PATIENT CHART
Chart for Jenny Brown Simulation #1
STUDENT NAME:_______________________________
PATIENT INITALS: ___J.B._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
1
Patient Name: Jenny Brown
Room:
DOB:
Age: 23
MRN: 234-56-7891
Doctor Name: Dr. Marianne Hough
Date Admitted:
Diagnosis: Generalized anxiety disorder with panic
attack, possible PTSD
Patient Report (Report from nurse ending shift)
Current time: 0700, 2 days after admission to short stay acute psychiatric unit
Situation: Jenny Brown is 23 years old, admitted two days ago for acute agitation and anxiety. She is 18
weeks pregnant with her first baby. She was voluntarily admitted from the Emergency Department where she
was taken following an episode of acute agitation after ultrasound in the hospital’s Imaging Services
Department. She received several doses of IV haloperidol in the ED before being transferred to our unit.
Background: While she was in Imaging for a routine ultrasound, Jenny had to be restrained. Apparently she
became extremely agitated when the perinatologist told her that the fetus, a girl, has a cleft lip and palate. She
was transferred to the Emergency Department and given three 2 mg doses of IV haloperidol over
approximately 4 hours. Her suicide assessment was negative but she doubted her ability to safely care for
herself at home and she agreed to admission for evaluation. On the first day of admission, she received 2 mg.
oral haloperidol regularly, every 4 hours. Yesterday she only had two doses and seemed much more stable.
She still had difficulty sleeping and woke screaming from nightmares the first night. Last night she refused the
haloperidol and slept on and off but there were no nightmares.
Assessment: Vital signs: T: 98.6, Pulse: 76, regular; Respirations: 16, BP: 112/74. Admitting diagnosis was
panic attack with underlying generalized anxiety disorder and possible PTSD. She has no psychotic behaviors
and is well oriented X3. Her prenatal admission assessment was done per protocol and everything looks good.
Fetal heart rate is in the 130s. She’s also had the full psychiatric intake exam. Last night she slept poorly. She
cries from time to time and is worried about her baby. Her vital signs have been stable. She has suicide checks
ordered every 12 hours but so far those are all negative. She says she won’t harm herself because of the
baby. She has showered and is well groomed with a normal train of thought and full vocabulary. She maintains
eye contact when speaking. She has rapid, pressured speech at times. She is sometimes fidgety when seated
and paces to calm herself. She’s been talking on the phone with her boyfriend from time to time all night – this
seems to help calm her.
Recommendation: She is due for a mental status check with depression, suicide, and PTSD evaluations – the
forms are on the chart. There will be a care conference later today to plan for discharge and follow-up, so the
team will need the results of your assessment.
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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Provider’s Orders
Allergies: NKA
Date/Time:
Acute Mental Status Change Admission Orders
Tuesday
Admit to Acute Short Stay Psychiatric Unit
2000
Service: Psychiatry
Condition of patient: Good
1. DIET: Regular diet as tolerated
2. VITAL SIGNS: q4h with fetal heart rate check; notify MD for Temp above 101.5,
HR>120, decline in neuro status, absence of FHT
3. ACTIVITY: as tolerated
4. SAFETY CHECKS: Q2h for first 24 hours, then q4h
5. LABS: H&H
6. MEDICATIONS:
a. Haloperidol 2 mg PO q4h prn agitation, anxiety; may repeat in 2 hrs prn
severe anxiety- notify physician
b. Haloperidol 5 mg IV for severe agitation – notify physician
c. Prenatal vitamin X 1 po daily in am
d. Acetaminophen (Tylenol) 650 mg q6h prn headache
7. IV ORDER: If need to start IV to administer medication, leave saline lock in
place
8. MISCELLANEOUS: When patient is stable, complete assessment forms for
anxiety and depression, PTSD, TBI, military sexual trauma, and suicide in
preparation for team conference Thursday afternoon.
Marianne Hough, MD
Stat Order Form
Date/Time:
STAT PHYSICIAN ORDER
Tuesday
Haloperidol 2 mg IV stat. Repeat every 2-4 hours prn for up to 4 doses.
1500
Katherine Shannon, MD
Lab Data
Date/Time:
Sunday 1600
Chemistries
Test:
Sodium
Result:
137 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
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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Hematology
Urinalysis
Chloride
103 mEq/L
96-106 mEq/L
Glucose
99 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
42%
38 – 43%
Hemoglobin
14 g/dl
12 – 16 mg/dl
Specific gravity
1.005
1.002 – 1.030
pH
5
5–7
Leukocytes
Neg
Neg
Nitrite
Neg
Neg
Protein (mg/dL)
Neg
Neg - Trace
Glucose (mg/dL)
Neg
Neg
Ketones
Neg
Neg
Urobilinogen
(mg/dL)
Neg
Neg
Bilirubin
Neg
0.2 – 1.0 Ehr U/dl
Micro
Neg
RBCs: 0-2/HPF
WBC: 0-2/HPF
RBC Casts: 0/HPF
Medication Administration Record
Allergies: NKA
Scheduled & Routine Drugs
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Prenatal
vitamin
Hours to
be
Given:
0900
Dates/Times
Given/Initials:
- Wednesday/
0900 AC
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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STAT Medications
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Haloperidol
2 mg
IV stat
Repeat
every 2-4
hours prn
for up to 4
doses
Hours to
be
Given:
Dates/Times
Given/Initials:
- Tuesday/
1600 RR
- Tuesday/
1800 RR
- Tuesday/
2000 RR
PRN Medications
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Hours
to be
Given:
Dates/Times
Given/Initials:
Haloperidol
2 mg
po
q4 hrs prn
agitation,
anxiety
- Tuesday/
2200 TJF
- Wednesday/
0200 TJF
- Wednesday/
0600 TJF
Haloperidol
5 mg
IV
for severe
agitation.
Notify
provider
-
Tylenol
(acetaminophen)
650 mg
q6h prn
headache
-
Nurse Signatures
Date/Time
Initial
TJF
RR
AC
Nurse Signature
Teresa Franklin, RN
Richard Reid, RN
Angela Corbo, RN
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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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
Prenatal vitamins
1 tab
PO
Daily
Tuesday AM
C
DC
Tylenol
650 mg
PO
PRN
Headache
N/A
C
DC
Provider Signatures
Date/Time
Tuesday 1700
Initial
MH
Provider Signature
Marianne Hough, MD
Initial
RR
Nurse Signature
Richard Reid, RN
Nurse Signatures
Date/Time
Tuesday 1700
Reviewed on Transfer by: Teresa Franklin, RN
Reviewed on Discharge by:
Scan to Pharmacy Time:
Date: Tuesday 2100
Date:
Date:
Patient Name: Jenny Brown
Physician: Marianne Hough, MD
Diagnosis: Generalized anxiety
disorder with panic attack,
possible PTSD
Age: 23
Gender: Female
Height: 5’6”
Weight: 130 lbs
Major Support: Boyfriend/partner
Eric
Phone: 555-555-5555
Eric (boyfriend) 555-555-5566
Type of Operation: None
History: IUP – 18 weeks, fetus
with known cleft lip & palate
Advanced Directives: No
Allergies: None known
Fall Precautions: High
Isolation Precautions: Standard
Restraints: No
Diet: Regular
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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Monitoring
Vital signs – Q4h
FHR checks – Q4h
Mental status checks – Q4h
Medication
Oral medications
IV medication
Respiratory
Social History
- Lives in own home with
boyfriend, Eric
- College student
- Parents live in another state
Consults
- Comprehensive care team:
Alicia Green, RN-C; Patricia
Gooding, LCSW; Diane
Moos, MD/R-1; Todd
Grainger, MD/R-3
Treatments
Activities of Daily Living
As tolerated, self-directed
Discharge Planning
- Consult neonatology, pediatric
surgeon to visit patient before
discharge
- Home care follow-up
Race/religion: Christian
Medication brought from home:
None
Diagnostic Studies
Lab – H&H on admission
Anxiety and Depression Scale and Scoring (Adapted for Interview)
Possible nursing prompts: “When you answer, please use the terms: ‘definitely,’ ‘sometimes,’ ‘not much,’ or
‘not at all.’ If you forget to use one of those words, I will remind you.”
“Would you say, ‘definitely,’ ‘sometimes,’ ‘not much,’ or ‘not at all’?”
Jenny’s Responses for
Scenario:
Question:
1. Do you have trouble sleeping at night?
2. Do you feel anxious or stressed for apparently
no reason at all?
3. Do you feel miserable or sad?
4. Does leaving your house make you feel
anxious?
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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5. Have you lost interest in things that you used
to enjoy?
6. Do you feel like your heart is racing?
7. Do you have a good appetite?
8. Do you sometimes feel scared or frightened
when there is no reason to do so?
9. Do you ever feel like the world would be better
without you in it?
10. Do you feel restless or fidgety?
11. Are you more irritable than usual?
12. Do you feel as if it’s hard to get things done?
13. Do you seem to worry all the time?
Score:
Scoring:
Questions 1-6,
8-13
Question 7
Scoring
Interpretation:
Definitely
3
0
0-7
Minimal concern
Sometimes
2
1
8-10
Borderline concern
Not often
1
2
11+
Concerning – may need
further intervention
Not at all
0
3
Anxiety Questions: # 2, 4, 6, 8, 10, 11, 13
Depression Questions: # 1, 3, 5, 7, 9, 12
Source:
Snaith R.P. The Hospital Anxiety and Depression Scale. Health and Quality of Life Outcomes 2003;1:29
http://www.hqlo.com/content/1/1/29; http://www.abiebr.com/node/410
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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Suicide Risk Assessment Screening Questions
Question:
Possible Nursing Prompts:
Jenny’s Responses for
Scenario:
1. Are you feeling hopeless about the
present/future?
2. Have you had thoughts of taking your
life?
3. When did you have these thoughts?
4. Do you have a plan to take your life?
5. Have you ever had a suicide
If yes, tell me what you’ve been
thinking (or about your plan).
If yes, can you tell me about
that time?
attempt?
Although the nursing role does not involve establishing a diagnosis of suicide risk, the nurse should notify a
licensed independent provider of the findings of any positive screen and take precautions to protect the safety
of the patient.
Source:
VA Suicide Risk Assessment Guide available at:
http://www.mentalhealth.va.gov/docs/VA029AssessmentGuide.pdf
Primary Care Post Traumatic Stress Disorder Screen (PC-PTSD)
Possible nursing prompt: “Would you say ‘yes’ or ‘no’?”
Base Question:
In your life, have you ever had any experience that was so
frightening, horrible, or upsetting that, in the past month, you:
Jenny’s Responses
for Scenario:
1. have had nightmares about it or thought about it when
you did not want to?
2. tried hard not to think about it or went out of your way to
avoid situations that reminded you of it?
3. were constantly on guard, watchful, or easily startled?
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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4. felt numb or detached from others, activities, or your
surroundings?
Although the nursing role does not involve establishing a diagnosis of PTSD, current research suggests that
the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items. The
nurse should notify a licensed independent provider of the findings of any positive screen.
Sources:
United States Department of Veterans Affairs National Center for PTSD; Professional Section
http://www.ptsd.va.gov/professional/provider-type/doctors/screening-and-referral.asp
http://www.ptsd.va.gov/PTSD/professional/pages/assessments/assessment-pdf/pc-ptsd-screen.pdf
3-Question TBI Screening Tool
Question:
Possible Nursing
Prompts:
1. Did you have any injury or injuries during your
deployment from any of the following:
 bomb fragment?
 bullet?
 any type of vehicle including airplanes?
 fall/injury?
 blast (improvised explosive device, RPG, land
mine, grenade, etc.?
 something else?
If yes, ask about the type
of injury.
2. Did any injury received while you were deployed
result in your:
 being dazed, confused, or “seeing stars”?
 not remembering the injury?
 losing consciousness (being “knocked out”) for
any length of time?
 having symptoms afterward like headache,
dizziness, irritability, etc.?
 head injury (closed or open) that required medical
treatment?
[No verbal response
necessary; make note of
each positive answer.]
Jenny’s Responses
for Scenario:
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
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3. Are you currently experiencing any of the following
problems that you think might be related to a possible
head injury or concussion:
 headaches?
 dizziness?
 memory problems?
 balance problems?
 ringing in the ears?
 irritability?
 sleep problems?
 other? (please be specific):
[No verbal response
necessary; make note of
each positive answer.]
Although the nursing role does not involve establishing a diagnosis of PTSD, current research suggests that
the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items. The
nurse should notify an appropriate licensed provider of the findings of any positive screen. Patient
endorsement of items in #2 meets criteria for positive TBI screen. Confirm symptoms of concussive
symptoms or head injury through clinical interview.
Source:
Schwab, K. A., Baker, G., Ivins, B., Sluss-Tiller, M., Lux, W., & Warden, D. (2006). The Brief Traumatic Brain
Injury Screen (BTBIS): Investigating the validity of a self-report instrument for detecting traumatic brain injury
(TBI) in troops returning from deployment in Afghanistan and Iraq. Neurology, 66(5)(Supp. 2), A235.
This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be
reproduced and distributed in its entirety without further permission from GAO
(http://www.gao.gov/assets/280/271994.html).
Chart Materials Jenny Brown – Simulation #1
© National League for Nursing, 2015
11