Demographic
Information
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Health History
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Care Prescriptions
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Age: xx
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Chronic Health Conditions & Previous Health Problems:
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Diet: NCS
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Gender: F
Race: xxx
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COPD, IBS, chronic diarrhea
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G tube
NG tube
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Code Status: DNR
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Weight: 137.0
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Height: 5’3”
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Activity: Sarita Lift
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Reason for Admission [residents own words]:
“Oh, I don’t know. Couldn’t take care of myself anymore, I guess.”
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Medical Complications:
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I & O: X voiding
Foley catheter
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Medical Diagnosis [medical terms]:
Depression, end stage COPD, dementia, PVD,
HTN, IBS, OA, ETOH/tobacco abuse, chronic diarrhea, diet-controlled DM, rt shoulder
pain, mildly elevated troponins.
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Tobacco use
immobility
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Wound Care:
N/A
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drains (Type, Location,
Drainage from]
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Pulmonary care:
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Date of admission: xxxxxx
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Nursing Diagnoses (3,
prioritized)
Impaired gas exchange r/t ventilation-perfusion inequality as evidenced by client’s
dependence on supplemental oxygen.
Impaired social interaction r/t social isolation because of oxygen use, activity
intolerance as evidenced by resident claiming that she never goes to social activities
because she requires oxygen all day, everday.
Risk for Disuse syndrome: Risk factor: immobilization.
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X O2
_2_ L/min via
X N/C
mask
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Previous Surgeries
When? N/A
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IS q ___ hrs.
MDI
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Med. albuterol atrovent
other _____________
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Allergies: sulfa, latex
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Glucometer:
ac & hs
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sliding scale insulin
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Other:
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Discharge Plan/ Long Term Goals
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Treat pain
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Name/Dose
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Why does resident receive?
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Major Side Effects
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Nursing Implications
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Acetaminophen
RP Tylenol
500mg tab
POevery 4 hours as needed
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As needed for temperature
greater than 101degrees Fahrenheit or pain
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Hepatotoxicity
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Monitor for S&S
of hepatotoxicity even with moderate does, especially in individuals with poor nutrition
or who have ingested alcohol over prolonged periods. Poisoning from accidental ingestion
or suicide attempts.
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Bisacodyl
RP Dulcolax
Insert 1 Suppository
in rectum
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As needed for constipation
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No systemic effects
reported. Mild cramping and fluid electrolyte disturbances.
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Evaluate periodically
the patient’s needs for continued use of drug; bisacodyl usually produces 1 or 2
soft stools daily.
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Senna Plus
RP Senokot
Give
PO
times daily
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As needed for constipation
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Abdominal cramping
and loss in water and electrolytes
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Reduce dose in patients
with considerable abdominal cramping
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Albuterol
RP Proventil
1 dosette with Ipratropium
Bromide twice daily
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For COPD
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Hypersensitivity
reaction CNS: tremor anxiety nervousness restlessness convulsions and weakness
CV: palpitations,
HTN
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Monitor therapeutic
effectiveness which is indicated by significant subjective improvement in pulmonary
function within 60-90 days after drug admin. Watch for S&S of fine tremors in
fingers, which may interfere with precision handwork. Also look for tachycardia
and GI symptoms those report immediately to physician. Give periodic ABGs,
pulmonary functions and pulse oximetry.
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Artificial tears
Instill 1 drop 4times
a day
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For dryness
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Severe eye pain
or vision impairment
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Monitor for severe
eye pain or visual impairment and stop giving drops immediate if they occur.
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Asacol
400mg tab
PO
twice daily
DO NOT CRUSH
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For GI
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Sensitivity reaction
shown in skin, rash purities alopecia, Interstial nephiritis
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DO NOT CRUSH. Monitor
carefully urinalysis, BUN and creatinine, especially in patients with preexisting
kidney disease. The kidney is the major target organ for toxicity. Assess for S&S
of allergic type reactions e.g. hives itching wheezing anaphylaxis. Expect response
to therapy within 3-21 days.
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Caltrate
Calcium with vitamin
D
600mg tab
1 tab
PO
daily
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For supplement
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Constipation or
laxative effect, acid rebound. Hypocalcaemia with alkalosis, metastatic calcinosis,
hypercalciuria, hypomagnesemia, hypophosphatemia.
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Note number and
consistency of stools. If constipation problem inform physician may be given with
magnesium antacid. Determine serum and urine calcium weekly in patients receiving
prolonged therapy and in patients with renal dysfunction. Record amelioration of
symptoms of hypocalcaemia. Observe for S&S of hypocalcaemia in patients receiving
frequency or high doses.
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Cozaar
50mg tab
1 tab
PO
at bedtime
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For HTN. Hold if
BP less than 130/70
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Dizziness Insomnia,
Myalgia, back or leg pain. Nasal congestion, cough, Upper respiratory infection,
sinusitis.
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Monitor BP at drug
trough(prior to a scheduled dose) Monitor drug effectiveness, especially in African
Americans. Monitor CBC, electrolytes, liver and kidney function with long term therapy.
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Cyanocobalamin
1000mcg/1mL vial
injection IM
6th of
every month
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For dementia
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Anaphylactic shock,
sudden death. Peripheral vascular thrombosis (she has PVD should she take this med?)
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Monitor potassium
levels risk for hyokalemia and sudden death. Monitor vital signs in patient, look
for S&S of pulmonary edema.
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Folic Acid
1 mg tab
1 tab
PO
once daily
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For dementia
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fever, general weakness
or discomfort, reddened skin, shortness of breath, skin rash or itching, and wheezing
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Monitor for hypersensitivity
to folic acid.
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Mucinex DM 600
130 mg tab
Give 1 tab
PO
every twelve hours
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COPD
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Nausea and Drowsiness
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DO NOT CRUSH. Persistent
cough may indicate a serious condition requiring further diagnostic work. Notify
physician if high fever rash or headache develops.
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Namenda
5 mg tab
1 tab
PO
at bedtime
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For dementia
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Fatigue pain flu
like symptoms, peripheral edema. TIA, ataxia, vertigo
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Monitor respiratory
and CV status, especially with preexisting heart disease. Assess for and report
S&S of focal neurological deficits. DO periodic Hct and Hgh, serum sodium,
alkaline phosphatase and blood glucose.
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Paroxetine
20mg tab
Give 1 tab
PO
daily
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Depression
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Postural Hypotension,
Urinary hesitancy, Isolated reports of elevated liver enzymes. Headache, weakness,
sedation, dizziness, insomnia, nausea, constipation, diarrhea, dry mouth, sweating,
male ejaculatory disturbance.
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Monitor for worsening
of depression or emergencies of suicidal ideation. Monitor for adverse effects which
include headache, weakness, sedation, dizziness, insomnia, nausea, constipation,
diarrhea, dry mouth, and sweating, male ejaculatory disturbance. Monitor older adults
for fluid imbalances. Monitor for suicidal ideation. Monitor for significant weight
loss.
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Seroquel
25 mg tab
Give 2 tab 50 mg
Po
at bedtime
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For Dementia with
psychosis.
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Asthenia, fever,
hyertonia, dysarthria, flu syndrome, weight gain, peripheral edema.
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Monitor for changes
in behavior that indicate suicidality. Reassess need to continued treatment periodically.
Withhold drug and immediately report S&S of tardive dyskinesia or neuroleptic
malignant syndrome. Monitor ECG especially if have known cardiovascular disease.
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