LOCATION: Left hip and leg

ONSET: Left hip fracture LAST ASSESSMENT AT: 1400 PAIN RATING: ̈ 0 ¨ 1 ̈ 2 ̈ 3 ¨ 4 ̈ 5 Q 6 ¨ 7

INTEGUMENTARY

DATE/TIME:

Q Clean/Dry/Intact Skin Assessment ¨ Site/Wound: REGION: ¨ Head ¨ Neck ¨ Shoulder ¨ Back ¨ Torso ̈ Arm ¨ Hand ̈ Hip ̈ Buttocks ¨ Groin ̈ Leg ¨ Ankle ̈ Foot

TYPE:

CHARACTERISTICS:

LENGTH: WIDTH:

DEPTH: ACTIONS:

NOTES:

BRADEN SCALE SCORE: 15

BEHAVIOR/AFFECT:

Q Appropriate ¨ Agitated ¨ Anxious ¨ Depressed ¨ Crying ̈ Fearful ¨ Hostile ¨ Inappropriate ¨ Help-rejecting/Complaining ¨ Embarrassed ¨ Evasive ̈ Resentful ¨ Angry ̈ Impulsive ¨ Disturbed Sleep ̈ Nightmares ̈ Night terrors ¨ Regression ¨ Other:

STRESSORS: Q Condition Q Hospitalization Q Diagnosis ̈ Procedure Q Surgery ̈ Family Death ¨ Family Illness ̈ Family Problems ̈ Finances ¨ Unknown Causes ¨ Abuse/Neglect ¨ Exposure to Violence ¨ Other:

COPING: ¨ Well Q Fair ¨ Poor

COPING STYLE:

COMMUNICATION:

COGNITIVE IMPAIRMENT SCREENING:

TOOL USED: Interpretation:

PRESENT REGIMEN:

THOUGHTS EXHIBITED: ¨ Delusional ¨ Hallucinatory ¨ Depersonalization

REACTION: ̈ Over-reactive ¨ Under-reactive ¨ Purposeful ¨ Disorganized ¨ Stereotypical Q Consistent Reactions ¨ Inconsistent Reactions

OTHER/NOTES:

TYPE: SIZE:

VASCULAR ACCESS

LOCATION:

DOCUMENTED AT:

DRESSING:

NOTES:

ACTIONS:

Securement device with transparent dressing

Left forearm 20 g

0700

Flushed with 0.9% sodium chloride, patent access

Peripheral

MUSCULOSKELETAL MUSCULOSKELETAL SYMPTOMS: Q Pain ¨ Joint Swelling

MOTOR STRENGTH GRADE: All: ¨ 5/5 ¨ 4/5 ¨ 3/5 ¨ 2/5 ¨ 1/5 ¨ 0/5 LUE: ¨ 5/5 Q 4/5 ¨ 3/5 ¨ 2/5 ¨ 1/5 ¨ 0/5 RUE: ¨ 5/5 Q 4/5 ¨ 3/5 ¨ 2/5 ¨ 1/5 ¨ 0/5 LLE: ¨ 5/5 ¨ 4/5 ¨ 3/5 Q 2/5 ¨ 1/5 ¨ 0/5 RLE: ¨ 5/5 ¨ 4/5 Q 3/5 ¨ 2/5 ¨ 1/5 ¨ 0/5

RANGE OF MOTION & CHARACTERISTIC: All: ¨ Passive ROM ̈ Active Assistive ROM ¨ Active ROM ¨ Spasm ¨ Paralysis ¨ Atrophy LUE: ¨ Passive ROM ¨ Active Assistive ROM Q Active ROM ¨ Spasm ¨ Paralysis ¨ Atrophy RUE: ¨ Passive ROM ¨ Active Assistive ROM Q Active ROM ¨ Spasm ¨ Paralysis ¨ Atrophy LLE: Q Passive ROM ¨ Active Assistive ROM ¨ Active ROM ¨ Spasm ¨ Paralysis ¨ Atrophy RLE: ¨ Passive ROM ¨ Active Assistive ROM Q Active ROM ¨ Spasm ¨ Paralysis ¨ Atrophy

WEIGHT BEARING/GAIT/POSTURE: ¨ Steady ¨ Independent ¨ Unsteady ¨ Dependent ¨ Asymmetrical ̈ Jerky ̈ Shuffling ̈ Spastic ¨ Developmentally Appropriate ¨ Lordosis ̈ Scoliosis ̈ Kyphosis Q None ACTIVITY: ¨ Up ad lib ¨ Walker ¨ Cane ¨ Crutches ¨ Wheelchair

ASSIST: ¨ x1 ¨ x2 ¨ Lift ¨ Bed Bound NOTES: Left hip fracture

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CONSULT:  Chaplain  Social Work  Psychiatry  Childhood

¨ Join Stiffness ̈ Contractures ̈ Deformities ̈ Crepitus ¨ Weakness ¨ Amputation Q Fractures ¨ Spasm ¨ None

¨ 8 ¨ 9 ¨ 10

AGGRAVATING FACTORS: Q Movement ¨ Coughing

¨ Breathing ¨ Eating

ALLEVIATING FACTORS: ¨ Rest ¨ Compression

Q Medication ¨ Ice Q Immobility

PAIN CHARACTERISTICS: ̈ Aching ̈ Throbbing ̈ Dull

¨ Stabbing ̈ Burning ̈ Piercing ̈ Sore ̈ Crushing

Q Radiating

FREQUENCY: Q Constant ¨ Intermittent DURATION: TYPE OF PAIN: ̈ Chronic Q Acute ̈ Cancer-related ACTION: Complete bed rest until surgery

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Date/Time:

1000

1400

ECG done. Shows normal sinus rhythm without ischemia / ML, RN

Vital signs stable. Patient skin intact. Pedal pulses intact. Turned and skin care given. Patient resting comfortably. 2 mg morphine administered IV for the pain level of 7.

Morse Fall Risk completed. Score: 1. History of falling 25 2. Secondary diagnosis 0 3. Ambulatory aid 0 4. IV reservoir 20 5. Gait 10 6. Mental status 0

Total /ML, RN

Initials: Nurse Signature:

ML Marjorie Lund, RN.

PROGRESS ION NOTES

Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No

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Date and Time: Orders Status: Timing: Freq. Initials: Due:

Admission Today 0800

Admit to pre-surgical department Active MP

Diagnosis: Left hip fracture, scheduled for surgery tomorrow am

Active MP

Activity: Bed rest Active Routine Continu- ous

MP

Vital signs Active Routine Every 4 hours

MP 1600

Nothing by mouth after midnight --- night before surgery

Active Routine MP 2400

Active Sched uled

Once MP 2100

Confirm informed consent before surgery

Active Sched uled

Once MP 2100

Lactated Ringer’s 84 mL/hr --- night before surgery

Active Sched- uled

Continu- ous

MP 2100

Enoxaparin sodium 40 mg subcutaneous

Active Sched- uled

Daily MP

Docusate sodium 100 mg oral Active Sched- uled

Daily MP

Morphine sulfate 2 mg IV for pain rating of 7-10

Active PRN Every 4 hours

MP PRN

Tramadol hydrochloride 50 mg oral for mild to moderate pain level 1-3

Active PRN Every 6 hours

MP PRN

Oxycodone/acetaminophen 5/325 mg for moderate pain level 4-7

Active PRN Every 4 hours

MP PRN

Labs: CBC, BMP, serum calcium, aPPT

Discon- tinued

MP On ad- mission

ECG Discon- tinued

MP

X-ray: AP pelvis, AP left hip Discon- tinued

MP

Anti-embolism stockings (knee-length)

Active Routine Continu- ous

MP

HR less than 60/min, greater than 110/min

Active Continu- ous

MP

RR less than 12/min, greater than 22/min SpO2 less than 90% Systolic BP less than 110 mmHg, greater than 140 mmHg

Hibiclens bath the night before surgery

PROVIDER ORDERS

Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No

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Diastolic BP less than 65 mmHg, greater than 90 mmHg Temperature greater than 38.5 °C (101.3 °F)

Initials: Provider Signature:

MP Mark Peterson, MD

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Scheduled and Routine Drugs

Medication Dose Route Freq. Last given

Enoxaparin sodium 40 mg Subcuta- neous

Daily 1000

Docusate sodium 100 mg Oral Daily 1000

PRN

Medication Dose Route Freq. Last given

Morphine sulfate 2 mg IV Every 4 hours as needed for pain

1400

Tramadol hydrochloride 50 mg Oral Every 6 hours

Oxycodone/acetaminophen 5/325 mg Oral Every 4 hours

Continuous Infusions

Medication Dose Route Freq. Last given

MEDICATION ADMINISTRATION RECORD

Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No

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Intake (mL) Output (mL)

Time/ date

Oral Tube feed

IV IVBP Other Urine Emesis NG Drains type

Other

23-07

Shift total:

07-15

Shift total:

15-23

Shift total:

This worksheet shall be used at the bedside to keep track of each intake and output. The totals will then be recorded on the 24-hour Fluid Balance Sheet

Fluid Measurements

• 1 cc = 1 mL • 1 ounce = 30 mL • 8 ounces = 240 mL • 1 cup = 8 ounces = 240 mL • 4 cups = 32 ounces = 1 quart or 1 liter = 1000 mL

Sample Measurements

• Coffee cup = 200 mL • Clear glass = 240 mL • Milk carton = 240 mL • Small milk carton = 120 mL • Juice, gelatin or ice cream cup = 120 mL • Soup bowl = 160 mL

INTAKE & OUTPUT

Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No

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Date Adm.

Time 0800 1200

BP 126/82 124/80

HR 78 82

RR 12 14

SpO2 96% RA

98% RA

Oxygen Flow (L/min) RA RA

Temperature (oC) 37.2 36.9

Nurse Initials T T T T

VITAL SIGNS

Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No ED IT

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Specimen collected: Today 0900

Venous Blood Analysis

Complete Blood Count:

Hgb (male 14-17.4 g/dL, female 12-16 g/dL) 14

HCT (male 42-52%, female 36-48%) 42

WBC (4.5-10.5 x 109) 8

Platelets (150-400*109) 195

Basic Metabolic Panel:

Na+ (136-145 mEq/L) 142

K+ (3.5-5 mEq/L) 3.8

Cl- (98-106 mEq/L) 100

25

BUN (8-20 mg/dL) 20

Creatinine (male 0.6-1.2 mg/ dL, female 0.4-1.0 mg/dL) 0.8

Glucose (70-110 mg/dL) 102

Miscellaneous:

Calcium --- Serum (4.5-5.5 mEq/L) 4.5

Prothrombin time (11-13 s) 11

INR (0.8-1.1) 0.9

APTT (21-35 s) 35

Type and screen

Blood type A+

Indirect antiglobulin 0

LABORATORY REPORT

HCO3 - (19-25 mEq/L)

Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No ED IT

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Before calling the provider:

1. Assess the patient 2. Have charts and relevant information in front of you

SBAR Report Patient Information Notes

Situation Identify yourself:

Patient’s name and reason for report:

Concerns:

Background History includes:

Current problems are:

Any patient complaints:

Assessment Vital signs:

Pain level:

Lab values:

Interventions completed:

Give your conclusions:

Recommendation What I need from you is:

Be specific about a time frame:

Suggestions for tests/treatments:

Verify orders and when to call back:

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SBAR

Edith Jacobson Gender Identification: Female

Allergies: No known allergies

DOB: 03/27/XX Age: 85 years Height: 152 cm (60 in) Weight: 47.5 kg (105 lb) MRN: 78519372

Diagnosis: Osteoporosis --- Left hip fracture Adm Date: Today at 0800 Adm Provider: Mark Peterson, MD

Facility: Preoperative surgical unit Adv Directive: No Isolation Precaution: No

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