Executive Solution Overview
– ## NURSINGASSESSMENT1.docx – ## NURSINGASSESSMENT2.docx – TemplateRelearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx **## NURSINGASSESSMENT1.docx** | | | | | | | | | — | — | — | — | — | — | — | | **NURSING ASSESSMENT & NOTES** | | 4/5 1105 | **Nursing Note:** Resp…
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– ## NURSINGASSESSMENT1.docx
– ## NURSINGASSESSMENT2.docx
– TemplateRelearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx
**## NURSINGASSESSMENT1.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **NURSING ASSESSMENT & NOTES** |
| 4/5 1105 | **Nursing Note:** Respiratory therapist unavailable to administer breathing treatment, administered by RN. Lungs before treatment with decreased breath sounds in all fields, wheezes noted, and cough is dry. |
| 4/5 1120 | **Nursing Note:** Lung assessment – increased air movement in upper fields, slight wheezes noted, bases remain decreased. Productive moist cough sputum sample obtained, slight greenish tint. |
| 4/5 1150 | **Nursing Note:** Respiratory therapist at bedside to obtain ABGs. |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 4/5 1015 | 99.6 °F<br>(37.6 °C) | 100 | 24 | 110/62 | 90% | 2L/NC |
| 4/5 1105 | 99.4 °F<br>(37.4 °C) | 106 | 22 | 116/68 | 94% | 2L/NC |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 4/5 1100 | **Prescriptions:**<br>· Albuterol and Ipratropium combination treatment (DuoNeb) x 1 treatment<br>· Arterial Blood Gas<br>· Urinalysis<br>· 2 view chest x-ray<br>· Sputum sample |
| **COLLABORATIVE CARE** |
**## NURSINGASSESSMENT2.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **NURSING ASSESSMENT & NOTES** |
| 3/3 0630 | **Name: Chantel Butler**<br>**Age: 38 years**<br>**Provider: R. Ahart MD**<br>**Allergies: NKA**<br>**Code Status: Full Code**<br>**Admit Wt: 132 lbs (59.8 kg)**<br>**BMI: 21.1**<br>**Nursing Note**: Slurred speech. The client came to the ED with “the worst headache ever.” She has right-sided facial drooping and tingling on the right arm and face. States tingling started several hours ago when she got up to the bathroom. She thought she was “laying funny” and went back to bed. When she got up at 0530, she noticed the facial drooping, and her boyfriend brought her to the emergency department. The slurring of speech began in the car ride to the hospital. |
| 3/3 0640 | **Nursing Note**: Client resting on a stretcher awaiting transport to CT. Denies a change in headache or tingling. Speech continues to be slurred, and facial dropping continues as noted. Labs drawn. |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 3/3 0630 | 98.2 °F<br>(36.8 °C) | 83 | 22 | 172/90 | 98% | RA |
| 3/3 0640 | 98.4 °F<br>(36.9 °C) | 96 | 20 | 174/92 | 99% | RA |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 3/3 0640 | **Prescriptions**:<br> <br>· Code Stroke<br>· Start IV<br>· IV to a saline lock<br>· CT head w/o contrast |
| 3/3 0710 | **Prescriptions**: <br> <br>· MRI- head without contrast |
| **LAB RESULTS** |
| **Date** | **Lab** | **Normal** | **Result** |
| 3/3 0710 | **Complete Blood Count (CBC)** | | |
| | Hemoglobin (Hgb) | 12 – 17 g/dL | 12 |
| | Hematocrit (Hct) | 36% – 51% | 36% |
| | White Blood Cells (WBC) | 4,000 – 10,000 mm3 | 8,500 |
| | Platelets | 150,000 – 350,000 mm3 | 350,000 |
| | Blood Glucose | 70-100 mg/dL | 94 |
| | HCG | Negative | negative |
| | | |
| — | — | — |
| **DIAGNOSTIC TEST RESULTS** |
| **Date** | **Diagnostic Test** | **Findings** |
| 3/3 0710 | CT Scan | inconclusive |
**Client Information**:
**Medical History**:
· Melanoma – left thigh
· Hypertension
· History of gallstones
· Irritable bowel syndrome
**Surgical History**:
· C-section
· Cholecystectomy
· Name: Chantel Butler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
· Admit Wt: 132 lbs (59tler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
59.8 kg)
· BMI: 21.1
· Chantel Butler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
· Admit Wt: 132 lbs (59.8 kg)
· BMI: 21.1
**TemplateRelearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/templaterelearning-clinical-judgment-plan-of-care-template-july243-docx)
**TemplateRelearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/templaterelearning-clinical-judgment-plan-of-care-template-july243-docx)
**## NURSINGASSESSMENT1.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **NURSING ASSESSMENT & NOTES** |
| 4/5 1105 | **Nursing Note:** Respiratory therapist unavailable to administer breathing treatment, administered by RN. Lungs before treatment with decreased breath sounds in all fields, wheezes noted, and cough is dry. |
| 4/5 1120 | **Nursing Note:** Lung assessment – increased air movement in upper fields, slight wheezes noted, bases remain decreased. Productive moist cough sputum sample obtained, slight greenish tint. |
| 4/5 1150 | **Nursing Note:** Respiratory therapist at bedside to obtain ABGs. |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 4/5 1015 | 99.6 °F<br>(37.6 °C) | 100 | 24 | 110/62 | 90% | 2L/NC |
| 4/5 1105 | 99.4 °F<br>(37.4 °C) | 106 | 22 | 116/68 | 94% | 2L/NC |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 4/5 1100 | **Prescriptions:**<br>· Albuterol and Ipratropium combination treatment (DuoNeb) x 1 treatment<br>· Arterial Blood Gas<br>· Urinalysis<br>· 2 view chest x-ray<br>· Sputum sample |
| **COLLABORATIVE CARE** |
**## NURSINGASSESSMENT2.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **NURSING ASSESSMENT & NOTES** |
| 3/3 0630 | **Name: Chantel Butler**<br>**Age: 38 years**<br>**Provider: R. Ahart MD**<br>**Allergies: NKA**<br>**Code Status: Full Code**<br>**Admit Wt: 132 lbs (59.8 kg)**<br>**BMI: 21.1**<br>**Nursing Note**: Slurred speech. The client came to the ED with “the worst headache ever.” She has right-sided facial drooping and tingling on the right arm and face. States tingling started several hours ago when she got up to the bathroom. She thought she was “laying funny” and went back to bed. When she got up at 0530, she noticed the facial drooping, and her boyfriend brought her to the emergency department. The slurring of speech began in the car ride to the hospital. |
| 3/3 0640 | **Nursing Note**: Client resting on a stretcher awaiting transport to CT. Denies a change in headache or tingling. Speech continues to be slurred, and facial dropping continues as noted. Labs drawn. |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 3/3 0630 | 98.2 °F<br>(36.8 °C) | 83 | 22 | 172/90 | 98% | RA |
| 3/3 0640 | 98.4 °F<br>(36.9 °C) | 96 | 20 | 174/92 | 99% | RA |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 3/3 0640 | **Prescriptions**:<br> <br>· Code Stroke<br>· Start IV<br>· IV to a saline lock<br>· CT head w/o contrast |
| 3/3 0710 | **Prescriptions**: <br> <br>· MRI- head without contrast |
| **LAB RESULTS** |
| **Date** | **Lab** | **Normal** | **Result** |
| 3/3 0710 | **Complete Blood Count (CBC)** | | |
| | Hemoglobin (Hgb) | 12 – 17 g/dL | 12 |
| | Hematocrit (Hct) | 36% – 51% | 36% |
| | White Blood Cells (WBC) | 4,000 – 10,000 mm3 | 8,500 |
| | Platelets | 150,000 – 350,000 mm3 | 350,000 |
| | Blood Glucose | 70-100 mg/dL | 94 |
| | HCG | Negative | negative |
| | | |
| — | — | — |
| **DIAGNOSTIC TEST RESULTS** |
| **Date** | **Diagnostic Test** | **Findings** |
| 3/3 0710 | CT Scan | inconclusive |
**Client Information**:
**Medical History**:
· Melanoma – left thigh
· Hypertension
· History of gallstones
· Irritable bowel syndrome
**Surgical History**:
· C-section
· Cholecystectomy
· Name: Chantel Butler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
· Admit Wt: 132 lbs (59tler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
59.8 kg)
· BMI: 21.1
· Chantel Butler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
· Admit Wt: 132 lbs (59.8 kg)
· BMI: 21.1
**TemplateRelearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/templaterelearning-clinical-judgment-plan-of-care-template-july243-docx)
**## NURSINGASSESSMENT1.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **NURSING ASSESSMENT & NOTES** |
| 4/5 1105 | **Nursing Note:** Respiratory therapist unavailable to administer breathing treatment, administered by RN. Lungs before treatment with decreased breath sounds in all fields, wheezes noted, and cough is dry. |
| 4/5 1120 | **Nursing Note:** Lung assessment – increased air movement in upper fields, slight wheezes noted, bases remain decreased. Productive moist cough sputum sample obtained, slight greenish tint. |
| 4/5 1150 | **Nursing Note:** Respiratory therapist at bedside to obtain ABGs. |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 4/5 1015 | 99.6 °F<br>(37.6 °C) | 100 | 24 | 110/62 | 90% | 2L/NC |
| 4/5 1105 | 99.4 °F<br>(37.4 °C) | 106 | 22 | 116/68 | 94% | 2L/NC |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 4/5 1100 | **Prescriptions:**<br>· Albuterol and Ipratropium combination treatment (DuoNeb) x 1 treatment<br>· Arterial Blood Gas<br>· Urinalysis<br>· 2 view chest x-ray<br>· Sputum sample |
| **COLLABORATIVE CARE** |
**## NURSINGASSESSMENT2.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **NURSING ASSESSMENT & NOTES** |
| 3/3 0630 | **Name: Chantel Butler**<br>**Age: 38 years**<br>**Provider: R. Ahart MD**<br>**Allergies: NKA**<br>**Code Status: Full Code**<br>**Admit Wt: 132 lbs (59.8 kg)**<br>**BMI: 21.1**<br>**Nursing Note**: Slurred speech. The client came to the ED with “the worst headache ever.” She has right-sided facial drooping and tingling on the right arm and face. States tingling started several hours ago when she got up to the bathroom. She thought she was “laying funny” and went back to bed. When she got up at 0530, she noticed the facial drooping, and her boyfriend brought her to the emergency department. The slurring of speech began in the car ride to the hospital. |
| 3/3 0640 | **Nursing Note**: Client resting on a stretcher awaiting transport to CT. Denies a change in headache or tingling. Speech continues to be slurred, and facial dropping continues as noted. Labs drawn. |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 3/3 0630 | 98.2 °F<br>(36.8 °C) | 83 | 22 | 172/90 | 98% | RA |
| 3/3 0640 | 98.4 °F<br>(36.9 °C) | 96 | 20 | 174/92 | 99% | RA |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 3/3 0640 | **Prescriptions**:<br> <br>· Code Stroke<br>· Start IV<br>· IV to a saline lock<br>· CT head w/o contrast |
| 3/3 0710 | **Prescriptions**: <br> <br>· MRI- head without contrast |
| **LAB RESULTS** |
| **Date** | **Lab** | **Normal** | **Result** |
| 3/3 0710 | **Complete Blood Count (CBC)** | | |
| | Hemoglobin (Hgb) | 12 – 17 g/dL | 12 |
| | Hematocrit (Hct) | 36% – 51% | 36% |
| | White Blood Cells (WBC) | 4,000 – 10,000 mm3 | 8,500 |
| | Platelets | 150,000 – 350,000 mm3 | 350,000 |
| | Blood Glucose | 70-100 mg/dL | 94 |
| | HCG | Negative | negative |
| | | |
| — | — | — |
| **DIAGNOSTIC TEST RESULTS** |
| **Date** | **Diagnostic Test** | **Findings** |
| 3/3 0710 | CT Scan | inconclusive |
**Client Information**:
**Medical History**:
· Melanoma – left thigh
· Hypertension
· History of gallstones
· Irritable bowel syndrome
**Surgical History**:
· C-section
· Cholecystectomy
· Name: Chantel Butler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
· Admit Wt: 132 lbs (59tler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
59.8 kg)
· BMI: 21.1
· Chantel Butler
· Age: 38 years
· Provider: R. Ahart MD
· Allergies: NKA
· Code Status: Full Code
· Admit Wt: 132 lbs (59.8 kg)
· BMI: 21.1
**TemplateRelearning_Clinical_Judgment_Plan_of_Care_Template_July243.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/templaterelearning-clinical-judgment-plan-of-care-template-july243-docx)
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