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Influenza vaccine0.5 mL IMAnnuallyUbidecarnone/Vitamin E200 mg (one cap PO)Once a dayVitamin C500 mg (1 tablet PO)Once a dayVitamin D3 (Cholecalciferol)MultivitaminDocusate sodium-sennaCyanocobalamin MAPAP (Acetaminophen)Zofran Biotene mouth wash oral rinse1,000 unit tablet (4 tablet PO)1 tablet1 tablet1,000 mcg (1 tablet PO)500 mg (2 tablets PO QID)4 mg (1 tablet q8h)15 CC Once a dayOnce a dayOnce a dayOnce a dayAs needed for painAs needed for nausea or vomitingBIDRisamine ointmentApply bilateral buttocks andsacral areaEvery shiftAmmonium LactateNystatinBengay greaseless cream12% LotionApply BLE dry skin100,000 unit/GM powderApplyto bilateral breast folds Topically to left shoulderBIDBID until healed BID
Nurse’s NoteDate / Time: 3/9/17ACCUCHECKNURSE’S NOTESWrite a narrative note, based on SBAR, for a newly identified patient concern.(This form will expand to fit your typing.)SPatient has an elevated blood sugar due to diabetesBPatient appears restless and has a history of diabetes. Patient is to receive an accucheck before administration of insulinAAfter Accucheck, patient was hyperglycemic and had a blood sugar of 450RNeeds an order for additional insulin
Physical Assessment WorksheetVital Signs: T: 97.6 FApical HR: 64Resp: 14BP: 138/70 Pulse ox: 99% RALOC-Orientation/Cognition Level of consciousness and orientation: x4, NKA(Include identification of patient & allergy assessment)Speech articulation: Somewhat clearHas 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 brushedHEENT/Sensory Perception(Include: Assessment of vital sign measurements & daily weight if indicated)Pain level on 0-10 scale & symptom analysis (intervention & evaluation) 0 painDepending on weather, but further assessment complained of pain in BLE and scored pain as a 6PERRLA: present PERRLAMucous membranes : pink/moist, no visible lesionsSkin Turgor: No tenting presentAssess for presence of hearing aids or eye glasses: Wears glasses for reading, No needed hearing aidRespiratory/OxygenationRespiratory effort & use of oxygen: No oxygen needed, Unlabored breathingBreath Sounds: Anterior: Clear and equalBreath Sounds: Posterior: Clear and equalCough & Deep Breathe(C&DB), any mucous? Assess color & amountNo mucus presentedEducate on & use Incentive Spirometer if ordered: No use of incentive SpirometerCardiac -PeripheralVascular/ PerfusionAuscultate Apical Heart Sounds:Rate: 64 Rhythm: RegularSkin Color: PinkCapillary refill: 3 secondsPretibial edema: R3+ L2+Dorsalis pedis pulse: R1+ L2+ (Doppler if needed)TED hose or SCD hose & DVT assessment: none