PATIENT CHART
Chart for Judy Jones Simulation #3
STUDENT NAME:_______________________________
PATIENT INITALS: ___J.J._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Judy Jones – Simulation #3
© 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: 1400 (day 9 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: Judy Jones is an 85-year-old female who was admitted 9 days ago with a diagnosis of
community-acquired pneumonia, which has resolved. Ms. Jones has a medical history of hypertension that
is controlled by spironolactone, cervical spondylosis, and hyperlipidemia that is controlled by diet. She has
mild dementia and during this hospitalization she developed delirium that was manifested by seeing
children underneath her hospital bed, wandering the halls, and agitation. She was given Ativan
(lorazapem) which seemed to help initially, but then she became more agitated and delirious.
A few days ago she developed atrial fibrillation and is being medicated with amiodarone 800mg PO every
day.
Tomorrow Ms. Jones is scheduled to be transferred to a rehabilitation center for a short time before
returning home.
Assessment: Ms. Jones is alert and oriented to self, but still needs periodic orientation to time and place.
She is forgetful and confusion is present all day. The last three days she has not been sleeping well. The
first Mini-Cog we did indicates possible dementia. She was having auditory and visual hallucinations at the
time. The second was even worse. That was done when she became more delirious after the doses of
lorazapam. Her most recent one was done yesterday and it was better, but her daughter says she is not
back to her baseline of cognitive functioning – her level before she developed the pneumonia.
Judy’s heart rate is irregular, ranging from 70 to 90 beats per minute. Dr. Parks wants us to call if she has a
heart rate greater than 120 beats per minute. Her last set of vital signs were: temperature 98.6 F, HR 76,
RR 18, BP 128/64, pulse oximetry 96% on room air.
Judy occasionally has a productive cough of white sputum. Her lungs are clear; occasionally you will hear
scattered rhonchi that clear with coughing and deep breathing. She needs to be reminded to use her
incentive spirometer, and how to use it.
Ms. Jones is on a regular diet and has a good appetite. Her abdomen is soft with positive bowel sounds;
her last bowel movement was this morning.
She is ambulating to the bathroom on her own with a steady gait and urinating without difficulty. Her skin is
clean, dry and intact with no areas of breakdown.
Recommendation: If Judy is sleeping, please let her rest. She really needs her sleep. If her heart rate
goes above 120 beats per minute be sure to call the doctor.
Chart Materials Judy Jones – Simulation #3
© National League for Nursing, 2014
2
Provider’s Orders
Allergies: Sulfa
Date/Time:
Tuesday
1. Transfer to Rehabilitation Center in AM
2. DIET: Regular diet
1500
3. VITAL SIGNS: Q4 hours. Call MD if HR greater than 120 per minute
4. ACTIVITY: OOB ad lib
5. THERAPY:
a. Incentive spirometry 10 times every hour while awake
6. MEDICATIONS:
a. Aricept 10 mg PO q hs
b. Spironolactone 50 mg PO q day, hold if systolic BP is less than 90
c. Ibuprofen 300 mg PO q 6 hours PRN neck pain
d. Amiodarone 800 mg PO Q day
Annette Parks, MD
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
Amiodarone
800 mg
PO
Daily
C
DC
Aricept
10 mg
PO
HS
C
DC
Spironolactone
50 mg
PO
C
DC
Ibuprofen
300 mg
PO
Daily, hold if
systolic BP is
less than 90
Q4 hours
PRN neck
pain
C
DC
Provider Signatures
Date/Time
Today
Initial
AP
Provider Signature
Annette Parks, MD
Initial
LS
Nurse Signature
Lisa Sousa, RN
Nurse Signatures
Date/Time
Today
Chart Materials Judy Jones – Simulation #3
© National League for Nursing, 2014
3
Reviewed on Transfer by:
Reviewed on Discharge by:
Scan to Pharmacy Time:
Date:
Date:
Date:
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
Call if heart rate is greater than
120 beats/min
Medication
Oral medications
Respiratory
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
- Transfer to Rehabilitation Center
tomorrow
Race:
Religion: Baptist
Medication brought from home:
None
Diagnostic Studies
Chart Materials Judy Jones – Simulation #3
© National League for Nursing, 2014
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Chart Materials Judy Jones – Simulation #3
© National League for Nursing, 2014
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Chart Materials Judy Jones – Simulation #3
© National League for Nursing, 2014
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Chart Materials Judy Jones – Simulation #3
© National League for Nursing, 2014
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