Professional Documents
Culture Documents
revised 10/14/16
Current
IV rate
Current
dose
Magnesiu
m sulfate
25 mL/
hour
2g
IV site location
(where is it
running?)
R antecubital
Data
revised 10/14/16
_________________________________________________________________________________________________
Integumentary: T:__98.7____ F or C
_____________________________________________________________________
_________________________________________________________________________________________________
Pain Assessment: _0800 pain= 7/10 at neck, radiates to left arm, stabing _________________
1000 pain= 5/10 _______________________________________________________________
Delirium Assessment:__Alert, oriented x 4. Intact memory.
____________________________________________________________________________
Psychosocial issues:______________________________________________________________________________
Other:___________________________________________________________________________________________
o
ECG strip:
Lead: ______ Atrial/ventricular rate: ______ Regular/irregular: _______ PR interval: _____ QRS interval: _______
(attach the ECG strip you analyzed above, here. Staple or tape it in place. NO NAMES or other identifying information left on strip.)
revised 10/14/16
LIST ALL VALUES that are pertinent to this patients situation. Provided all values highlighted please.
Lab
Normals
Results/Date
WBC
4.0-10.0
K/L
4.00-5.00
M/L
150-430
K/CU MM
N/A
7.2
N/A
N/A
12.0-15.0
GM/DL
36.0-45.0
%
136-145
meq/L
3.5-5.1
meq/L
98-107
meq/L
N/A
13.8
7-21
mg/dL
0.57-1.25
mg/dL
70-105
mg/dL
17
RBC
PLT
PT/I
NR
PTT
HgB
Hct
Na
K
Cl
Osmolality
BUN
Creatinine
Glucose
Albumin
4.77
280
N/A
37.9
131
5.4
102
N/A
1.91
75
N/A
Ca (Serum or Ionized?)
9.6
Mg
8.5-10.5
mg/dL
1.2
CK
N/A
N/A
CK-MB
N/A
N/A
1.2
Troponin
4.69
Arterial : pH
0.03
PaCO2
N/A
N/A
PaO2
N/A
N/A
HCO3
N/A
N/A
BE
N/A
N/A
Ventilator settings
for the blood gas
Urinary: pH
N/A
6.0
Specific gravity
1.015
sodium
N/A
N/A
osmolality
N/A
N/A
Creat. clearance
N/A
N/A
revised 10/14/16
GFR
32
Amylase and
Lipase
Liver
transaminases
N/A
N/A
N/A
N/A
Protein, urine
0-14
12
Uric acid
2.5-8
6.8
Lipid profile
Cholesterol
Triglyceride
HDL
LDL
Hemoglobin A1C
<200
<150
>=60
<100
4.3-6.1
210
183
33
140
5.3
Vitamin B12
213-816
580
Folate
>=7
13.2
TSH
0.35-4.94
0.01
Free T4
0.7-1.48
1.08
PTH
15-90
74.4
ANA
Negative
Negative
Ds DNA Ab
Negative
Negative
C3 complement
82-193
144
C4 complement
15-57
41
Hepatitis B surface
Ag
Hepatitis C Ab
Nonreactiv
e
Nonreactiv
e
Nonreactive
Nonreactive
Result
revised 10/14/16
response._____________________________________________________________
_08/05/15 Urine electrophoresis: Urine electrophoresis shows no evidence of
monclonal proteins or free light
chains________________________________________________________________
_04/15/15 DEXA Bone Density
These findings are consistent with a normal BMD of the lumbar spine
and bilateral femoral necks. There is no increased risk of an
osteoporotic fracture as compared to the young adult population__]
_05/01/15 _Ultrasound right breast_____
There is no sonographic evidence of malignancy.
The 5 mm oval cyst in the right breast is benign. A 1 year screening mammogram
is recommended
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________
revised 10/14/16
Atorvastatin
(Lipitor)
Clopidogrel
(Plavix)
Enoxaparin
(Lovenox)
Famotidine
(PF)
Famotidine
(Pepcid)
Gabapentin
(Neurontin)
Hydrocortis
one (Cortef)
Magnesium
sulfate IVPB
Spironolact
one
(Aldactone)
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
80
mg
Q night
PO
75
mg
Daily
PO
30m
g
Q 24 h
Sub
Q
20m
g/2m
L
2 times
daily
IV
20m
g
2 times
daily
PO
300
mg
3 times
daily
PO
20m
g
Daily
PO
2g in Once
50m
L
steril
e
wate
r
25m Daily
g
IV
PO
revised 10/14/16
PRN Medications
Medication
Dosag
e
Morphine
1mg
injection
10 mg
Frequenc
y
Q4 hour
Rout
e
IV
Why patient is
getting.
Severe pain 7-10
Q 6 hour
IV
N/V
Prochlorperazine
(Compazine)
revised 10/14/16
Problem list
List 5-10 problems, ranking them in order of importance. The most important items become
your care plan focus.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
revised 10/14/16
revised 10/14/16
Diagnosi
s#
revised 10/14/16