PATIENT CHART
Chart for Ertha Williams Simulation #2
STUDENT NAME:_______________________________
PATIENT INITALS: ___E.W._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
1
Patient Name: Ertha Williams
Room:
DOB: 01/19/xx
Age: 74
MRN: 02345
Doctor Name: Joan Rivers, MD
Date Admitted:
Diagnosis: Dementia, Alzheimer’s vs. vascular type
Patient Report (Report from nurse employed by the assisted living
facility)
Current time: 1800
Situation: Ertha has shown some marked deterioration since Henry died 4 weeks ago. She is unkempt, more
confused and agitated, cries frequently, and looks everywhere for Henry. We called her daughter-in-law Betty
and she will be here shortly.
Background: Ertha has shown some marked deterioration since Henry died 4 weeks ago. She is unkempt,
more confused and agitated, cries frequently, and looks everywhere for Henry. We called her daughter-in-law
Betty and she will be here shortly.
Assessment: Ertha is not eating well. A staff member has to go and get her and take her to the dining room.
She can’t sit at the table very long and eats very little. Other residents have tried to be supportive, but she
cannot socialize. Ertha had clear deficits on the Brief Evaluation of Executive Dysfunction when it was done a
few months ago, but we think she is worse. Her living space is very messy and she only comes out of her room
when we go to get her. Dr. Rivers prescribed Prozac and trazadone and increased the dose on her Exelon
patch a few days ago, but it has not helped. We now have staff administering her medications, but we all feel
that Ertha needs a higher level of care now. We called our long term care facility and there is a room available.
Recommendation: Get some vital signs on Ertha and do a Mini-Cog. Meet with Betty and help her see that
Ertha needs more care than we can provide in assisted living. If she agrees, we can move her tomorrow. Dr.
Rivers will be waiting for your call and is prepared to write a transfer order, so call as soon as you finish your
visit. I put a Medication Reconciliation form in her chart. If she is being transferred, you will need to get it filled
out.
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
2
Provider’s Orders
Allergies: NKA
Date/Time:
4 months Condition of patient: Good
ago/ 1300 1. DIET: Regular diet as tolerated
2. VITAL SIGNS: Monthly
3. ACTIVITY: As tolerated
4. SAFETY CHECKS: has alert system
5. LABS: RPR, TSH, CBC with differential, B12 folate, LFT
6. MEDICATIONS:
a. Acetaminophen (Tylenol) 650 mg q 6h prn headache/pain
b. Rosuvastatin calcium 20 mg daily/evening
c. Atenolol 50 mg daily
d. Zolpidem Tartrate 5 mg every evening for sleep
e. Rivastigmine transdermal system (Exelon patch) 4.6 mg daily
7. MISCELLANEOUS: Assess for depression, executive dysfunction
Joan Rivers, MD
Date/Time:
1. MEDICATIONS:
2 days
ago/ 1300
a. Trazadone 25 mg at bedtime
b. Prozac 10 mg q day
c. Rivastigmine transdermal system (Exelon patch) increase dose from
4.6 mg to 9.5 mg daily
d. Continue other medications as previously ordered
2. MISCELLANEOUS:
a. Discuss transfer to long term care facility with family
b. Assess for cognitive changes with Mini-Cog
Joan Rivers, MD
Lab Data
Date/Time:
8 months ago
Chemistries
Test:
Sodium
Result:
139 mEq/L
Reference range:
135-145 mEq/L
Potassium
4.0 mEq/L
3.5-5.2 mEq/L
Calcium
8.5 mg/dl
8.5 – 10.2 mg/dl
Carbon Dioxide
26 mEq/L
20-29 mEq/L
Chloride
103 mEq/L
96-106 mEq/L
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
3
Hematology
Liver Function
Test
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
Hematocrit
42%
38 – 43%
Hemoglobin
12.8 g/dl
12 – 16 mg/dl
ALT
25 units per liter
(U/L)
7 to 55 units per
liter (U/L)
AST
18 U/L
8 to 48 U/L
Albumin
4.5 g/dL
3.5 to 5.0 (g/dL)
Total protein
6.8 g/dL
6.3 to 7.9 (g/dL
Bilirubin
0.8 mg/dL
0.1 to 1.0 mg/dL
LD
130 U/L
122 to 222 U/L
PT
11.5 seconds
9.5 to 13.8
seconds
TSH
3.0 mlU/L
0.4 – 4.0 mlU/L
B12
350 pg/ml
200 – 900 pg/ml
Folate
5.0 ng/ml
2.7 – 17.0 ng/ml
RPR
Nonreactive
Nonreactive
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
4
Medication Administration Record
Allergies: NKA
Scheduled & Routine Drugs
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Rivastigmine
(Exelon)
4.6 MG
transdermal
system
daily
Hours to
be
Given:
0900
Atenolol
(Tenormin).
50 mg
daily
0900
Zolpidem
tartrate
(Ambien)
5 mg
every
evening
2000
Rosuvastatin
calcium
(Crestor)
20 mg
daily/evening
2000
- Monday/
LR
- Tuesday/
LR
- Wednesday/
LR
Rivastigmine
(Exelon)
9.5 mg
daily
0900
Prozac
10 mg
daily
0900
- Thursday/
JMC
- Friday/
JMC
- Thursday/
JMC
- Friday/ JMC
transdermal
system
Dates/Times
Given/Initials:
- Monday/
JMC
- Tuesday/
JMC
- Wednesday/
JMC
- Thursday discontinued
- Monday/
JMC
- Tuesday/
JMC
- Wednesday/
JMC
- Monday/
LR
- Tuesday/
LR
- Wednesday/
LR
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
5
Trazadone
25 mg
at bedtime
2000
- Thursday/
LR
- Friday/ LR
Frequency:
Hours
to be
Given:
Dates/Times
Given/Initials:
PRN Medications
Date
of
Order:
Medication:
Dosage:
Tylenol
(acetaminophen)
650 mg
Route:
q 6h prn
pain/headache
-
Nurse Signatures
Date/Time
Initial
JMC
LR
Nurse Signature
Jeanne M. Cleary, RN
Laureen Ryley, RN
Patient Name: Ertha Williams
Physician: Joan Rivers, MD
Diagnosis: Dementia,
Alzheimer’s vs. Vascular Type
Age: 74
Gender: Female
Height: 5’4”
Weight: 130 lbs
Major Support: Daughter-in-law
Betty
Phone: 998-665-2323
Betty: 320-222-1111
Type of Operation: None
History: Progressive confusion
Advanced Directives: No
Allergies: none known
Fall Precautions:
Isolation Precautions:
Restraints:
Diet: Regular
Monitoring
Vital signs – monthly
Nightly safety checks
Emergency Alert device
See Dr. Rivers or Mary Lake,
APRN, GNP q 3 months
Medication
Oral medications –
administered by staff
Suggested Available Activities
- Exercise class (M, W, F)
- Monthly book club
- Weekly trip to supermarket
- Weekly trip to shopping mall
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
6
Social History
- Sold home and moved into this
facility 4 months ago
- Husband Henry died 4 weeks
ago
Consults
- Comprehensive care team
- Assisted living staff
Treatments
Activities of Daily Living
Needs reminders. Aide
comes 3x/week to help with
bathing.
Meals
- Breakfast and dinner in the
community dining room
- May need to bring her to dining
room and supervise.
- Has lost weight.
Race:
Religion: Baptist
Medication brought from home:
All medications listed in Provider
Orders
Diagnostic Studies
Lab – RPR, TSH, CBC with
differential, B12, folate, LFT
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
C
DC
Provider Signatures
Date/Time
Initial
Provider Signature
Initial
Nurse Signature
Nurse Signatures
Date/Time
Reviewed on Transfer by:
Reviewed on Discharge by:
Scan to Pharmacy Time:
Date:
Date:
Date:
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
7
Responses from Brief Evaluation of Executive Dysfunction (from
first assisted living visit):
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
8
Responses from Geriatric Depression Scale (from first assisted
living visit):
Chart Materials Ertha Williams– Simulation 2
© National League for Nursing, 2014
9