Chart for Eugene Shaw Simulation #3

PATIENT CHART

STUDENT NAME:______

PATIENT INITALS: ___E.S.______

CLINICAL DATE(S): ______

INSTRUCTOR: ______

Patient Name: Eugene Shaw / MRN:09625
Room: / Doctor Name: Dr. Ian Stein
DOB: 05/21/xx / Date Admitted:
Age: 82 / 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:
Monday 1100 / Post-Operative Medical Orders
Condition of patient: Good

DIET: resume 1800 ADA diet as tolerated
FLUIDS: discontinue IV fluids as soon as able to tolerate oral fluids
VITAL SIGNS: q. 4h. If temperature > 101 F (38.33 C) notify resident
ACTIVITY:
Up in chair with leg elevated
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
Electrolytes, CBC
MEDICATIONS:
Vicodin 5/500 mg q2h PRN for pain
Lasix 10mg daily
Plavix 75mh PO daily
CHECK THE BLOOD SUGAR (BS): before every meal & before bedtime
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

Docusate (Colace) 100 mg PO daily, may repeat X1 PRN for constipation
Ferrous Sulfate 325 mg PO daily
Zocor (Simvastatin) 20 mg PO daily
Zestril (Lisinopril) 5 mg PO daily
Glucotrol 30mg 1 tab PO bid
Citracal 180 mg 1 tab PO daily
Enoxaparin (Lovenox) 30 mg subcutaneous q.12h
Bactrim DS one tab bid
Penicillin VK 500mg PO Q6H

Robert Moses, MD

Stat Order Form

Date/Time: / STAT PHYSICIAN ORDER

Lab Data

Date/Time: / Test: / Result: / Reference range:
Monday 1600 / Chemistries / Sodium / 137 mEq/L / 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
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 / 15 mg/dl / 7-20 mg/dl
Creatinine / 1.0 mg/dl / 0.8 – 1.4 mg/dl
Hematology / Hematocrit / 39% / 38 – 43%
Hemoglobin / 15 g/dl / 12 – 16 mg/dl
Red blood cells / 4.8 million/mm3 / 4.6-6.2 million/mm3
Erythrocyte sedimentation rate / 19 mm/hr / 20 mm/hr
Leukocytes / 9,000/mm3 / 5000-10,000/mm3
Platelets / 325,000/mm3 / 150,000-450,000/mm3
Prothrombin time (PT) / 10.2 sec / 9.6-11.8 sec
Partial thromboplastin time (PTT) / 32 / 30-40 sec
HgbA1C / 5.8% / 4-5.6%
Renal / BUN / 7 mg/dl / 6-20 mg/dl
Creatinine / 1.2 mg/dl / 0.6-1.3 mg/dl
Urine Test / pH / 4.4 / 4.5-8.0
Specific gravity / 1.018 / 1.010-1.025

Medication Administration Record

Allergies: NKA

Scheduled & Routine Drugs

Date of Order: / Medication: / Dosage: / Route: / Frequency: / Hours to be Given: / Dates/Times Given/Initials:
Colace (Docusate) / 100mg / PO / daily / 0900 / -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
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 / -Sunday/ 0900 NN
-Sunday/ 2100 CR
-Monday/ 0600 NN
-Monday/ 2100 CR
-Tuesday/ 0600 NN
-Tuesday/ 2100 CR
-Wednesday/ 0600 NN
-Wednesday/ 2100 CR
Zestril (Lisinopril) / 5 mg / PO / daily / 0900 / -Sunday/ 0900 NN
-Monday/ hold
-Tuesday/ 0900 NN
-Wednesday/ 0900 NN
Lasix (Furosemide) / 10 mg / PO / daily / 0900 / -Sunday/ 0900 NN
-Monday/ hold
-Tuesday/ 0900 NN
-Wednesday/ 0900 NN
Citracal / 180 mg
1 tab / PO / daily / 0900 / -Sunday/ 0900 NN
-Monday/ hold
-Tuesday/ 0900 NN
-Wednesday/ 0900 NN
Glucotrol / 30mg
1 tab / PO / bid / 0900
2100 / -Sunday/ 0700 NN
-Sunday 2100 CR
-Monday/ hold
-Tuesday/ 0900 NN
-Tuesday/ 2100 CR
-Wednesday/ 0900 NN
-Wednesday/ 2100 CR
Cephazolin Injection (Ancef) / 1 g / IVPB / 1 hour prior to surgery / 1 hour prior to surgery / -Monday/ 0700
Bactrim DS / one tab / bid / 0900
2100 / -Tuesday/ 0900 NN
-Tuesday/ 2100 CR
-Wednesday/ 0900 NN
-Wednesday/ 2100 CR
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 / Nurse Signature
AB / Ann Brennan, RN
NN / Nancy Nurse, RN
CR / Carol Reynolds, RN

PRN Medications

Date of Order: / Medication: / Dosage: / Route: / Frequency: / Hours to be Given: / Dates/Times Given/Initials:
Vicodin (hydrocodonebitartrate/acetaminophen 5/500) / 1 tab / PO / Q2h prn for pain / -Sunday/ 0100 AB
-Sunday/ 0430 AB
-Sunday/ 0730 NN
-Sunday/ 1100 NN
-Sunday/ 1300 NN
-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 / Nurse Signature
AB / Ann Brennan, RN
NN / Nancy Nurse, RN
CR / Carol Reynolds, RN
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: Femoral-popliteal 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
Medication brought from home: None / Consults
-Physical therapy
-Rehabilitation medicine / Treatments
-Foley removed on Tuesday
Diagnostic Studies / Activities of Daily Living
Up in chair with pillow
Assist with ambulation / Discharge Planning
-Physical therapy consult for post-op activity and outpatient rehabilitation

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
Colace (Docusate) / 100 mg / PO / BID / Saturday AM / C DC
Plavix (Clopidogrel) / 75mg / PO / Daily / Saturday AM / C DC
Ferrous Sulfate / 325 mg / PO / Daily / Saturday AM / C DC
Zocor (Simvastatin) / 20 mg / PO / Daily / Saturday AM / C DC
Zestril (Lisinopril) / 5mg / PO / Daily / Saturday AM / C DC
Citracal / 180mg / PO / Daily / Saturday AM / C DC
Glucotrol / 30mg / PO / Twice Daily / Saturday AM / C DC
Lasix / 10 mg / PO / Daily / Saturday AM / C DC

Provider Signatures

Date/Time / Initial / Provider Signature
Saturday 2330 / IS / Ian Stein, MD

Nurse Signatures

Date/Time / Initial / Nurse Signature
Saturday 2330 / AB / Ann Brennan, RN
Reviewed on Transfer by: Nancy Nurse, RN / Date: Sunday 0600
Scan to Pharmacy Time: / Date:

Downtime Documentation

24-hour Abbreviated Neurovascular Assessment Flowsheet

Chart Materials Eugene Shaw Simulation 3

Date/Time: Monday 0600 / Patient Name: Eugene Shaw / Nurse Signature: Nancy Nurse, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent

Chart Materials Eugene Shaw Simulation 3

Post- Op Recovery Room

Date/Time: Monday 1130 / Patient Name: Eugene Shaw / Nurse Signature: Jennifer Williams, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Monday 1330 / Patient Name: Eugene Shaw / Nurse Signature: Jennifer Williams, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Monday 1530 / Patient Name: Eugene Shaw / Nurse Signature: Jennifer Williams, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Monday 1730 / Patient Name: Eugene Shaw / Nurse Signature: Carol Reynolds, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Monday 1930 / Patient Name: Eugene Shaw / Nurse Signature: Carol Reynolds, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Monday 2130 / Patient Name: Eugene Shaw / Nurse Signature: Carol Reynolds, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Monday 2330 / Patient Name: Eugene Shaw / Nurse Signature: Carol Reynolds, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Tuesday 0130 / Patient Name: Eugene Shaw / Nurse Signature: Carol Reynolds, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Tuesday 0330 / Patient Name: Eugene Shaw / Nurse Signature: Carol Reynolds, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Tuesday 0530 / Patient Name: Eugene Shaw / Nurse Signature: Carol Reynolds, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Tuesday 0730 / Patient Name: Eugene Shaw / Nurse Signature: Nancy Nurse, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Tuesday 0930 / Patient Name: Eugene Shaw / Nurse Signature: Nancy Nurse, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent
Date/Time: Tuesday 1130 / Patient Name: Eugene Shaw / Nurse Signature: Nancy Nurse, RN / Diagnosis: Peripheral Vascular Disease; surgery: femoral-popliteal graft - RIGHT / Extremity to be assessed: Right leg
Pallor (Color): / Polar (Temp): / Pedal Pulse: / Popliteal Pulse: / Pain (passive, motion) / Paresthesia (numbness, tingling): / Movement:
Pink
Pale
Dusky
Cyanotic / Warm
Cool
Cold / Present
Faint
Absent / Present
Faint
Absent / None
Moderate
Severe / Present
Moderate
Severe
Absent / Present
Decreased
Absent

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