ED/NURSING NOTE Has ADDENDA
ASSUMED CARE AND INTRODUCTION TO PT AT: 2050
Patient identification band on: WRIST
Patient identification band validated by writer of this note
PROBLEM: xfer from barstow, afib, sob, copd
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SUBJECTIVE
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PSYCHOSOCIAL / COMMUNICATION SYSTEM
WNL: Affect, appearance, behavior, speech appropriate to age and situation
NEUROLOGICAL SYSTEM
Within Normal Limits (A&O x 4, follows commands, speaks clearly, responds to
visual/auditory stimuli)
CARDIO-VASCULAR SYSTEM
Within Normal Limits no cyanosis/edema, extremities warm to touch
RESPIRATORY SYSTEM
DV: 2l o2 via NC, sob, non productive cough
GASTRO-INTESTINAL / NUTRITIONAL SYSTEM
Within Normal Limits (Soft abdomen, no distension, continent, appetite: good
to
fair)
GENITO-URINARY SYSTEM
Within Normal Limits (Voids clear yellow urine, continent, voids without
difficulty)
MUSCULO – SKELETAL SYSTEM
Within Normal Limits (Able to move all extremities, normal coordination /
gait)
INTEGUMENTARY SYSTEM
DV: bruising bilat arms, left scalp
PATIENT/FAMILY EDUCATION DOCUMENTATION
Barriers to Learning: None
Readiness to Learn: Ready to learn
Learning Preference: Verbal
Instruction given to: Patient
Topics discussed: Disease Process, Medications
Teaching Method Used: Discussion
Assessment of Learning: Good
Understanding measured by: Verbalization
Psych
Has anyone been hurting you physically or emotionally? No
Do you suspect that this patient may be a perpetrator or victim of abuse? No
Are you feeling hopeless about the present or future? No
Have you had thoughts about taking your life? No
Do you have a plan to take your life? No
Have you ever had a suicide attempt? No
Is the patient homicidal? No
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(I) INTERVENTIONS
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CARDIAC MONITOR: 2055
SPO2 MONITOR: 2055
NIBP MONITOR: 2055
INTRAVENOUS ACCESS: 18g LFA, 20g rt hand
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SUBSEQUENT VITAL SIGNS
TIME BP PULSE RESP O2% TEMP PAIN
cprs
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MEDICATION ADMINISTRATION
TIME MEDICATION DOSE ROUTE
bcma
2230 vancomycin 2gm per dr zaidi ivpb
pharmacist delay to clear meds, dr zaidi informed.
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INTRAVENOUS FLUIDS
TIME SOLUTION VOLUME RATE/BOLUS
bcma
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NARRATIVE
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2045: pt biba, xfer from barstow comm ed for afib and sob/copd exacerbation.
pt calm quiet cooperitive, gcs 15 a/ox4, respirations even, shallow,
unlabored, non productive cough, speaking in 2-7 word senctences, 2L o2 via NC
“as needed” per pt, skin warm and dry, mucous membranes moist, no distress,
ekg completed, placed on cardiac monitor, labs drawn and sent per md orders.
dr zaidi at bedside for eval.
2101: radiology at bedside for portable chest film, pt tolerated well, no
distress, rmains on cardiac monitor.
2142: RT at bedside for breathing tx, tolerated well, no distress, on cardiac
monitor.
2201: dr zaidi at bedside for re-eval.
2243: bing pharmaicist at bedsdie for eval.
2245: sbar to irene rn. pt remains resting comfortably in gurney, gcs 15 a/ox4,
respirations even and unlabored, 2l o2 via NC, unproductive cough, skin warm and
dry, no distress, on cardiac monitor.
RN
2240 SBAR REPORT RECEIVED FROM OUTGOING NURSE JASON. PT PRESENTED TO ED
BIBA FROM COMMUNITY ED C/O AFIB, SOB MHX COPD. PER RN REPORT, SEEN AND
EVALUATED BY ERMD WITH ORDER FOR HOSPITAL ADMISSION, GIVEN IV NS 250 ML BOLUS,
BREATHING TX, STARTED VANCO IVPB AFTER BLOOD CULTURES X 2 DONE, TOLERATING
WELL 02 INH 2L/NC. PT A/O X 3, CONVERSANT, BREATHING LABORED DURING
CONVERSATION WITH RN, + AFIB HR 108/MIN, SKIN WARM AND DRY, + ABRASIONS AND
HEAMATOMA TO HEAD AND BUE, NO ACTIVE BLEEDING NOTED. IV ACCESS X 2 > G 18 L FA
AND G 22 TO R WRIST, NO S/S OF INFILTRATION NOTED. PT CALM AND COOPERATIVE, ABLE
TO MOVE BILATERAL UPPER AND LOWER EXTREMITIES WHEN GIVEN DIRECTIONS. VS STABLE,
WILL CONTINUE TO MONITOR.
2255 MEDICATED WITH CEFIPIME IVPB AS ORDERED. PLEASE SEE BCMA
2330 + URGE TO VOID, UNABLE TO VOID PER PT. BLADDER SCAN 652 ML. ERMD
ZAIDI WITH ORDER FOR FOLEY CATH PLACEMENT
2335 PT ADMITTED TO HOSPITALIST DX: PNEUMONIA UNDER THE SERVICE OF DR
SMITHWICK. TO AWAIT FOR BED ASSIGNMENT AT THIS TIME
2340 FOLEY CATHETER FR 16 PLACEMENT USING STERILE TECHNIQUE. PT TOLERATED
WELL.
0002 SBAR INITIATED AND SIGNED FOR ADMISSION. RN CHARGE BING MADE AWARE FOR
FLOOR BED ASSIGNMENT
0025 PSYCH NP FAUSAT AT BEDSIDE EVALUATING PT AT THIS TIME.
0110 + SOILED PANTS. PERINEAL CARE DONE. + RASH NOTED TO PERINEAL AREA.
BUTTERFLY DRESSING APPLIED. REPOSITIONED COMFORTABLY ON BED. VS STABLE, WILL
CONTINUE TO MONITOR
0120 BELONGINGS INVENTORIED PER PROTOCOL
0140 LEFT ED VIA GURNEY IN STABLE CONDITION, HOOKED TO MONITOR PER ACLS
PROTOCOL ACCOMPANIED BY RN. ALL PERSONAL BELONGINGS WITH PT
STAFF NURSE