PATIENT CHART
Chart for Eugene Shaw Simulation #3
STUDENT NAME:_______________________________
PATIENT INITALS: ___E.S._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Eugene Shaw Simulation 3
© 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: 1530 on Wednesday afternoon
Situation: Mr. Eugene Shaw, age 82, is in his second postoperative day. He came to the ER on Saturday at
2100 with complaints of pain and a burning sensation in his right leg. He had 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 had femoral-popliteal bypass surgery on Monday morning.
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: Gene is alert and orientated to person, place and time. His vital signs have been stable with
temperature of 98.6 F (37 C), BP 128/70, heart rate 88, respirations 16, SpO2 96% on room air. Mr. Shaw’s
blood glucose was 115 mg/dL at 0600. His neurovascular checks have greatly improved. There is some
swelling in his leg. He has been eating well and voiding. He had a bowel movement this morning. He continues
to complain of some pain, but says it is not as bad as before surgery and he no longer has the aching and
burning in his leg. His last dose of Vicodin was at 1300. The incision site is healing well. Gene has had some
difficulty ambulating and needs a lot of assistance.
Recommendation: He is due for vitals and a pain assessment, along with a dressing change. His wife is
visiting. Encourage him to ambulate. He may be discharged in 2 days so we need to assess how he will
manage at home.
Provider’s Orders
Allergies: NKA
Date/Time:
Post-Operative Medical Orders
Monday
Condition of patient: Good
1100
1. DIET: resume 1800 ADA diet as tolerated
2. FLUIDS: discontinue IV fluids as soon as able to tolerate oral fluids
3. VITAL SIGNS: q. 4h. If temperature > 101 F (38.33 C) notify resident
4. ACTIVITY:
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
2
5.
6.
7.
8.
a. Up in chair with leg elevated
b. Ambulate with assistance
NEUROVASCULAR CHECKS: Q 2 h for first 24 hours, then every shift
LABS: Call abnormal results to orthopedic resident or attending surgeon
a. Electrolytes, CBC
MEDICATIONS:
a. Vicodin 5/500 mg q2h PRN for pain
b. Lasix 10mg daily
c. Plavix 75mh PO daily
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
i. Bactrim DS one tab bid
j. Penicillin VK 500mg PO Q6H
Robert Moses, MD
Stat Order Form
Date/Time:
STAT PHYSICIAN ORDER
Lab Data
Date/Time:
Monday 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
Chloride
103 mEq/L
96-106 mEq/L
Bicarbonate
21 MEq/L
19-25 mEq/L
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
3
Hematology
Renal
Urine Test
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
12 – 16 mg/dl
3
4.6-6.2 million/mm3
Red blood cells
4.8 million/mm
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
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
4
Medication Administration Record
Allergies: NKA
Scheduled & Routine Drugs
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Colace
(Docusate)
100mg
PO
daily
Hours
to be
Given:
0900
Dates/Times
Given/Initials:
-
Sunday/
0900 NN
Monday/
hold
Tuesday/
0900 NN
Wednesday/
0900 NN
Plavix
75mg
PO
daily
0900
- Sunday/
0900 NN
- Monday/
hold
- Tuesday/
0900 NN
- Wednesday/
0900 NN
Ferrous
Sulfate
325 mg
PO
daily
0900
-
Sunday/
0900 NN
- Monday/
hold
- Tuesday/
0900 NN
- Wednesday/
0900 NN
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
5
Zocor
(Simvastatin)
20 mg
PO
daily
0900
-
Sunday/
0900 NN
- Monday/
hold
- Tuesday/
0900 NN
- Wednesday/
0900 NN
Lovenox
(Enoxaparin)
30 mg
Subcutaneous
q.12h
0900
2100
-
Zestril
(Lisinopril)
5 mg
PO
daily
0900
-
Lasix
(Furosemide)
10 mg
PO
daily
0900
-
Sunday/
0900 NN
Sunday/
2100 CR
Monday/
0600 NN
Monday/
2100 CR
Tuesday/
0600 NN
Tuesday/
2100 CR
Wednesday/
0600 NN
Wednesday/
2100 CR
Sunday/
0900 NN
Monday/
hold
Tuesday/
0900 NN
Wednesday/
0900 NN
Sunday/
0900 NN
Monday/
hold
Tuesday/
0900 NN
Wednesday/
0900 NN
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
6
Citracal
180 mg
1 tab
PO
daily
0900
-
Glucotrol
30mg
1 tab
PO
bid
0900
2100
-
Cephazolin
Injection
(Ancef)
1g
IVPB
Bactrim DS
one tab
Sunday/
0900 NN
Monday/
hold
Tuesday/
0900 NN
Wednesday/
0900 NN
Sunday/
0700 NN
Sunday
2100 CR
Monday/
hold
Tuesday/
0900 NN
Tuesday/
2100 CR
Wednesday/
0900 NN
Wednesday/
2100 CR
1 hour prior
to surgery
1 hour
prior to
surgery
-
Monday/
0700
bid
0900
2100
-
Tuesday/
0900 NN
Tuesday/
2100 CR
Wednesday/
0900 NN
Wednesday/
2100 CR
-
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
7
Penicillin VK
500mg
PO
Q6H
0900
1500
2100
0300
-
Tuesday/
0900 NN
Tuesday/
1500 NN
Tuesday/
2100 CR
Tuesday/
0300 CR
Wednesday/
0900 NN
Wednesday/
1500 NN
Wednesday/
2100 CR
Wednesday/
0300 CR
Nurse Signatures
Date/Time
Initial
AB
NN
CR
Nurse Signature
Ann Brennan, RN
Nancy Nurse, RN
Carol Reynolds, RN
PRN Medications
Date
of
Order:
Medication:
Dosage: Route: Frequency:
Vicodin (hydrocodone
bitartrate/acetaminophen
5/500)
1 tab
PO
Hours
to be
Given:
Dates/Times
Given/Initials:
Q2h
prn for
pain
- Sunday/
0100 AB
- Sunday/
0430 AB
- Sunday/
0730 NN
- Sunday/
1100 NN
- Sunday/
1300 NN
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
8
- Sunday/
1600 NN
- Sunday/
1900 CR
- Sunday/
2200 CR
- Monday/
0130 CR
- Monday/
0500 CR
- Monday/
1800 CR
- Monday/
2300 CR
- Tuesday/
0600 NN
- Tuesday/
1630 CR
- Tuesday/
2200 CR
- Wednesday/
0400 CR
- Wednesday/
0900 NN
- Wednesday/
1300 NN
Xanax
0.5mg
PO
0800
q. 8h
prn
anxiety
- Sunday/ 1530
NN
Nurse Signatures
Date/Time
Initial
AB
NN
CR
Nurse Signature
Ann Brennan, RN
Nancy Nurse, RN
Carol Reynolds, RN
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
9
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 shift
Bedside Glucose Monitoring
Medication
IV access – 1 peripheral IV
in right antecubital placed
Saturday –
DISCONTINUED ON
TUESDAY
Oral medications
Respiratory
Incentive spirometer 10 times
every hour while awake – deep
breath and cough
Social History
- Lives with wife in own home
Son lives out of state
Race/religion: Catholic
Consults
- Physical therapy
- Rehabilitation medicine
Treatments
- Foley removed on Tuesday
Activities of Daily Living
Up in chair with pillow
Assist with ambulation
Discharge Planning
- Physical therapy consult for
post-op activity and outpatient
rehabilitation
Medication brought from home:
None
Diagnostic Studies
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
10
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 3
© National League for Nursing, 2013
11
Downtime Documentation
24-hour Abbreviated Neurovascular Assessment Flowsheet
Date/Time:
Monday 0600
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Nancy Nurse, RN
Pedal
Pulse:
Warm
Cool
Cold
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
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Post- Op Recovery Room
Date/Time:
Monday 1130
Patient Name:
Eugene Shaw
Pallor (Color):
Polar
(Temp):
Pink
Pale
Dusky
Cyanotic
Warm
Cool
Cold
Nurse Signature:
Jennifer Williams, 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
Extremity to be
assessed: Right
leg
Movement:
Present
Decreased
Absent
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
12
Date/Time:
Monday 1330
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:
Jennifer Williams, RN
Pedal
Pulse:
Date/Time:
Monday 1730
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Monday 1530
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Jennifer Williams, RN
Present
Faint
Absent
Nurse Signature:
Carol Reynolds, 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 3
© National League for Nursing, 2013
13
Date/Time:
Monday 1930
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:
Carol Reynolds, RN
Pedal
Pulse:
Date/Time:
Monday 2330
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Monday 2130
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Carol Reynolds, RN
Present
Faint
Absent
Nurse Signature:
Carol Reynolds, 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 3
© National League for Nursing, 2013
14
Date/Time:
Tuesday 0130
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:
Carol Reynolds, RN
Pedal
Pulse:
Date/Time:
Tuesday 0530
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Tuesday 0330
Pink
Pale
Dusky
Cyanotic
Nurse Signature:
Carol Reynolds, RN
Present
Faint
Absent
Nurse Signature:
Carol Reynolds, 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 3
© National League for Nursing, 2013
15
Date/Time:
Tuesday 0730
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:
Tuesday 1130
Pink
Pale
Dusky
Cyanotic
Popliteal
Pulse:
Present
Faint
Absent
Date/Time:
Tuesday 0930
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 3
© National League for Nursing, 2013
16
Date: Sunday
Time: 900
Patient Name: Eugene Shaw
Impression: Normal
Date: Sunday
Time: 1100
Patient Name: Eugene Shaw
Impression: Normal
Chart Materials Eugene Shaw Simulation 3
© National League for Nursing, 2013
17