PATIENT CHART
Chart for Ertha Williams Simulation #3
STUDENT NAME:_______________________________
PATIENT INITALS: ___E.W._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
1
Patient Name: Ertha Williams
Room:
DOB: 01/19/xx
Age: 74
MRN: 78911
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 been getting progressively more confused, going into other patients’ rooms, stealing
items, and looking for her husband, who died a few weeks before she came here. Staff is finding food stashed
under her mattress and she recently began striking out at staff, especially at bath time. This morning she was
particularly combative. We called Dr. Rivers and she prescribed Haldol, but it has not helped. We think we
need to move her to the behavioral health unit. We need to discuss this with her daughter-in-law Betty, who
just came to visit.
Background: Ertha was diagnosed with Alzheimer’s about 2½ years ago. She came to us from assisted living
6 months ago, a few weeks after her husband Henry died. She is in good health, but has had to deal with many
changes in this last year.
Assessment: Ertha’s aggressive behavior began getting considerably worse a few days ago. We are really
afraid she could hurt someone. She has been taking two antidepressant medications and an Exelon patch for
the past 6 months but there has been little to no improvement.
This past week she is walking more slowly and her appetite has not been good, which is unusual for her.
Recommendation: Please assess Ertha and see if you can do a Mini-Cog. One of the aides suggested that
maybe Ertha is having some pain. Use the tool for assessing pain in patients with dementia and see what you
think. She does have an order for acetaminophen. Talk with Betty about a move to a behavioral health unit.
When you finish, call Dr. Rivers and give her a report.
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
2
Provider’s Orders
Allergies: NKA
Date/Time:
On
admission
to long
term care/
1300
Condition of patient: Good
1. DIET: Regular diet as tolerated
2. VITAL SIGNS: Monthly
3. ACTIVITY: As tolerated
4. SAFETY CHECKS:
5. 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) 9.5 mg daily
f. Trazadone 25 mg at bedtime
g. Prozac 10 mg q day
Joan Rivers, MD
Stat Order Form
Date/Time:
Today
Haloperidol 1 mg IM
0900
STAT PHYSICIAN ORDER
Joan Rivers, MD
Lab Data
Date/Time:
6 months ago
Chemistries
Test:
Sodium
Result:
140 mEq/L
Reference range:
135-145 mEq/L
Potassium
4.1 mEq/L
3.5-5.2 mEq/L
Calcium
9.5 mg/dl
8.5 – 10.2 mg/dl
Carbon Dioxide
25 mEq/L
20-29 mEq/L
Chloride
102 mEq/L
96-106 mEq/L
Glucose
89 mg/dl
74 -106 mg/dl
BUN
16 mg/dl
7-20 mg/dl
Creatinine
1.0 mg/dl
0.8 – 1.4 mg/dl
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
3
Hematology
Liver Function
Test
Hematocrit
40%
38 – 43%
Hemoglobin
12.5 g/dl
12 – 16 mg/dl
ALT
35 units per liter
(U/L)
7 to 55 units per
liter (U/L)
AST
19 U/L
8 to 48 U/L
Albumin
4.4 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
135 U/L
122 to 222 U/L
PT
11.6 seconds
9.5 to 13.8
seconds
TSH
3.0 mlU/L
0.4 – 4.0 mlU/L
B12
355 pg/ml
200 – 900 pg/ml
Folate
5.5 ng/ml
2.7 – 17.0 ng/ml
RPR
Nonreactive
Nonreactive
Medication Administration Record
Allergies: NKA
Scheduled & Routine Drugs
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Rivastigmine
(Exelon)
9.5 MG
transdermal
system
daily
Hours
to be
Given:
0900 -
Dates/Times
Given/Initials:
Monday/ JFB
Tuesday/ JFB
Wednesday/ JFB
Thursday – JFB
Friday/ JMC
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
4
Atenolol
(Tenormin).
50 mg
daily
0900
-
Monday/ JFB
Tuesday/ JFB
Wednesday/ JFB
Thursday/ JFB
Friday/ JMC
Fluoxetine
(Prozac)
10 mg
daily
0900
-
Monday/ JFB
Tuesday/ JFB
Wednesday/ JFB
Thursday/ JFB
Friday/ JMC
Zolpidem
tartrate
(Ambien)
5 mg
every
evening
2000
-
Monday/ SF
Tuesday/ SF
Wednesday/ SF
Thursday/ SF
Friday/ SF
Rosuvastatin
calcium
(Crestor)
20 mg
daily/evening
2000
-
Monday/ SF
Tuesday/ SF
Wednesday/ SF
Thursday/ SF
Friday/ SF
Trazadone
25 mg
at bedtime
2000
-
Monday/ SF
Tuesday/ SF
Wednesday/ SF
Thursday/ SF
Friday/ SF
PRN and STAT Medications
Date
of
Order:
Medication:
Dosage:
Tylenol
(acetaminophen)
650 mg
Haloperidol
1 mg
Route:
Frequency:
Hours
to be
Given:
q 6h prn
pain/headache
IM
Dates/Times
Given/Initials:
-
now
- JMC
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
5
Nurse Signatures
Date/Time
Initial
JFB
SF
JMC
Nurse Signature
Jean F. Byrd, RN
Susan Forneris, RN
Jeanne M. Cleary, RN
Patient Name: Ertha Williams
Physician: Joan Rivers, MD;
Mary Lake, MS, APRN, GNP
Diagnosis: Dementia,
Alzheimer’s vs. Vascular Type
Age: 74
Gender: Female
Height: 5’4”
Weight: 124 lbs
Major Support: Daughter-in-law
Betty
Phone: Betty: 320-222-1111
Type of Operation: None
History: Progressive confusion
Advanced Directives: No
Allergies: none known
Fall Precautions: High
Isolation Precautions:
Restraints: No
Diet: Regular, encourage high
protein foods, finger foods she
can eat while moving. Ensure
daily or supplemental drinks.
Monitoring
Vital signs – monthly
Nightly safety checks
Emergency Alert device
Medication
Oral medications
Cognitive
- Pictures in room
- Photos at door
- Large number calendar
- Journal or tablets for writing
- Books
- Bible
Social History
Consults
- Comprehensive care team
Treatments
Activities of Daily Living
As tolerated, self-directed
Discharge Planning:
Race:
Religion: Baptist
Medication brought from home:
Diagnostic Studies
Lab – RPR, TSH, CBC with
differential, B12, folate, LFT on
admission then q 6 months
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
6
Responses from Brief Evaluation of Executive Dysfunction (from
first assisted living visit):
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
7
Responses from Geriatric Depression Scale (from first assisted
living visit):
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
8
Responses from Mini-Cog (from second assisted living visit):
Chart Materials Ertha Williams– Simulation 3
© National League for Nursing, 2014
9