Report in Electronic Health Record from ED – pt being admitted to General Medicine Service
Emergency Department Care Nurse Note
87 y.o. female arrived this AM in ED with BP of 86/40, HR 120, Resp. = 20, Pulse Ox 97, room air Temp. 36.7.
Alert and oriented x 1, had bloody stool x 2 that morning. Denies pain. Pt’s daughter said she had black tarry stools x 3
days, refuses to eat, sometimes complains of nausea. History of diverticulosis, colon polyps, hypertension, CAD,
hyperlipidemia, diabetes, recurrent UTI, chronic back pain.
18 gauge IV placed left forearm. Pt. received 2L. bolus NS, then NS @ 75 cc/hr. NG lavage negative, pt made npo.
KUB, C-Xray done; BMP, CBC, Cardiac enzymes, Type & Screen sent. Urine for ua/c&S sent. Protonix drip @ 8 mg. per
hour. BP of 122/60, HR 86, Resp. = 20, Pulse Ox 97, room air Temp. 36.4. Alert and oriented x 3. H/H = 7.3/23,
Creatinine 2.5, BUN 25. PT, PTT, INR pending.
F. Nightingale, RN 3/16/2012 @ 1730
Kept NPO, 2 units regular insulin given subq, BG = 120. Transfused with 2 units PRBC, premedicated with 650 of Tylenol
po and 25 mg of Benadryl po. No stools, no complaints of pain. Sleeping at times, fidgets but did not try to get out of
bed. Daughter at patient’s bedside. VS: BP = 110/60, HR 90,
Resp. = 20, Pulse Ox 97, room air Temp. 36.4.
F. Nightingale, RN 3/16/2012 @ 2350
Care assumed from previous shift. VS: BP of 104/60, HR 98, Resp. = 20, Pulse Ox 97, room air Temp. 36.4. One large
tarry stool noted – pt cleaned, MD aware. Pt. sleeping after being cleaned, skin intact, daughter stayed with patient all
night. MDs making arrangements for colonoscopy after transfer to floor.
Ida Tarbell, RN 3/17/2012 @ 0400
Patient resting comfortably, daughter at bedside, report uploaded to 8300.
Ida Tarbell, RN 3/17/2012 @ 0500
MD note :
Patient here for LGIB. Had black tarry stool x 4 for the past 3 days per patient’s daughter and 2 large black tarry stool
per the care nurse this morning. On exam afebile, denies abdominal pain. Tachycardia, regular but rapid rhythm,
dehydrated with pale conjunctivae, lung CTA, abdomen soft non tender, no rash, and no extremity edema. Rectal area
with melanic stool. Guaiac positive. We will have GI and Surgery evaluate. IVF resuscitation. Broad spectrum ABX and
Protonix gtt on going. Will need stepdown bed for Lower GIB
Provisional diagnosis – Lower GI bleed, Diverticulitis vs ulcer
General Appearance: well nourished, Cooperative. No obvious discomfort.
Chest Wall: No chest tenderness
Lungs: Good air exchange bilaterally and CTA
Pulses: intact
CV: RRR, no murmurs, rubs, gallops
Skin: Intact, poor turgor,
GI: Bowel sounds x 4, hypoactive
MS: MAE, strength 4/5 throughout,
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Case developed by E. McConnell, PhD, RN, GCNS-BC & Duke University Health System Geriatric Resource Nurses 2013
Home Medications: Lisinopril 5mg po daily, Glipizide 2.5 mg po BID, Oxycodone 5mg po Q6hr PRN, Motrin 400mg po
q8hrs PRN, Lipitor 20mg po daily QHS, Fish Oil 1000mg po BID, donepezil 10 mg. daily.
General Medicine service nursing change of shift report – takes place in front of patient’s door:
General format…
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Name
Age
Diagnosis
History
Day of admission (HD__[insert #])
Where they come from (admitted from ER with….)
Current vital signs, presenting symptoms & current status of symptom control
Mobility status
Tests or procedures completed
Being prepared for (tests…..)
Pertinent labs
Other symptoms
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Case developed by E. McConnell, PhD, RN, GCNS-BC & Duke University Health System Geriatric Resource Nurses 2013
Hospital Day 2 – Change of Shift Report – 2200 HRS
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Mrs. Annie Jones is an 83 y.o. woman admitted yesterday from the ED for a lower GI bleed. She has a history of
diabetes, hypertension, CAD, hyperlipidemia and dementia.
She presented with melanotic stools, and had her last stool at noontime. Her vitals are stable – last BP = 110/60,
p = 92, PT/INR were WNL. She is alert & oriented, up with assistance only. NS infusing 75 cc per hour. She has
an indwelling catheter, and is now finishing her colonoscopy prep which is scheduled for the AM.
KUB has been done, cxray was done in ED and were unrevealing.
H/& H before was 7.5/23, after 2 U PBRC is now 9/33.
Pertinent labs – metabolic panel normal.
She denies any pain, and is sleeping comfortably.
Hospital Day 3 – change of shift report, 3PM
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Mrs. Annie Jones is an 83 y.o. woman admitted 2 days ago from the ED for a lower GI bleed. She has a history of
diabetes, hypertension, CAD, hyperlipidemia and dementia. She presented with melanotic stools, and had her
last stool yesterday . Her vitals are stable but she has a low grade fever 99.2 – last BP = 110/60, p = 92, PT/INR
were WNL. She is alert & oriented, up with assistance only. NS infusing 75 cc per hour. She has an indwelling
catheter, and had a colonoscopy this AM, during which they removed several polyps and cauterized the
bleeders.
H/& H on admission was 7.5/23, after 2 U PBRC is now 9/33, and has remained stable. Metabolic panel normal.
She has slept a good deal since the scope, seems less with it than before, and tried to get OOB x 1 without help.
They plan to start her on clear liquids this evening.
Hospital Day 4 – change of shift report 8AM
Mrs. Annie Jones is an 83 y.o. woman admitted 3 days ago from the ED for a lower GI bleed. She has a history of
diabetes, hypertension, CAD, hyperlipidemia, and dementia. She presented with melanotic stools, and had her
last stool 2 days ago . She had a colonoscopy yesterday; they removed several polyps and cauterized the
bleeders.
Her vitals are stable but she has a low grade fever 99.2 – last BP = 110/60, p = 92. H/& H on admission was
7.5/23, after 2 U PBRC is now 9.2/38, and has remained stable. Metabolic panel normal.
She is alert this AM but was disoriented last night – got OOB & nearly fell. NS infusing 50 cc per hour because
she ate poorly. They want us to try to really push fluids on her today, and try to get her to eat. Once she is
eating and drinking, they want to discharge her.
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Case developed by E. McConnell, PhD, RN, GCNS-BC & Duke University Health System Geriatric Resource Nurses 2013
Supplementary References:
Use of Donepezil and other Dementia Medications
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a697032.html
http://annals.org/article.aspx?articleid=739913
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Case developed by E. McConnell, PhD, RN, GCNS-BC & Duke University Health System Geriatric Resource Nurses 2013