PATIENT CHART
Chart for Eugene Shaw Simulation #2
STUDENT NAME:_______________________________
PATIENT INITALS: ___E.S._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
1
Patient Name: Eugene Shaw
Room:
DOB: 05/21/xx
Age: 82
MRN: 09625
Doctor Name: Dr. Ian Stein
Date Admitted:
Diagnosis: Peripheral Vascular Disease; Surgery:
Femoral-popliteal graft - RIGHT
Patient Report (Report from nurse ending shift)
Current time: 0630 Monday morning
Situation: Mr. Eugene Shaw, age 82, came to the ER on Saturday at 2100 with complaints of pain and a
burning sensation in his right leg. He has some small ulcerations of the skin, especially on the heel, with bluish
discoloration of his right foot and some ankle edema. He was admitted to our unit Sunday morning at 0600.
The surgeon evaluated him and said his angiogram revealed a clot in the artery just below the right knee. He
reluctantly agreed to surgery and is scheduled for a femoral-popliteal bypass this morning at 0800. The plan is
to discharge him about 2-5 days post-op. Physical therapy will evaluate him to develop a post-op plan of care.
Background: Mr. Shaw has a 30-year history of hypertension, osteoarthritis of the knee and foot, fallen
arches and chronic cold sensitization. For the past 40 years he has had nocturnal pain in lower limbs and
hands. He was diagnosed with Type 2 Diabetes 20 years ago. He admits that he does not stick to his diet and
the doctor put him on Simvastatin to prevent his cholesterol from going up. Mr. Shaw insists that he takes his
medications regularly. He says he stopped smoking at home over 50 years ago when his son was born, but
still sneaks a few cigarettes when out with friends at the local bar.
Assessment: At 0600 hours his vitals were stable with temperature of 98.6 F (37 C), BP 128/70, heart rate 88,
respirations 6, SpO2 96% on room air, and pain at 7 on a scale of zero to ten. He has continued to complain of
burning pain in his right leg and has been medicated with Vicodin for pain about every 2 hours. His last dose
was at 0500. Mr. Shaw’s blood glucose was 130 mg/dL at 0600. Our neurovascular checks remain the same a popliteal pulse but no pedal pulse. Pulses in the other limbs are normal. He has a left antecubital IV with
Lactated Ringers running at 125 mL/hr. We inserted a Foley at 0600 in preparation for surgery. He is alert and
orientated to person, place and time. He and his wife finally did a durable power of attorney last night.
Recommendation: He is due for vitals and a pain assessment. Complete the pre-op checklist and give him his
pre-op antibiotic. The blood type and crossmatch were sent directly to the OR.
Provider’s Orders
Allergies: NKA
Date/Time:
ED Admission Orders
Saturday
Admit to Orthopedic Unit Service
2330
Condition of patient: Fair
1. DIET: 1800 ADA diet as tolerated
2. VITAL SIGNS: q. 4h. If temperature > 101 F (38.33 C) notify resident
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
2
3. ACTIVITY:
a. Up in chair with leg elevated
b. Weight-bearing status: partial weight-bearing
4. NEUROVASCULAR CHECKS: Q 2 h for first 24 hours, then every shift
5. LABS: Call abnormal results to orthopedic resident or attending surgeon
a. CBC, Chemistry, Platelets, PT/PTT
6. ORTHOPEDIC VASCULAR SURGICAL CONSULT:
7. STAT EKG:
8. MEDICATIONS:
a. Vicodin 5/500 mg q2h PRN for pain
b. Lasix 10mg daily
c. Plavix 75mh PO daily
9. CHECK THE BLOOD SUGAR (BS): before every meal & before bedtime
a. with regular insulin coverage as follows:
0-150: no insulin
150-199: 2 units
200-249: 4 units
250-299: 7 units
300-349: 10 units
Over 350: 12 units and notify MD
b. Docusate (Colace) 100 mg PO daily, may repeat X1 PRN for
constipation
c. Ferrous Sulfate 325 mg PO daily
d. Zocor (Simvastatin) 20 mg PO daily
e. Zestril (Lisinopril) 5 mg PO daily
f. Glucotrol 30mg 1 tab PO bid
g. Citracal 180 mg 1 tab PO daily
h. Enoxaparin (Lovenox) 30 mg subcutaneous q.12h
Ian Stein, MD
Provider’s Orders
Allergies: NKA
Date/Time:
Surgery: Femoral-popliteal graft - RIGHT
Sunday
Provider Orders Pre-Operative Medical Orders
1500
Continue with admission orders per Dr. Stein
1. Femoral- popliteal bypass scheduled for tomorrow at 0800
2. NPO after midnight
3. Hold all oral morning medications
4. Discontinue Enoxaparin 24 hours prior to surgery
5. Blood for type and cross match
6. Consult: Request PT to evaluate patient and plan post-op rehab
7. Incentive spirometer 10 times every hour while awake
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
3
8. Xanax 0.5 mg PO q8h for anxiety
9. Insert Foley catheter prior to surgery
Pre-Op Medication: Cephazolin Injection (Ancef) 1 g IVPB 1 hour prior to surgery
Robert Moses, MD
Stat Order Form
Date/Time:
STAT PHYSICIAN ORDER
Sunday
Stat chest X-ray. Call if abnormal results.
1500
Robert Moses, MD
Lab Data
Date/Time:
Sunday 0600
Chemistries
Hematology
Test:
Sodium
Potassium
Result:
137 mEq/L
4.0 mEq/L
Reference range:
135-145 mEq/L
3.5-5.2 mEq/L
Chloride
103 mEq/L
96-106 mEq/L
Bicarbonate
21 MEq/L
19-25 mEq/L
Calcium
8.6 mg/dl
8.5 – 10.2 mg/dl
Phosphorus
2.8 mg/dl
2.4-4.7 mg/dl
Magnesium
1.9 mg/dl
1.8-3.0 mg/dl
Glucose
199 mg/dl
74 -106 mg/dl
Bun
Creatinine
15 mg/dl
1.0 mg/dl
7-20 mg/dl
0.8 – 1.4 mg/dl
Hematocrit
39%
38 – 43%
Hemoglobin
15 g/dl
12 – 16 mg/dl
Red blood cells
4.8 million/mm3
4.6-6.2 million/mm3
Erythrocyte
sedimentation
rate
19 mm/hr
< 20 mm/hr
Leukocytes
9,000/mm3
5000-10,000/mm3
Platelets
325,000/mm3
Prothrombin time
(PT)
10.2 sec
150,000450,000/mm3
9.6-11.8 sec
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
4
Renal
Urine Test
Partial
thromboplastin
time (PTT)
32
30-40 sec
HgbA1C
5.8%
4-5.6%
BUN
7 mg/dl
6-20 mg/dl
Creatinine
1.2 mg/dl
0.6-1.3 mg/dl
pH
4.4
4.5-8.0
Specific gravity
1.018
1.010-1.025
Medication Administration Record
Allergies: NKA
Scheduled & Routine Drugs
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Colace
(Docusate)
100mg
PO
daily
Hours to
be
Given:
0900
Dates/Times
Given/Initials:
-
Sunday/
0900 NN
Monday/
hold
Plavix
75mg
PO
daily
0900
- Sunday/
0900 NN
- Monday/
hold
Ferrous
Sulfate
325 mg
PO
daily
0900
-
Zocor
(Simvastatin)
20 mg
PO
daily
0900
-
Sunday/
0900 NN
Monday/
hold
Sunday/
0900 NN
Monday/
hold
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
5
Lovenox
(Enoxaparin)
30 mg
Subcutaneous
q.12h
0900
2100
-
Zestril
(Lisinopril)
5 mg
PO
daily
0900
-
Lasix
(Furosemide)
10 mg
PO
daily
0900
-
Citracal
180 mg
1 tab
PO
daily
0900
-
Glucotrol
30mg
1 tab
PO
bid
0900
2100
-
Cephazolin
Injection
(Ancef)
1g
IVPB
1 hour prior
to surgery
1 hour
prior to
surgery
-
Sunday/
0900 NN
Monday/
0600 NN
Sunday/
0900 NN
Monday/
hold
Sunday/
0900 NN
Monday/
hold
Sunday/
0900 NN
Monday/
hold
Sunday/
0700 NN
Monday/
hold
Monday/
0700
PRN Medications
Date
of
Order:
Medication:
Dosage:
Vicodin (hydrocodone
bitartrate/acetaminophen
5/500)
1 tab
Route: Frequency:
PO
Hours
to be
Given:
Dates/Times
Given/Initials:
Q2h
prn for
pain
- Sunday/
0100 AB
- Sunday/
0430 AB
- Sunday/
0730 NN
- Sunday/
1100 NN
- Sunday/
1300 NN
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
6
Xanax
0.5mg
PO
0800
q. 8h
prn
anxiety
- Sunday/
1600 NN
- Sunday/
1900 CR
- Sunday/
2200 CR
- Monday/
0130 CR
- Monday/
0500 CR
- Sunday/
1530 NN
Nurse Signatures
Date/Time
Initial
AB
NN
CR
Nurse Signature
Ann Brennan, RN
Nancy Nurse, RN
Carol Reynolds, RN
Patient Name: Eugene Shaw
Physician: Robert Moses, MD
Diagnosis: Peripheral Vascular
Disease
Age: 82
Gender: Male
Height: 5’7”
Weight: 257 lbs
Major Support: Wife
Phone: 648-888-0002
Robert (son) 555-720-0953
Type of Operation: Femoralpopliteal graft - RIGHT
History: hypertension, and Type
2 Diabetic
Advanced Directives: No
Allergies: None known
Fall Precautions: High
Isolation Precautions: Standard
Restraints: No
Diet: 1800 ADA Regular
Monitoring
Vital signs – Q shift
Neurovascular checks - Q 2
hours
Bedside Glucose Monitoring –
AC (6:30 AM)
Medication
IV access – 1 peripheral IV
in right antecubital placed
Saturday
IV medication – see pre-op
order
Oral medications
Respiratory
Incentive spirometer 10 times
every hour while awake
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
7
Social History
- Lives with wife in own home
Son lives out of state
Race/religion: Catholic
Consults
- Physical therapy
- Rehabilitation medicine
Treatments
- Insert Foley catheter morning of
surgery in pre-operative holding
area
Activities of Daily Living
Up in chair with pillow
Partial weight bearing
Assist as needed
Discharge Planning
- Physical therapy consult for post
op activity and outpatient
rehabilitation
Medication brought from home:
None
Diagnostic Studies
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
Colace (Docusate)
100 mg
PO
BID
Plavix
(Clopidogrel)
75mg
PO
Daily
Ferrous Sulfate
325 mg
PO
Zocor
(Simvastatin)
20 mg
Zestril (Lisinopril)
Last
Dose
Saturday
AM
Continue/DC
C
DC
Saturday
AM
C
DC
Daily
Saturday
AM
C
DC
PO
Daily
Saturday
AM
C
DC
5mg
PO
Daily
Saturday
AM
C
DC
Citracal
180mg
PO
Daily
C
DC
Glucotrol
30mg
PO
Twice Daily
Saturday
AM
Saturday
AM
C
DC
Lasix
10 mg
PO
Daily
Saturday
AM
C
DC
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
8
Provider Signatures
Date/Time
Saturday 2330
Initial
IS
Provider Signature
Ian Stein, MD
Initial
AB
Nurse Signature
Ann Brennan, RN
Nurse Signatures
Date/Time
Saturday 2330
Reviewed on Transfer by: Nancy Nurse, RN
Date: Sunday 0600
Scan to Pharmacy Time:
Date:
Downtime Documentation
24-hour Abbreviated Neurovascular Assessment Flowsheet
Date/Time:
Saturday 2400
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Warm
Cool
Cold
Nurse Signature:
Ann Brennan, RN
Pedal
Pulse:
Popliteal
Pulse:
Present
Faint
Absent
Present
Faint
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
9
Date/Time:
Sunday 0200
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Pedal
Pulse:
Warm
Cool
Cold
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Popliteal
Pulse:
Present
Faint
Absent
Patient Name:
Eugene Shaw
Present
Faint
Absent
Nurse Signature:
Ann Brennan, RN
Pedal
Pulse:
Date/Time:
Sunday 0600
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Sunday 0400
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Ann Brennan, RN
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Popliteal
Pulse:
Present
Faint
Absent
Present
Faint
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
10
Date/Time:
Sunday 0800
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Pedal
Pulse:
Warm
Cool
Cold
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Popliteal
Pulse:
Present
Faint
Absent
Patient Name:
Eugene Shaw
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Date/Time:
Sunday 1200
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Sunday 1000
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Nancy Nurse, RN
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Popliteal
Pulse:
Present
Faint
Absent
Present
Faint
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
11
Date/Time:
Sunday 1400
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Pedal
Pulse:
Warm
Cool
Cold
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Popliteal
Pulse:
Present
Faint
Absent
Patient Name:
Eugene Shaw
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Date/Time:
Sunday 1800
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Sunday 1600
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Nancy Nurse, RN
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Popliteal
Pulse:
Present
Faint
Absent
Present
Faint
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
12
Date/Time:
Sunday 2000
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Pedal
Pulse:
Warm
Cool
Cold
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Popliteal
Pulse:
Present
Faint
Absent
Patient Name:
Eugene Shaw
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Date/Time:
Sunday 2400
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Sunday 2200
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Nancy Nurse, RN
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Popliteal
Pulse:
Present
Faint
Absent
Present
Faint
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
13
Date/Time:
Monday 0200
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Pedal
Pulse:
Warm
Cool
Cold
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Pallor (Color):
Polar
(Temp):
Warm
Cool
Cold
Popliteal
Pulse:
Present
Faint
Absent
Patient Name:
Eugene Shaw
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Date/Time:
Monday 0600
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Monday 0400
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Nancy Nurse, RN
Present
Faint
Absent
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Popliteal
Pulse:
Present
Faint
Absent
Present
Faint
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
14
Date: Sunday
Date: Sunday
Time: 900
Patient Name: Eugene Shaw
Time: 1100
Patient Name: Eugene Shaw
Impression: Normal
Impression: Normal
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
15
History and Physical Exam
Past Medical History: 82- year-old Korean War Veteran with documented injuries during military service in Korea.
Records from previous VHA Hospital confirm removal of 3 toes on right foot due to trench foot 60 years ago, the loss
of 4th digit 1 year later and diagnosis of Type 2 Diabetes 20 years ago. He has been hypertensive for 30 years,
controlled with medication. He has osteoarthritis of the knee and foot, fallen arches and chronic cold sensitization.
Patient reports he usually seeks treatment at his local Veterans Hospital.
History of Present Illness: Patient presented at the Veterans Health Administration Emergency Department at
2100 with complaints of chronic pain in his right calf for the past several days and right foot, in particular the heel
after hitting his foot on the car door. Leg is dusky in color. He describes pain as aching and burning. He also has
discomfort in the muscles of his feet, calves and thighs. A few small ulcerations on right leg; larger one on heel. He
has some unilateral edema of the right leg with dryness and scaling of the skin. He has diminished peripheral pulses
on the right side and the nail on his right big toe is brittle.
Social History: Retired commercial illustrator. Lives with his wife of 59 years, Nancy. Has one son, Robert Shaw,
who lives 500 miles away. Close friend Jim Reynolds.
Family History: Mother died at age 85 from stroke; father at age 90 from “old age.” Does not know anything more
about their health problems. Older male sibling died at age 86 from colon cancer; younger female sibling died in auto
accident at age 77.
Primary Medical Diagnosis on Admission: Peripheral vascular disease, Diabetes Mellitus, Type 2
Surgeries/Procedures: Surgical removal of 3 toes on right foot 60 years ago, subsequent loss of 4th digit on right
foot 1 year later
Physical Examination: Mr. Shaw is complaining of pain in right leg, but says it is being controlled with Vicodin.
Weight: 116.5 kg (257 pounds); Height: 170 cm (67 inches)
Vital Signs: Temperature 98.6 F (37 C), BP 120/80, heart rate 80, respirations 18, SpO2 96% on room air
CNS: Unremarkable, alert & oriented x 3
Neurovascular Assessment: Pain scale 3, pallor to right lower leg, positive pulses to left leg with right diminished
pulses (pedal/popliteal), negative paralysis, negative paresthesia
Cardiovascular: Normal EKG; no murmurs; history of hypertension for 30 years controlled with Lisinopril; on
Simvastatin prophylactically
Genitourinary: Reports mild benign prostate hypertrophy, no treatment required
Endocrine: Type 2 Diabetes kept under control with Glucotrol
Pulmonary: Chest X-ray normal; lung sounds normal. Quit smoking at home 50+ yrs. ago, but has a few cigarettes
once or twice a week when meeting friends in local bar.
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
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Gastrointestinal: Normal findings, bowel sounds present
Allergies: No known allergies
Immunizations: Up to date
Lab Results: All in normal range
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
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Chart Materials Eugene Shaw Simulation 2
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Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
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Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
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Nursing Pre-Operative Checklist
Name of Patient: _____________________________________________________________
Surgical Procedure: ________________________________________________________
Review Chart for the Following Items:
Initials
1. History and physical
2. Laboratory report
3. EKG report
4. Chest X-ray
5. Consent for surgery, signed & witnessed
6. Consent for anesthesia, signed & witnessed
7. Consent for blood transfusion, signed & witnessed
8. Medication Reconciliation Form completed and signed
Pre-Operative Preparation:
Initials
1. Identification bracelet accurate and affixed to wrist/ankle
2. Allergies checked, recorded on ID bracelet and chart
3. Contact lenses, glasses, dentures, prostheses, hairpieces, hairpins
removed
4. Jewelry and other valuables removed and given to
______________________
5. NPO since _______________
6. Vital signs
Time
Initials
_______
Temp
_______
Pulse
_______
B/P
_______
Print Name
Signature
Chart Materials Eugene Shaw Simulation 2
© National League for Nursing, 2013
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