Quality and Safety Education for Nurses



Patient Information Sheet Patient Name: Elenaor Simulo Age 85 DOB 8/14/23 Gender femaleAdmitting Diagnosis: Altered mental status, abdominal pain R/O UTI, R/O diverticulitisReason for Hospitlization: Sudden change in mental status, weakness, chills ,nausea and abdominal pain Medical History: CHF, MI , Hypertension , Type 2 DM, urinary retention , dementia, CVA , dysphagia diverticulosis Height 5 “ 2” Weight 99 lb Physician: Sim Feelbetter MD Advanced Directive: at daughter’s home The patient was recently hospitalized 10 days ago for management of CHF and urinary retention. She was discharged to a subacute facility with a Foley catheter and G tube. The Foley catheter is now draining a moderate amount of cloudy foul smelling urine with clumps of sediment Pre admission medicationsDigoxin 0.125 mg PO daily Colace 100 mg PO dailyAtenolol 25 mg PO dailyLasix 20 mg PO dailyEnalapril 2.5 mg PO dailyGlucophage 500 mg PO BIDASA 81 mg PO dailyER AssessmentAlert and oriented X 1 ( person only) B/P 118/ 72 Pulse 84S1 S2 regular rhythmResp 16Sa O2 96 %Lungs clearFoley drained 200 ml of cloudy urine with sedimentAbd soft , non-distendedAdmission MD orders-Admit to Medical Service ( Dx: altered mental status, R/O UTI, R/O diverticulitis )-Digoxin 0.125 mg PO daily (hold until dig level available) -Colace 100 mg PO daily-Atenolol 25 mg PO daily-Lasix 20 mg PO daily-Enalapril 2.5 mg PO daily-ASA 81 mg daily-Tylenol 650 mg PO q 6 hrs PRN for pain or fever over 101-Levaquin 500 mg IVPB daily-IV 0.45 % NS @ 80 ml/hr-I & O-Vital Signs and SaO2 q 4 hrs -Telemetry-Change Foley Catheter -Jevity @ 50 ml /hr via G Tube-Alternating pressure mattressMD orders : Diagnostic testsChest XRay EKG CBC , Complete Metabolic panel, Hgb A1 C , BNP , Digoxin level (all done in ER) CT of the Abdomen with ContrastUrinalysisUrine for Culture and Sensitivity Social HistoryOccupation: retired seamstressLived with daughter and her family prior to last hospital admissionCurrently admitted from subacute facilityRace: CaucasianReligion: Roman CatholicCulture: Italian Smoking noneETOH hx. occasional glass of wine Safety:Fall Precautions YesAlternating Pressure Mattress Braden score on admission (12) and every three days Aspiration Precautions YesADL Full AssistDischarge Planning /Learning needsDaughter may not be able to care for patient at homeInvolve family in discharge planningExplain all procedures to patientTeach daughter rationale for all care ................
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