PATIENT CHART
Chart for Eugene Shaw Simulation #1
STUDENT NAME:_______________________________
PATIENT INITALS: ___E.S._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Eugene Shaw Simulation 1
© 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: 1600 Sunday afternoon
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 is
scheduled for a femoral-popliteal bypass tomorrow, Monday morning, at 0800. The plan is to discharge him to
a rehabilitation facility 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: On admission to this medical-surgical unit at 0600 hours his vitals were stable with temperature
of 98.6 F (37 C), BP 128/70, heart rate 86, respirations 16, SpO2 96% on room air, and pain at 6 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 3 hours. His last dose was at 1300. Mr. Shaw’s blood glucose was 130 mg/dL at 0630
before breakfast. Our neurovascular checks reveal 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. He has had 1,000
mL of IV fluids and has been voiding. He is alert and orientated to person, place and time. He got pretty
anxious after the surgeon talked to him about the femoral-popliteal bypass so we gave him a stat dose of
Xanax. Right now he is in bed. He’s been dozing on and off since he was medicated and seems to be doing
OK for now. Gene has not been ambulating because of his inability to put pressure on his right foot. Physical
therapy has come to evaluate for post-operative plan of care.
Recommendation: He is due for vitals and a pain assessment. Make sure the consent is signed and start
some pre-op teaching.
Provider’s Orders
Allergies: NKA
Date/Time:
Admit to Orthopedic Unit Service
Saturday
Condition of patient: Fair
2330
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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1. DIET: 1800 ADA diet as tolerated
2. VITAL SIGNS: q. 4h. If temperature > 101 F (38.33 C) notify resident
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
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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1. Femoral- popliteal bypass scheduled for tomorrow at 0800
2. NPO after midnight
3. Hold all oral morning medications
4. Blood for type and cross match
5. Consult: Request PT to evaluate patient and plan post-op rehab
6. Incentive spirometer 10 times every hour while awake
7. Xanax 0.5 mg PO q8h for anxiety
8. 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
Result:
137 mEq/L
Reference range:
135-145 mEq/L
Potassium
4.0 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
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
39%
38 – 43%
Hemoglobin
15 g/dl
Red blood cells
4.8 million/mm
12 – 16 mg/dl
3
4.6-6.2 million/mm3
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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Renal
Urine Test
Erythrocyte
sedimentation
rate
19 mm/hr
< 20 mm/hr
Leukocytes
9,000/mm3
5000-10,000/mm3
Platelets
325,000/mm3
Prothrombin time
(PT)
Partial
thromboplastin
time (PTT)
10.2 sec
150,000450,000/mm3
9.6-11.8 sec
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
100mg
PO
daily
Hours to
be
Given:
0900
Dates/Times
Given/Initials:
Plavix
75mg
PO
daily
0900
- Sunday/
0900 NN
Ferrous
Sulfate
325 mg
PO
daily
0900
-
Sunday/
0900 NN
Zocor
(Simvastatin)
20 mg
PO
daily
0900
-
Sunday/
0900 NN
Lovenox
(Enoxaparin)
30 mg
Subcutaneous
q.12h
0900
2100
-
Sunday/
0900 NN
-
(Docusate)
Sunday/
0900 NN
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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Zestril
(Lisinopril)
5 mg
PO
daily
0900
-
Sunday/
0900 NN
Lasix
(Furosemide)
10 mg
PO
daily
0900
-
Sunday/
0900 NN
Citracal
180 mg
1 tab
PO
daily
0900
-
Sunday/
0900 NN
Glucotrol
30mg
1 tab
PO
bid
0900
2100
-
Sunday/
0700 NN
Cephazolin
Injection
(Ancef)
1g
IVPB
1 hour prior
to surgery
1 hour
prior to
surgery
-
Monday/
0700
PRN Medications
Date
of
Order:
Medication:
Dosage:
Route: Frequency:
Vicodin (hydrocodone
bitartrate/acetaminophen
5/500)
1 tab
PO
Xanax
0.5mg
PO
0800
Hours
to be
Given:
Dates/Times
Given/Initials:
Q2h
prn for
pain
- Sunday/
0100 AB
- Sunday/
0330 AB
- Sunday/
0630 NN
- Sunday/
0900 NN
- Sunday/
1200 NN
q. 8h
prn
anxiety
- Sunday/
1530 NN
Nurse Signatures
Date/Time
Initial
AB
NN
Nurse Signature
Ann Brennan, RN
Nancy Nurse, RN
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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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
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
Social History
- Lives with wife in own home
Son lives out of state
Race/religion: Catholic
Consults
- Physical therapy
- Rehabilitation medicine
Treatments
Activities of Daily Living
Up in chair with pillow
Partial weight bearing
Assist as needed
Discharge Planning
Medication brought from home:
None
Diagnostic Studies
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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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
Colace (Docusate)
100 mg
PO
BID
Plavix
(Clopidogrel)
75mg
PO
Daily
Ferrous Sulfate
325 mg
PO
Daily
Zocor
(Simvastatin)
20 mg
PO
Zestril (Lisinopril)
5mg
Citracal
Last
Dose
Saturday
AM
Saturday
AM
Continue/DC
C
DC
C
DC
Saturday
AM
C
DC
Daily
Saturday
AM
C
DC
PO
Daily
Saturday
AM
C
DC
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
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:
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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Downtime Documentation
24-hour Abbreviated Neurovascular Assessment Flowsheet
Date/Time:
Saturday 2400
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
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Sunday 0200
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Ann Brennan, RN
Present
Faint
Absent
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
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
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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Date/Time:
Sunday 0400
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 0800
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Sunday 0600
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 1
© National League for Nursing, 2013
10
Date/Time:
Sunday 1000
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 1400
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Sunday 1200
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 1
© National League for Nursing, 2013
11
Date/Time:
Sunday 1600
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Pedal
Pulse:
Warm
Cool
Cold
Date: Today
Nurse Signature:
Nancy Nurse, RN
Popliteal
Pulse:
Present
Faint
Absent
Time: 900
Present
Faint
Absent
Diagnosis: Peripheral Vascular
Disease; surgery: femoral-popliteal
graft - RIGHT
Pain (passive,
motion)
None
Moderate
Severe
Patient Name: Eugene Shaw
Paresthesia
(numbness,
tingling):
Present
Moderate
Severe
Absent
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Impression: Normal
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
12
Date: Today
Time: 1100
Patient Name: Eugene Shaw
Impression: Normal
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).
Chart Materials Eugene Shaw Simulation 1
© National League for Nursing, 2013
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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.
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 1
© National League for Nursing, 2013
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© National League for Nursing, 2013
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