PATIENT CHART
Chart for Judy Jones Simulation #1
STUDENT NAME:_______________________________
PATIENT INITALS: ___J.J._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Judy Jones – Simulation 1
© 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: 1900, 24 hours after admission
Situation: Judy Jones is an 85-year-old female patient of Dr. Annette Parks who was admitted yesterday
afternoon with a diagnosis of community-acquired pneumonia. She is being treated with IV Azithromycin
and IV fluids.
Background: Judy Jones has a medical history of hypertension, which is controlled by spironolactone,
cervical spondylosis with pain controlled with ibuprofen when needed, hyperlipidemia that is controlled by
diet. She also has mild dementia. She hasn’t been confused but is forgetful and easily redirected. She has
a history of carpal tunnel surgery on both wrists.
Assessment: She is alert and oriented to self, but needs frequent reorientation to place and time. She is
forgetful. At 1600 her vital signs were temp 99.9, heart rate 103, respirations 24, BP 130/68, pulse ox 95%
on 2 liters of O2 via nasal cannula. Her heart rhythm is regular. She has D5 .45 NSS running at 42 mL/hr
into her left forearm.
She frequently removes her nasal cannula, and when she does, her pulse ox goes down as low as 90%.
Upon auscultation she has rhonchi bilaterally and occasional wheezing. There are PRN respiratory
treatments ordered to relieve her wheezing. We are encouraging her to use the incentive spirometer every
hour.
Ms. Jones is on a regular diet; her appetite is poor. Her abdomen is soft with positive bowel sounds. Her
last bowel movement was two days ago and she denies any feelings of constipation at this time.
She has been urinating without difficulty in the bathroom, but needs someone’s help to get into the
bathroom, basically to manage the IV pole. Her skin looks great. I didn’t see any areas of breakdown, but
she is at risk for skin breakdown because she is sitting a lot in the bed.
Recommendation: I recommend checking on her frequently due to the forgetfulness and to be sure she
keeps her nasal cannula on. It is important that we continually assess her respiratory status. Her last
albuterol treatment was at 1200, and she can have her next one whenever she needs it. Be sure to remind
and reteach her each time how to use the incentive spirometer; she forgets. Don’t forget we are starting our
new Quality Improvement project today. We are doing Mini-Cog assessments three times a week on each
patient that scored a 3 or more on the Family Questionnaire for Dementia. You will need to do the Mini-Cog
assessment on Ms. Jones before the end of your shift.
Chart Materials Judy Jones – Simulation 1
© 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
Stat Order Form
Date/Time:
STAT PHYSICIAN ORDER
Lab Data
Date/Time:
Tuesday 1600
Chemistries
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
Chart Materials Judy Jones – Simulation 1
© National League for Nursing, 2014
3
Hematology
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
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
Dates/Times
Given/Initials:
Azithromycin
500 mg
IV
q day
1600
- Tuesday
TJF
- Wednesday
LS
Spironolactone
50 mg
PO
q day, hold
if systolic
BP is less
than 90
0900
- Wednesday
LS
Hours to
be
Given:
Dates/Times
Given/Initials:
- Tuesday
TJF
PRN Medications
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Ibuprofen
300 mg
PO
q 6 hours
PRN neck
pain
- Tuesday/
2200 TJF
Chart Materials Judy Jones – Simulation 1
© National League for Nursing, 2014
4
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
Nurse Signatures
Date/Time
Initial
TJF
RR
LC
Nurse Signature
Teresa Franklin, RN
Richard Reid, RN
Lisa Sousa, RN
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
- Wednesday/
1545 LS
Discontinued
Date/Time
and Initials:
- Tuesday/
1545 LS
-
IV Sites
Location:
Gauge:
Left Forearm
#20
Inserted
Date/Time and
Initials:
- Tuesday/ 1545
TJF
Discontinued
Date/Time and
Initials:
-
Catheter intact
after removal:
Chart Materials Judy Jones – Simulation 1
© National League for Nursing, 2014
5
Nurse Signatures
Date/Time
Initial
TJF
RR
LS
Nurse Signature
Teresa Franklin, RN
Richard Reid, RN
Lisa Sousa, RN
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 fluids
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
Race:
Religion: Baptist
Medication brought from home:
None
Chart Materials Judy Jones – Simulation 1
© National League for Nursing, 2014
6
Diagnostic Studies
Lab – CBC & Chem 7 on
admission
Radiology – chest X-ray every
day
Activities of Daily Living
As tolerated, self-directed
Discharge Planning
- Discharge to home
Intake and Output
Tuesday
Day 1:
In
Wednesday
Day 2:
In
Out
11-7
400
260
7-3
786
300
3-11
Daily Total:
Out
763
300
+436
Chart Materials Judy Jones – Simulation 1
© National League for Nursing, 2014
7
Chart Materials Judy Jones – Simulation 1
© National League for Nursing, 2014
8