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