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, 1 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… 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 2 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 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 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. 3 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 4 Case developed by E. McConnell, PhD, RN, GCNS-BC & Duke University Health System Geriatric Resource Nurses 2013