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25.08.2025
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NURSINGASSESSMENT1.docx
NURSINGASSESSMENT2.docx
TemplateRelearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx

NURSINGASSESSMENT1.docx

NURSING ASSESSMENT & NOTES
4/5 1030	Name: Gloria Cox Age: 92 years Provider: U. Beaker MD Allergies: NKDA Code Status: Full Code Admit Wt: 85 lbs (38.5 kg) BMI: 17.2 Neurologic/Cognitive: Alert, oriented to name only. Pupils 4 mm PERRLA. Can follow commands, utilized wheelchair due to fatigue, grips moderate and equal. Cardiovascular: S1/S2 with occasional PVCs per monitor. Respiratory: Tachypnea, decreased breath sounds with scattered wheezes in all fields, productive cough, greenish tint. Gastrointestinal: Abd soft with active bowel sounds. Last bowel movement was 2 days ago per son. Genitourinary: Client is incontinent of urine, recently started about a month ago. Musculoskeletal: Weakness, using wheelchair. Was walking independently until about a month ago. Integumentary: Skin is dry, per son, the client will not get in the shower.
4/5 1105	Nursing Note: Respiratory therapist unavailable to administer breathing treatment, administered by RN. Lungs before treatment with decreased breath sounds in all fields, wheezes noted, and cough is dry.
4/5 1120	Nursing Note: Lung assessment - increased air movement in upper fields, slight wheezes noted, bases remain decreased. Productive moist cough sputum sample obtained, slight greenish tint.
4/5 1150	Nursing Note: Respiratory therapist at bedside to obtain ABGs.
VITAL SIGN TREND
Date	Temp	HR	RR	BP	SpO2	O2
4/5 1015	99.6 °F (37.6 °C)	100	24	110/62	90%	2L/NC
4/5 1105	99.4 °F (37.4 °C)	106	22	116/68	94%	2L/NC
PROVIDER PRESCRIPTIONS & NOTES
4/5 1100	Prescriptions: · Albuterol and Ipratropium combination treatment (DuoNeb) x 1 treatment · Arterial Blood Gas · Urinalysis · 2 view chest x-ray · Sputum sample
COLLABORATIVE CARE
4/5 1015	Urgent Care Note: Client accompanied by son with report of increasing dyspnea for the past two weeks. Was 1 pack/day smoker x 50 years, quit 10 years ago. History of COPD first diagnosed last year. Progressive weight loss over the past 6 months. Occasional use of O2 at 2L via NC until the past 2 weeks, now continuous. Productive cough for the last 6 months with thick, occasional green sputum production. Using her albuterol MDI, 2 puffs every 2 hours, for the past 14 days. Has not been getting relief from MDI for the 2 weeks. The client's son has the MDI with him. No doses remaining. "I didn't know there was a counter. I wonder how long it has been empty.” “My mom has been more confused the last couple of weeks. She was always sharp, and now she doesn’t remember if she took her medicine. She has been calling my wife by my sister’s name.”

NURSINGASSESSMENT2.docx

NURSING ASSESSMENT & NOTES
3/3 0630	Name: Chantel Butler Age: 38 years Provider: R. Ahart MD Allergies: NKA Code Status: Full Code Admit Wt: 132 lbs (59.8 kg) BMI: 21.1 Nursing Note: Slurred speech. The client came to the ED with “the worst headache ever.” She has right-sided facial drooping and tingling on the right arm and face. States tingling started several hours ago when she got up to the bathroom. She thought she was “laying funny” and went back to bed. When she got up at 0530, she noticed the facial drooping, and her boyfriend brought her to the emergency department. The slurring of speech began in the car ride to the hospital.
3/3 0640	Nursing Note: Client resting on a stretcher awaiting transport to CT. Denies a change in headache or tingling. Speech continues to be slurred, and facial dropping continues as noted. Labs drawn.
VITAL SIGN TREND
Date	Temp	HR	RR	BP	SpO2	O2
3/3 0630	98.2 °F (36.8 °C)	83	22	172/90	98%	RA
3/3 0640	98.4 °F (36.9 °C)	96	20	174/92	99%	RA
PROVIDER PRESCRIPTIONS & NOTES
3/3 0640	Prescriptions: · Code Stroke · Start IV · IV to a saline lock · CT head w/o contrast
3/3 0710	Prescriptions: · MRI- head without contrast
LAB RESULTS
Date	Lab	Normal	Result
3/3 0710	Complete Blood Count (CBC)
	Hemoglobin (Hgb)	12 - 17 g/dL	12
	Hematocrit (Hct)	36% - 51%	36%
	White Blood Cells (WBC)	4,000 - 10,000 mm3	8,500
	Platelets	150,000 - 350,000 mm3	350,000
	Blood Glucose	70-100 mg/dL	94
	HCG	Negative	negative

DIAGNOSTIC TEST RESULTS
Date	Diagnostic Test	Findings
3/3 0710	CT Scan	inconclusive

Client Information: Medical History:

· Melanoma - left thigh

· Hypertension

· History of gallstones

· Irritable bowel syndrome

Surgical History:

· C-section

· Cholecystectomy

· Name: Chantel Butler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

· Admit Wt: 132 lbs (59tler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

59.8 kg)

· BMI: 21.1

· Chantel Butler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

· Admit Wt: 132 lbs (59.8 kg)

· BMI: 21.1

NURSINGASSESSMENT1.docx

NURSING ASSESSMENT & NOTES
4/5 1030	Name: Gloria Cox Age: 92 years Provider: U. Beaker MD Allergies: NKDA Code Status: Full Code Admit Wt: 85 lbs (38.5 kg) BMI: 17.2 Neurologic/Cognitive: Alert, oriented to name only. Pupils 4 mm PERRLA. Can follow commands, utilized wheelchair due to fatigue, grips moderate and equal. Cardiovascular: S1/S2 with occasional PVCs per monitor. Respiratory: Tachypnea, decreased breath sounds with scattered wheezes in all fields, productive cough, greenish tint. Gastrointestinal: Abd soft with active bowel sounds. Last bowel movement was 2 days ago per son. Genitourinary: Client is incontinent of urine, recently started about a month ago. Musculoskeletal: Weakness, using wheelchair. Was walking independently until about a month ago. Integumentary: Skin is dry, per son, the client will not get in the shower.
4/5 1105	Nursing Note: Respiratory therapist unavailable to administer breathing treatment, administered by RN. Lungs before treatment with decreased breath sounds in all fields, wheezes noted, and cough is dry.
4/5 1120	Nursing Note: Lung assessment - increased air movement in upper fields, slight wheezes noted, bases remain decreased. Productive moist cough sputum sample obtained, slight greenish tint.
4/5 1150	Nursing Note: Respiratory therapist at bedside to obtain ABGs.
VITAL SIGN TREND
Date	Temp	HR	RR	BP	SpO2	O2
4/5 1015	99.6 °F (37.6 °C)	100	24	110/62	90%	2L/NC
4/5 1105	99.4 °F (37.4 °C)	106	22	116/68	94%	2L/NC
PROVIDER PRESCRIPTIONS & NOTES
4/5 1100	Prescriptions: · Albuterol and Ipratropium combination treatment (DuoNeb) x 1 treatment · Arterial Blood Gas · Urinalysis · 2 view chest x-ray · Sputum sample
COLLABORATIVE CARE
4/5 1015	Urgent Care Note: Client accompanied by son with report of increasing dyspnea for the past two weeks. Was 1 pack/day smoker x 50 years, quit 10 years ago. History of COPD first diagnosed last year. Progressive weight loss over the past 6 months. Occasional use of O2 at 2L via NC until the past 2 weeks, now continuous. Productive cough for the last 6 months with thick, occasional green sputum production. Using her albuterol MDI, 2 puffs every 2 hours, for the past 14 days. Has not been getting relief from MDI for the 2 weeks. The client's son has the MDI with him. No doses remaining. "I didn't know there was a counter. I wonder how long it has been empty.” “My mom has been more confused the last couple of weeks. She was always sharp, and now she doesn’t remember if she took her medicine. She has been calling my wife by my sister’s name.”

NURSINGASSESSMENT2.docx

NURSING ASSESSMENT & NOTES
3/3 0630	Name: Chantel Butler Age: 38 years Provider: R. Ahart MD Allergies: NKA Code Status: Full Code Admit Wt: 132 lbs (59.8 kg) BMI: 21.1 Nursing Note: Slurred speech. The client came to the ED with “the worst headache ever.” She has right-sided facial drooping and tingling on the right arm and face. States tingling started several hours ago when she got up to the bathroom. She thought she was “laying funny” and went back to bed. When she got up at 0530, she noticed the facial drooping, and her boyfriend brought her to the emergency department. The slurring of speech began in the car ride to the hospital.
3/3 0640	Nursing Note: Client resting on a stretcher awaiting transport to CT. Denies a change in headache or tingling. Speech continues to be slurred, and facial dropping continues as noted. Labs drawn.
VITAL SIGN TREND
Date	Temp	HR	RR	BP	SpO2	O2
3/3 0630	98.2 °F (36.8 °C)	83	22	172/90	98%	RA
3/3 0640	98.4 °F (36.9 °C)	96	20	174/92	99%	RA
PROVIDER PRESCRIPTIONS & NOTES
3/3 0640	Prescriptions: · Code Stroke · Start IV · IV to a saline lock · CT head w/o contrast
3/3 0710	Prescriptions: · MRI- head without contrast
LAB RESULTS
Date	Lab	Normal	Result
3/3 0710	Complete Blood Count (CBC)
	Hemoglobin (Hgb)	12 - 17 g/dL	12
	Hematocrit (Hct)	36% - 51%	36%
	White Blood Cells (WBC)	4,000 - 10,000 mm3	8,500
	Platelets	150,000 - 350,000 mm3	350,000
	Blood Glucose	70-100 mg/dL	94
	HCG	Negative	negative

DIAGNOSTIC TEST RESULTS
Date	Diagnostic Test	Findings
3/3 0710	CT Scan	inconclusive

Client Information: Medical History:

· Melanoma - left thigh

· Hypertension

· History of gallstones

· Irritable bowel syndrome

Surgical History:

· C-section

· Cholecystectomy

· Name: Chantel Butler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

· Admit Wt: 132 lbs (59tler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

59.8 kg)

· BMI: 21.1

· Chantel Butler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

· Admit Wt: 132 lbs (59.8 kg)

· BMI: 21.1

NURSINGASSESSMENT1.docx

NURSING ASSESSMENT & NOTES
4/5 1030	Name: Gloria Cox Age: 92 years Provider: U. Beaker MD Allergies: NKDA Code Status: Full Code Admit Wt: 85 lbs (38.5 kg) BMI: 17.2 Neurologic/Cognitive: Alert, oriented to name only. Pupils 4 mm PERRLA. Can follow commands, utilized wheelchair due to fatigue, grips moderate and equal. Cardiovascular: S1/S2 with occasional PVCs per monitor. Respiratory: Tachypnea, decreased breath sounds with scattered wheezes in all fields, productive cough, greenish tint. Gastrointestinal: Abd soft with active bowel sounds. Last bowel movement was 2 days ago per son. Genitourinary: Client is incontinent of urine, recently started about a month ago. Musculoskeletal: Weakness, using wheelchair. Was walking independently until about a month ago. Integumentary: Skin is dry, per son, the client will not get in the shower.
4/5 1105	Nursing Note: Respiratory therapist unavailable to administer breathing treatment, administered by RN. Lungs before treatment with decreased breath sounds in all fields, wheezes noted, and cough is dry.
4/5 1120	Nursing Note: Lung assessment - increased air movement in upper fields, slight wheezes noted, bases remain decreased. Productive moist cough sputum sample obtained, slight greenish tint.
4/5 1150	Nursing Note: Respiratory therapist at bedside to obtain ABGs.
VITAL SIGN TREND
Date	Temp	HR	RR	BP	SpO2	O2
4/5 1015	99.6 °F (37.6 °C)	100	24	110/62	90%	2L/NC
4/5 1105	99.4 °F (37.4 °C)	106	22	116/68	94%	2L/NC
PROVIDER PRESCRIPTIONS & NOTES
4/5 1100	Prescriptions: · Albuterol and Ipratropium combination treatment (DuoNeb) x 1 treatment · Arterial Blood Gas · Urinalysis · 2 view chest x-ray · Sputum sample
COLLABORATIVE CARE
4/5 1015	Urgent Care Note: Client accompanied by son with report of increasing dyspnea for the past two weeks. Was 1 pack/day smoker x 50 years, quit 10 years ago. History of COPD first diagnosed last year. Progressive weight loss over the past 6 months. Occasional use of O2 at 2L via NC until the past 2 weeks, now continuous. Productive cough for the last 6 months with thick, occasional green sputum production. Using her albuterol MDI, 2 puffs every 2 hours, for the past 14 days. Has not been getting relief from MDI for the 2 weeks. The client's son has the MDI with him. No doses remaining. "I didn't know there was a counter. I wonder how long it has been empty.” “My mom has been more confused the last couple of weeks. She was always sharp, and now she doesn’t remember if she took her medicine. She has been calling my wife by my sister’s name.”

NURSINGASSESSMENT2.docx

NURSING ASSESSMENT & NOTES
3/3 0630	Name: Chantel Butler Age: 38 years Provider: R. Ahart MD Allergies: NKA Code Status: Full Code Admit Wt: 132 lbs (59.8 kg) BMI: 21.1 Nursing Note: Slurred speech. The client came to the ED with “the worst headache ever.” She has right-sided facial drooping and tingling on the right arm and face. States tingling started several hours ago when she got up to the bathroom. She thought she was “laying funny” and went back to bed. When she got up at 0530, she noticed the facial drooping, and her boyfriend brought her to the emergency department. The slurring of speech began in the car ride to the hospital.
3/3 0640	Nursing Note: Client resting on a stretcher awaiting transport to CT. Denies a change in headache or tingling. Speech continues to be slurred, and facial dropping continues as noted. Labs drawn.
VITAL SIGN TREND
Date	Temp	HR	RR	BP	SpO2	O2
3/3 0630	98.2 °F (36.8 °C)	83	22	172/90	98%	RA
3/3 0640	98.4 °F (36.9 °C)	96	20	174/92	99%	RA
PROVIDER PRESCRIPTIONS & NOTES
3/3 0640	Prescriptions: · Code Stroke · Start IV · IV to a saline lock · CT head w/o contrast
3/3 0710	Prescriptions: · MRI- head without contrast
LAB RESULTS
Date	Lab	Normal	Result
3/3 0710	Complete Blood Count (CBC)
	Hemoglobin (Hgb)	12 - 17 g/dL	12
	Hematocrit (Hct)	36% - 51%	36%
	White Blood Cells (WBC)	4,000 - 10,000 mm3	8,500
	Platelets	150,000 - 350,000 mm3	350,000
	Blood Glucose	70-100 mg/dL	94
	HCG	Negative	negative

DIAGNOSTIC TEST RESULTS
Date	Diagnostic Test	Findings
3/3 0710	CT Scan	inconclusive

Client Information: Medical History:

· Melanoma - left thigh

· Hypertension

· History of gallstones

· Irritable bowel syndrome

Surgical History:

· C-section

· Cholecystectomy

· Name: Chantel Butler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

· Admit Wt: 132 lbs (59tler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

59.8 kg)

· BMI: 21.1

· Chantel Butler

· Age: 38 years

· Provider: R. Ahart MD

· Allergies: NKA

· Code Status: Full Code

· Admit Wt: 132 lbs (59.8 kg)

· BMI: 21.1

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