Shawnee Payne

KB 60 F 107 3) 10/24

wound on L lateral tee

Sole on 1 buttock

non d/f obesity

ambulatory

NIA RA 95

NIA Sister is a caretaker for her

N/A

Mee
constant

N/A

last noted BM 3 days age O

schenk
1 :
1350
0 : 2000

16 Fr Indwelling Urinary sathete

 KB 68 F 107 3/10/24 Full ·
shellfish , penicillin , huts Sister
Melling
& hand 229 bllat Al 209
Co diarched and weakness , .

Facial surgery
Cholecystectomy
,

abdominal pain 3/1

generalized anxiety NIA
O
Obesity NA
Allemia 61 bleed
, ,
HTN N/A
N/A
elevated lactic and ,
Tobacco use
acute lidnay fallure ↓
, pea
7. Y

aremi
.5
25 y
calm ,
appropriately dressed 5 8
.
N

158 N -

A 40x4 14
buttock
133 ↓
63S 15 sole on L
4 8
. N - -

PERRLA wound L
on lateral knee
106 y M
14 N - -

1 8 N
-

y
.

15 .
9 6 bleed
PT
Edema In Lower extremities It 3
to walk
NIA
Unable
Irregular heart rhythm
Active ROM X4

NA
CBL
continuous pulse ox
mood and affect congment BMP
RA

diminished lower lobes generativity

is stagnation
ky
180cm 158 3
.
48 52
.

O
1927
135/6
last BM 3
days ago 80

discharge education 1899

Ra
37
.a

1
:
1350 0 :
2000 8350
2000

braden Citalopram Cath care nemo CBC

meek
mouse hydrocorsone BMP
pantoprazole

I knee pain -keep patient pain level below an 8 throughout the shift
I thee wound-risk ofInfection need throughout shift
dressing clean/dry/intact and change
as
-

keep
↓ moisture In skin
folds/pen area
-

keep skin clean ,

warm ,
and apply hystafin as needed

provide honpharmacological Interventions (ice restl , -

ot pain level was well controlled throughout shift

-

change dressing as needed monitor for /x of Infection

, -
dressing was keptnear , dry ,
and infact
-

change bedding/gown as needed throughout shifta monitor for -

hystatin was applied ,

skin was
kept warm ,
, and
dry infact
Skin breakdown apply hystatin as needed
,
 Citalopram Komg DO BID hydrocortisone topical BID
SSRI corticosteroid
correct electrolyte disturbances , watch for s/x of
increased risk of sucade systems absorption , monitor for electrolyte disturbance
mood/affect) electrolytes electroly lif

anxiety/depression suicidality Inflammation may cause

prolonged &T , NID hypercorflcism ,

purning erythema
,

after
advise family/caregivers to follow-up how to apply ,
wash hands
on patient Increased Usk of suludalit application
40 my levothyroxme
pantoprazole IVP BID Somag PO
daily
PPI thyroidhormone
bone
long from therapy may cause
prolonged use may cause
low magnesium increase risk of loss during
,
CDAD premenopause
thyroid hormone
dyspepsia s/x levels

dyspepsia increased risk of hypothyroidism don't use I

fractures other therapeutic agents for

Osteoporosis related
may cause TIN treatment of opesity or
weight loss
teach to take as prescribed take drug consistantly at same time each

day
foll acd Img PO daily magnesium oxide 800
my Poday
Vitamin/foll and denrative magnesium salf/antacid
monitor CNS &61 adverse reactions monitor magnesium level

CNS/anemia indigestion/mg levels

anemia undiagnosed anemia Indigestion

altered sleep pattern confusion
, , contraindicated i severe ladney disease

malaise abnormal
use caution :
ladnay funcion
teach about proper nutation to prevent anamin
report s/sx of diarmea ,
61 bleeding
tarry stool or coffee ground emesis
Thiamine
loomg PO
daily NIA
B Vitamin NIA
may passInto breastmilk
N/A
mutational status N/A

warmth, screating ,
N/A
Vit B , deficiency skn discoloration
N /A

high does may cause stomach

N/A
upset

Acetaminophen 500
my 94h -fover/pain
PO hydralazine lomg IVP 9th -

HiN

bisacody) long PO BID constipation

-

Melatonin 3mg PO 95
-

Insomnia
calcium carbonate I tab PO 96h heartburn -

morphine 4mg Ip 924-severe pain

cyclobenzaphne long POMD-spasms ondansetron Kmg IVP gbh handed-
 DW 85 M III
319/24

drainage at surgical Inasion I

sanguineous fluid
dressing was fully saturated and replaced

NIA RA 97

L hip
4 days
NIA

N/A
4
last BM 1 day ago

N/A
1 : 750

0 :

800

1 Fr Indwelling Urinary cathete

 Du 85 M (l) 3) 9/24 Full O
NKDA Wife Melling
20g L hand 3/10
2/0 AMS , Confusion anemia L total hip PICC R Basilic 3/12
bacteremia
hypotension CAD
PCI
NIA
Cardsac cath I SCA 2
HTN
N/A
hyponatremi Cataract surgery
metabolic encephalopathy Iron colonoscopy
N/A
deficiency N /A
acute (adney Injury
leukocytosis vasectomy
hyponatremia , hyperkalemia
anemia UTI paroxysmal afib shoulder replacement 7 3 .
Y ↓ anemia
,

portal ran thrombosis 23 - 6 Y ↓ anemia

calm ,
appropriately dressed 13 6 -

Y ↑ Infection
270 N - -

A 40x4 19
135 N

=
En
PERRLA surgical wound on 2 hip 4 4
.
N

95 N

31 Y ↑
2 . 08 Y ↑ AK

NIA

edema in lower extremities It G NIA

Unable to e
Walk
Irregular heart mythm Cabb)

CBC N/A
unlabored equal respirations BMP NIA
mood and affect cougment
,

BIPAP e NOC

Integrity vs despair
ITICM 100 .

8kq
4

pain I
in hip at surgical site 1904

it
54
last BM reportedI day ago

a
fall risk education
Pa
M
change position slowly 36 7 .

1 750
:
0 :
800
4

indwelling Urinary catheter 750

800

Cath care lopramide Piperaallin braden

CH6-
pradem BMP central line morke
CBC
morse fall Neuro check

-
risk for falls -

Pt will be free from falls this shift

-
AMS/Confusion -

It will be reoriented If showing s/sx of confusion

-

sleep disturbances -

It will have minimal sleep disturbances throughout night

this shift
-
teach patient how to use call button when wanting to get up -

pt was free from falls

shift
-
reorient pt to person ,
time , place situationIf
,
confused -

pt wasreoriented occassionally throughout

bundle cares follet pt before bed apply bipap before bed Pt cares were bundled and sleep disturbances were minimal
-
-

, ,
 operamide <my Po 96h Zosyn 3 .

3759 IVPB g8h

antidiarrheal antibiotys
consider of for
as a
possible cause
may UPAD , risk
cause
unexplained cardiac events renal failure
Kidney function

diarrhea bloody diarrhea ,

joint Infection renal Impairment
abdominal pain without diarrhen or secure disorder

carefully follow OTC/ Prescription dosing report discomfort at IV site

apixaban Smy PO BID atorvastatin 80 mg PO

daily
anticoagulant antilipemics
monitor for bleeding/blood loss It should follow cholesterol lowering det

before/during therapy
bleeding molesterol levels

high risk of risk of

afib high molesterol ↑ myopathy
bleeding/acute Pt 4 hemodynamically and rhabdomyolysis
unstable
do not discontinue without talking to Dr .

proper dietary management weight control , .

adverse reactions
report exeruse

Sotalol 80mg PO BID tamsulosin 0 .

4 mg PO daily
BPH drug cpha blocker
antiarrhythmicsto arrythmic
-

events may occur

, monitor for low BP may ,
cande
OT interval be <450 msec before starting drg IV/ suspension
must oral
Orthostatic hypotension
heart rate/rhythm BP

a fil Severe sinns BPH sulfa allergy

node disfunction/sinns bradycardin

adverse reactions dizziness sudden BP-rise Slowly

report such as
, may cause drop In

lightheaded Irregular
, heart beat
NIA N/A
NIA NIA
NIA N/A

N/A N/A

N/A N/A N/A

N/A

N/A N/A

acetaminophen 500
my PO 9th -

fover/mild pain ondansetron 4mg IVP abh -

nanced
alteplase Img IVP
Heparin flush10u/mL IVP
=
3m) -

Central Venous cath .

lidocaine 1 1OmL
%
Injectable SQ once
pain
-
 DD 7 F 112 3/10/24

runs of atlb : RVR

mottled skin on
arms/legs ,
purple hands i edema

22 NG 97

N/A
N/A

N/A

no complaints
ofpain

melling
O 1000
:
 DD 7 F 112 Full O
3/10/24
Melling
shellfish , percocet
L As

1/0 lethargy and altered CAD

endarter
mental status CVA
estomy R
3/11/24
CHF
tonsillectomy NA
GERD Cholecystectomy
0 9 % normal sallne
colonoscopy
.

HTN
aspiration pneumonia 30ML
aortic value stenosis aortic value replacement
metabolic encephalopathy
AV block rotator suff repair
severe sepsis without shock
pacemake tubal litigation 12 5 .

N
-

lactic audosis 37 2 N
i
.

AMS ,
slightly disherded falls seluies .5
15 Y

138 y ↓
A 4OX2 overted to self and place 10
13 N
=
,

traumatic Injury to L knee I foot I elbow N

drowsy ,
, ,

concentration difficulties
R forearm , R foot 97 N
-

19 N
-

mottled skin blat extremities

on
, purple hands 0 57.

y ↓
NA
Mus of afb : PVR H
NIA
Active ROM XK
generalized edema
bed fast unable to ambulate d/t obesity
tachycardia ,

bilat lobes
expiratory wheezesIn
mood and affect congment
diminished slightly In 1 lobe

Integrity vs despair
162 um
92kq .
35 44
*
2241

family 1/0 poor nutational 13

Intake and lack of 16
97
appetite
fall risk DA

risk for Infection 37 5.

:
O
D :
1008

1000ML

morse narro piperacillin Morse

potassium
braden meek braden
level

-
fall risk -

pt will remai free from fulls throughout smft

-
Impaired skin Integrity pt skn Integrity will remain at baseline
shift
-

-
altered mental status -

ot will be reoriented as needed throughout

-
teach use of call light ,
respond quickly to call light -

pt remamed free from falls throughout shift

-

eliminate controllable moisture as much as possible/nystatin -

pt skin Integrity remained at baseline

no worsening ,

reonent needed It relented needed shift

to place situation was
throughout
-

person time as
-

ot as
, , ,
 tazobactam amodarone
piperacillin 3
375g IVPB
goh 200
my PO BID
-
.

antibiotys antiarrhythmic
may UPAD , risk
cause for high risk of adverse reactions

renal failure Obtain baseline thyroid function

Kidney function heart rhythm

renal Impairment HX of arrhythmias hypersensitive to lodine

Pneumonia ,

or secure disorder cardiogenic shock/2nd/3rd'AVB

report discomfort at IV site wear sunscreen/protective clothing to prevent

sensitivity reaction to sun

ascorbic and 500mg daily

Po Clonazepam 0 .

Smg PO BID
Vitamin
C
anticonvulsant-benzochazepine
high doses may lead to kidney stones moultor for changes In behavior
don't stop abruptly
urination status behavior

Vit
deficiency allergic reaction , selzme cautiously In
Use
unne
unable to pass older adults , high risk for abused
addiction

bestIf taken with a meal , do not Increase usk of abuse/misuse/addiction

cher , crush ,
or break

diltiazem 240 my PO
daily furosemide zomg IVP
CCB-antihypertensive antihypertensive-loop amretic
monitor BP 4HR monitor weight , BP, pulse rate
maximal effect may like up to 14 days watch
,
parameters
BP/H2 weight , BP ,
pulse

tachycardia Sick Sinus syndrome

, edema annua ,
sulfa allergy,
2nd/3rd degree ArB hypotension arrhosis
, hepatic
may tinnitus/hearing loss
cause

take as prescribed even when

charge position slowly take In AM
,

feeling better
levetiracetam <Somg PO BID megestrol 625mg daily Po
anticonvulsant antineoplastic
selfire can occur = abmpt stoppage may increase gincose level ,
monitor for s/x of somnolence/fatigue not for prophylactic use
s/sx selzve nutution status

any phylaxis & significant weight

Selzures

angloedema may occur loss/ poor appetite thrombophleb Hs

older adults use cautiously
seek medical attention for emerging / must be taken for at least 2 months

for
worsening depression/suvidality/manges in mood/behavior therapeutic effect

acetaminophen Soomg PO-pain/fover hydrocodone I tab PO 9th

-

seve
pain
Calcium carbonate turns I tab Po-heartburn ondansetron king IVP 96h
-

nausea
diltiazem long /P
-

tachycardia polyethylene glycol Mg POBID

-

constipation
droperido) 0 62S
.

my IVP q6h-N/
 pain management risk for Infection AMS

dry reorent needed

pain medication keep dressing clean Intact
pt as
-
-

,
-

-
Ice -

perform wound care -

teach use of call button

rest
perform dressingchange
-

frequentmecks on pt
position changes
-

-
monitor for s/x of Infection
guided meditation
keep It calm
-
-

keep pain level at

8
-
or below an
keep patients surgical wound dean , reonent patient to person place , ,

throughout the shift dry andIntact throughout the situation ,

needed
,
time and as

shift and mange dressing as needed

teach how to use call button

ot was given pain medication -

pt dressing was saturated

and -

pt was romented to person place , ,

to help Velleve pain

. Replaced with new dressing
removed time ,
and situation through out
Shift
-

It was repositioned to help

performed wound care on surgical
-

how to
relieve discomfort
and
-

Ot was taught use the

site and was cleansed = NS
call button
-

It was allowed to rest In dried thoroughly

room to relieve discomfort -

It was checked on every

new dressing was kept clean dry,
throughout the shift
,

hour
-

throughout shift
-

pt was given le pack to and Intact

apply to affected arca

-

Vitals were taken and pt was

-

pt remained calm and

monitored for s/x of Infection semi-ovented throughout shift

throughout shift

ot pain goal stayed below ot dressing and surgical wound pt was reorented throughout
-

at or
-
-

an 8 for the remainder of the was kept clean , dry andIntact

, shift , kept calm ,
and taught
shift how to use call button ,
as well

as
glh checks
 CAUSES

↑
SIGNS/syMPTOMS
genetic problems
-

liver/kidney disease -

confusion
-

Infections -

trouble with attention/remembering

-

Alcohol/illegal drug use -

Irritable behavior

drugs that treat depression , pain infections

secure
sleepy or not being able to sleep
-

, , -

with
-
Issues other body systems such as diabetes ,
HF , liver disease , etc
.
-
seizures
-

organ failure not actually there

seeing things that are
-

personality changes
-

uncontrollable/involuntary movement

trouble
scollowing
~

ENCEPHALOPATHY
TMBOK
NOsHSs/nABs TREATMENTS POTENTIAL
-

nutritional supplements COMPLICATIONS

MRI
-

dialysis
CT
-

permanent prain damage

organ transplant
-

neurological exam -

medications for seizures

-

developmental delays
com a
medications (lactlote
level
reducing
-

EEG -
ammonia
-
death
treat underlying cause
blood/urine test
-

-
Seizure
-

dief modification
-

spinal fluid best -

organ fallure
-
stress free environment
-
altered consciousness
-

delirium