Influenza vaccine 0.5 mL IM Annually Ubidecarnone/Vitamin E 200 mg (one cap PO) Once a day Vitamin C 500 mg (1 tablet PO) Once a day Vitamin D3 (Cholecalciferol) Multivitamin Docusate sodium-senna Cyanocobalamin MAPAP (Acetaminophen) Zofran Biotene mouth wash oral rinse 1,000 unit tablet (4 tablet PO) 1 tablet 1 tablet 1,000 mcg (1 tablet PO) 500 mg (2 tablets PO QID) 4 mg (1 tablet q8h) 15 CC Once a day Once a day Once a day Once a day As needed for pain As needed for nausea or vomiting BID Risamine ointment Apply bilateral buttocks and sacral area Every shift Ammonium Lactate Nystatin Bengay greaseless cream 12% Lotion  Apply BLE dry skin 100,000 unit/GM powder  Apply to bilateral breast folds Topically to left shoulder BID BID until healed BID

Nurse’s Note Date / Time: 3/9/17 ACCUCHECK NURSE’S NOTES Write a narrative note, based on SBAR, for a newly identified patient concern. (This form will expand to fit your typing.) S Patient has an elevated blood sugar due to diabetes B Patient appears restless and has a history of diabetes. Patient is to receive an accucheck before administration of insulin A After Accucheck, patient was hyperglycemic and had a blood sugar of 450 R Needs an order for additional insulin

Physical Assessment Worksheet Vital Signs: T: 97.6 F Apical HR: 64 Resp: 14 BP: 138/70 Pulse ox: 99% RA LOC-Orientation/ Cognition Level of consciousness and orientation: x4, NKA (Include identification of patient & allergy assessment) Speech articulation: Somewhat clear  Has no teeth/dentures to fluently articulate General appearance/Facial expression/mood/affect: Calm and alert, Dressed somewhat appropriately clothes should be changed due to stains and spills, Somewhat groomed hair was not brushed HEENT / Sensory Perception (Include: Assessment of vital sign measurements & daily weight if indicated) Pain level on 0-10 scale & symptom analysis (intervention & evaluation) 0 pain  Depending on weather, but further assessment complained of pain in BLE and scored pain as a 6 PERRLA: present PERRLA Mucous membranes : pink/moist, no visible lesions Skin Turgor: No tenting present Assess for presence of hearing aids or eye glasses: Wears glasses for reading, No needed hearing aid Respiratory/ Oxygenation Respiratory effort & use of oxygen: No oxygen needed, Unlabored breathing Breath Sounds: Anterior: Clear and equal Breath Sounds: Posterior: Clear and equal Cough & Deep Breathe(C&DB), any mucous? Assess color & amount  No mucus presented Educate on & use Incentive Spirometer if ordered: No use of incentive Spirometer Cardiac - Peripheral Vascular/ Perfusion Auscultate Apical Heart Sounds: Rate: 64 Rhythm: Regular Skin Color: Pink Capillary refill: 3 seconds Pretibial edema: R  3+ L  2+ Dorsalis pedis pulse: R  1+ L  2+ (Doppler if needed) TED hose or SCD hose & DVT assessment: none