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
Physical Assessment Worksheet
Musculoskeletal-
Skin/
Mobility
1.
