PATIENT CHART
Chart for Judy Jones Simulation #2
STUDENT NAME:_______________________________
PATIENT INITALS: ___J.J._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
1
Patient Name: Judy Jones
Room:
DOB: 11/13/xx
Age: 85
MRN: 57428
Doctor Name: Annette Parks, MD
Date Admitted:
Diagnosis: Pneumonia
Patient Report (Report from nurse ending shift)
Current time: 2300, Thursday, forty-eight hours after admission (Day 3 of hospitalization)
Situation: Judy Jones is an 85-year-old female patient of Dr. Annette Parks who was admitted 2 days ago with
a diagnosis of community-acquired pneumonia. We are currently treating her with IV antibiotics and respiratory
treatments.
Background: Ms. Jones has a medical history of hypertension that is controlled by spironolactone, cervical
spondylosis - she takes ibuprofen for pain as needed- and hyperlipidemia that is controlled by diet. She has
mild dementia manifested by short term memory issues, and sequencing and executive functioning deficits.
During the day she is easily redirected, but earlier tonight was much more interesting. She went into the
employee refrigerator and took two sandwiches back to her room and ate a little of each. Then she proceeded
to take out her saline lock and placed it like a toothpick in one of the sandwiches. The resident on call doubled
her dose of Ativan (lorazapem) to 2mg. She is sleeping now; I predict a calm night.
Assessment: Ms. Jones is alert and oriented to self. She needs to be reoriented often to place and time. She
is forgetful. Her vital signs at 2000 were temp 99.2, HR 96 and rhythm regular. RR was 24, BP 128/62. Pulse
ox was 95% on 2 liters of oxygen via nasal cannula. She frequently removes her cannula, and when she takes
it off I have seen her pulse oximetry go as low as 90%. Upon auscultation she has rhonchi bilaterally and
occasional wheezing. There are PRN respiratory treatments if she is wheezing. We are encouraging her to use
the incentive spirometer every hour.
She is on a regular diet and her appetite is good. Her abdomen is soft with positive bowel sounds; she had a
bowel movement today.
Judy has been ambulating to the bathroom and urinating without difficulty. Her gait is steady. She forgets to
reapply her nasal cannula when she gets back into bed after ambulating. Her skin looks good; there are no
areas of breakdown. She has a saline lock in her left hand.
Recommendation: I would recommend checking on her frequently due to the forgetfulness, and removal of
the oxygen. It is important that we continually assess her respiratory status and encourage the incentive
spirometry; her last albuterol treatment was at 1830.
When you go to assess Ms. Jones she will need her saline lock flushed and her Mini-Cog Assessment
completed. I was unable to do the Mini-Cog on her because when I went back to reassess her after the
lorazepam she was asleep.
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
2
Provider’s Orders
Allergies: Sulfa
Date/Time:
Admit to Medical-Surgical Unit
Tuesday
Service: Medical Team B/Dr. Annette Parks
1500
Condition of patient: Good
Code Status: Full Code
1. DIET: Regular diet as tolerated
2. VITAL SIGNS: Q4 hours with pulse oximetry. Call MD if les than 92%
3. ACTIVITY: Bed rest with bathroom privileges
4. TESTS:
a. Check X-ray daily
b. Repeat blood chemistry and hematology on Thursday
5. THERAPY:
a. Oxygen, 2 liters via nasal cannula
b. Incentive spirometry 10 times every hour while awake
6. FLUIDS:
a. D5.45 NSS @42 mL/hr
b. Intake and output
7. MEDICATIONS:
a. Aricept 10 mg PO q hs
b. Azithromycin 500 mg IV q day, administer over 1 hour
c. Spironolactone 50 mg PO q day, hold if systolic BP is less than 90
d. Ibuprofen 300 mg PO q 6 hours PRN neck pain
e. Albuterol 2.5 mg via nebulizer q4 PRN if wheezing
Annette Parks, MD
Date/Time:
Wednesday 1. ACTIVITY: OOB ad lib
0700
2. Discontinue I&O
Annette Parks, MD
Date/Time:
Thursday 1. Discontinue IV Fluids
0700
2. Insert saline lock. Flush with 3mL NSS q8h
Annette Parks, MD
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
3
Stat Order Form
Date/Time:
STAT PHYSICIAN ORDER
Wednesday/ Lorazapam 1 mg PO now
0800
Thursday/
Annette Parks, MD
Lorazapam 2 mg PO now
1900
Avery James, MD
Lab Data
Date/Time:
Tuesday 1600
Chemistries
Hematology
Test:
Sodium
Result:
147 mEq/L
Reference range:
135-145 mEq/L
Potassium
4.9 mEq/L
3.5-5.2 mEq/L
Magnesium
1.9 mg/dl
1.7-2.2 mg/dl
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
Glucose
201 mg/dl
74 -106 mg/dl
BUN
29 mg/dl
7-20 mg/dl
Creatinine
0.9 mg/dl
0.8 – 1.4 mg/dl
White Blood Cells
13 th/uL
4-10 th/uL
Hematocrit
48%
38 – 43%
Hemoglobin
13 g/dl
12 – 16 mg/dl
Test:
Result:
Reference range:
Sodium
140 mEq/L
135-145 mEq/L
Potassium
4.5 mEq/L
3.5-5.2 mEq/L
Magnesium
1.8 mg/dl
1.7-2.2 mg/dl
Calcium
8.6 mg/dl
8.5 – 10.2 mg/dl
Carbon Dioxide
26 mEq/L
20-29 mEq/L
Chloride
100 mEq/L
96-106 mEq/L
Lab Data
Date/Time:
Thursday 0800
(day 3)
Chemistries
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
4
Hematology
Glucose
196 mg/dl
74 -106 mg/dl
BUN
19 mg/dl
7-20 mg/dl
Creatinine
0.9 mg/dl
0.8 – 1.4 mg/dl
White Blood Cells
12 th/uL
4-10 th/uL
Hematocrit
37%
38 – 43%
Hemoglobin
13 g/dl
12 – 16 mg/dl
Medication Administration Record
Allergies: Sulfa
Scheduled & Routine Drugs
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Aricept
10 mg
PO
q hs
Hours to
be
Given:
2100
Azithromycin
500 mg
IV
q day
1600
Spironolactone
50 mg
PO
q day, hold
if systolic
BP is less
than 90
0900
Heplock Flush
3mL NSS
q 8h
2400
0800
1600
Dates/Times
Given/Initials:
- Tuesday
TJF
- Wednesday
RR
- Thursday
TJF
- Tuesday
TJF
- Wednesday
LS
- Thursday
TJF
- Wednesday
LS
- Thursday
LS
-
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
5
PRN/STAT Medications
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Hours to
be
Given:
Dates/Times
Given/Initials:
Ibuprofen
300 mg
PO
q 6 hours
PRN neck
pain
- Tuesday/
2200 TJF
- Wednesday/
0630 RR
- Thursday/
1300 LS
Albuterol
2.5 mg
via nebulizer
q4 hours
PRN
wheezing
- Tuesday/
1600 TJF
- Tuesday/
2000 TJF
- Wednesday/
2400 RR
- Wednesday/
0400 RR
- Wednesday/
0800 LS
- Wednesday/
1200 LS
- Thursday/
0600 RR
- Thursday/
1200 LS
- Thursday/
1830 TJF
Lorazapam
1 mg
PO
- Wednesday/
0800 LS
Lorazapam
2 mg
PO
- Thursday/
2000 TJF
Nurse Signatures
Date/Time
Initial
TJF
RR
LS
CB
Nurse Signature
Teresa Franklin, RN
Richard Reid, RN
Lisa Sousa, RN
Chris Butler, RN
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
6
Intravenous Fluid Administration Record
Allergies: Sulfa
Continuous IV Fluids
Date
of
Order:
IV Fluid:
Rate:
Site:
Volume:
D5 .45 NSS
bag #1
42 mL/hr
Left forearm
1000 mL
D5.45 NSS
Bag #2
42 mL/hr
Left forearm
1000 mL
Date/Time
Hung and
Initials:
- Tuesday/
1600 TJF
Discontinued
Date/Time
and Initials:
- Tuesday/
1545 LS
- Wednesday/ - Wednesday/
1545 LS
1930 RR
IV Sites
Location:
Gauge:
Left Forearm
#20
Left hand
#20
Inserted
Date/Time and
Initials:
- Tuesday/ 1545
TJF
- Thursday/ 2145
TJF
Discontinued
Date/Time and
Initials:
- Thursday/ 2120
TJF
Catheter intact after
removal:
Yes – removed by
patient
-
Nurse Signatures
Date/Time
Initial
TJF
RR
LS
Nurse Signature
Teresa Franklin, RN
Richard Reid, RN
Lisa Sousa, RN
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
7
Patient Name: Judy Jones
Physician: Annette Parks,
MD/Medical Team B
Diagnosis: Pneumonia
Age: 85
Gender: Female
Height: 5’7”
Weight: 115 lbs
Major Support: Daughter Karen
Jones
Phone: 555-555-5555
Karen (daughter) 555-555-5566
Type of Operation: None
History: Hypertension, cervical
spondylosis, hyperlipidemia, and
dementia (short term memory
issues, sequencing and executive
functioning deficits)
Advanced Directives: No
Allergies: Sulfa
Fall Precautions: High
Isolation Precautions: Standard
Restraints: No
Diet: Regular
Monitoring
Vital signs – Q4h
Pulse oximetry Q4h call if pulse
oximetry is less than 92%
Medication
Oral medications
IV medication
IV saline lock with flushes
Q8hr
Respiratory
2 Liters nasal cannula
Incentive spirometry 10 times
every hour while awake
Social History
- Widowed
- Lives at home with her daughter
Karen
- Her two sons live approximately
one hour away
Consults
Treatments
Activities of Daily Living
As tolerated, self-directed
Discharge Planning
- Discharge to home
Race:
Religion: Baptist
Medication brought from home:
None
Diagnostic Studies
Lab – CBC & Chem 7
Radiology – chest X-ray every
day
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
8
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
9
Chart Materials Judy Jones – Simulation 2
© National League for Nursing, 2014
10