Nursing Generic Patient Report Paper.

Stratford University School of Nursing Generic Patient Report Form NSG 240/315/430 (Attachment 2) Student Name _________________________________ Date________________________________ Healthcare Facility Age Primary Language Room/bed Gender Female Male No CPR Advance Directive Full Code No Code Meds Only Precaution Contact C-diff Standard Other Enteric Droplet Fall Neutropenic Airborne Aspiration Primary Admitting Diagnosis Secondary Diagnoses Allergies Vital Signs Time Time BG Blood pressure Location /position Heart Rate Respiratory Rate Temperature /route SpO2 Oxygen delivery NEURO Orientation Person Place Disoriented Verbal Time Situation Non Verbal Strength LUE RUE LLE RLE Behavioral/Emotional Moves Well Upon Request Calm/cooperative Weak Movement Upon Request Restless Moves Well When Stimulated Combative Weak Movement When Stimulated Confused No Movement Agitated Hearing Normal Loss Hearing aid Eyes PERRLA Drainage Glasses Dentures Full Partial Upper Lower CARDIOVASCULAR RATE Heart Sounds S1S2 Regular Irregular Capillary Refil < 3 sec >3 sec absent Pulses

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Check one per column RATE ALL LUE RU E L L E S3 S4 Edema RLE AL LU L E Absent Absent Intermittent Trace +1 1+ +2 2+ +3 3+ Bounding 4+ Non pitting Pitting RESPIRATORY Murmur RU E LL RLE E RUL LU L L L L RM L RLL Rate Clear Additional comments Rales Crackles Rhonchi Wheeze Diminished Respiratory symptoms cough nonproductive productive Sputum 🡪 SOB hypoventilating hyperventilating cyanosis Dyspnea Nasal drainage Use of accessory muscle other GI Bowels sounds ALL LU Q RU Q RLQ LLQ GI Symptoms Present Constipation Hypoactive Diarrhea Hyperactive Abd pain Absent Flatulence Incontinence Distention Bloody stool Tenderness GU Urinary Symptoms Urine color Character Elimination Dysuria yellow clear Voiding w/o difficulty Frequency amber cloudy Voiding with difficult Oliguria orange concentrated Indwelling catheter Polyuria brown sediment Inability to void Anuria red bloody Condom catheter Incontinence pink clots Suprapubic catheter Hematuria odor Urostomy Nephrostomy tube Dialysis Ileal conduit Output Intake Diet NPO Anorexia Nausea Tolerate Dysphagia Other🡪 Vomiting IV lines INTEGUMENTARY Sensory Perception Nutrition Activity Mobility Completely limited Poor Bedrest intact complete immobile Very limited inadequate OOB to chair redden limited Slightly limited Adequate BRP No impairment Excellent Ambulate no limitations Bruises Lesions Masses Wounds 🡪 MUSCULOSKELETAL pain Pain Scale Devices swelling location walker stiffness onset cane contractures duration deformities frequency weakness Aggravating factor amputation Alleviating factor fractures Quality cast ALL LUE RUE LLE RLE Muscle strength Full ROM Impaired ROM LABS Pt Results High/low Reason for abnormality Diagnostic tests /results SBAR Communication Worksheet This is not part of the medical record Patient Initials: ______________ Patient Date of Birth: _______________________________ Room Number _______________ Date: _________________ Time: ________________ Location: _____________________________________________ Pre-call preparation: Gather the following information: Patient’s name; age; chart. Rehearse in your mind what you plan to say. Run it by another nurse if unsure. If calling about pain, when and what was last pain medication? If calling about fever, what was the most recent temperature? If calling about an abnormal lab, what was the result of the last test? What is the goal of your call? Remember to start by introducing yourself by name and location. Use area below as a checklist to gather your thoughts and prepare. Situation: Briefly describe the current situation. Give a clear, succinct overview of pertinent issues : ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ B ackground: Briefly state the pertinent history. What got us to this point?: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ A ssessment: Summarize the facts and give your best assessment. What is going on? Use your best judgement: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ R ecommendation: What actions are you asking for? What do you want to happen next? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Follow-up Action (Next Steps): Document the call and “read back” orders to ensure accuracy. Is there a change in the plan of care? Yes No ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ List of Problems can be actual, risk or potential with supporting subjective or objective data Nursing Diagnosis with supporting objective/subjective data Goal with expected outcome should be (S specific, M measurable, A achievable, R reality based, T time oriented) Nursing actions to meet goals 1. Rational for each nursing action (EBP) 2. Evaluation of outcome Educational Nursing Diagnosis with supporting objective/subjective data Goal with expected outcome should be (S specific, M measurable, A achievable, R reality based, T time oriented) Nursing actions to meet goals 1. 2. Evaluation of outcome Rational for each nursing action (EBP) Stratford University School of Nursing Medication Administration Record NSG 240/245/ 430 (Attach I have confirmed I have the right patient, drug, dose, If not administered, route, and time. Select a reason for not administering I have completed my THREE checks (i.e. medication safety retrieved/pulled, when I am preparing/pouring the medication, and right before I give the medication to the patient) Patient Secondary ID Check Medication /classification Full name 1 Refused 2 NPO 3 Nauseated 4 Unable to swallow 5 Off unit 6 Wasted/ Dropped 7 Drug not available 8 Other Birth Date Dosage /route/ Reason for frequency administration Q Nursing consideration/ Side effects Administer Not Administer Enter code Student Name __________Christiana_____Ajakaye__________________ Date____09/302/21____________________________ Healthcare Facility Inova Alexandria Room/bed Age: 60 Primary Language English Gender Female Male No CPR Advance Directive Full Code No Code Meds Only Precaution Contact C-diff Standard Other Enteric Droplet Fall Neutropenic Airborne Aspiration Primary Admitting Diagnosis Abdominal Wall Abscess: Abdominal wall abscess are localized collections of pus that are confined in the peritoneal cavity by an inflammatory barrier. The barrier may include the omentum, inflammatory adhesions, or contiguous viscera, The abscesses usually contain a mixture of aerobic and anaerobic bacteria from the gastrointestinal (GI) tract. Past Medical History Type 2 diabetes controlled diet, Right breast cancer, Bipolar, Asthma, Hyperthyroidism, Lymphedema, Schizoaffective disorder, Neuropathy feet chemo related, Weak heart, Hormone disorder, Diverticulosis, Depression, Claustrophobia, Hypertensive disorder, Diverticulitis. Allergies Lyrica, Tramadol, Clonazepam, Seroquel, Adhesive wound dressing adhesive) band-aids Vital Signs Time: 10:00am Blood pressure 120/79 Location /position right feet/Lying because of Lymphedema on her right arm BP was taken on her feet Heart Rate 77 Respiratory Rate 19 Temperature /route 97 orally SpO2 98% Oxygen delivery Room air Time BG NEURO 1 Orientation Person (Oriented): The patient states her name and date of birth correctly and matches her wrist band Place (Oriented): Patient states that she is at the Inova Alexandria. Disoriented Time (Oriented): Patient states the date and time correctly. Situation: (Oriented): Patient explained why she came for treatment. Verbal Non Verbal Patient is verbal. Speech is normal and clear to understand.

Strength LUE RUE LLE RLE Behavioral/Emotional Moves Well Upon Request Patie nt was able to move her hand as reque sted. Patient was able to move her left leg upon request . Patie nt move s well upon reque st Patient moves her hands well as request er but affecte d by lymphe dema. Calm/cooperative: Patient is calm and cooperative. Answered all question asked appropriately Weak Movement Upon Request Restless Moves Well When Stimulated Combative Weak Movement When Stimulated Confused No Movement Agitated Hearing Normal (No hearing aid): She answered all question, no difficulty hearing. Eyes PERRLA: Pupils are equal, round, reactive to light and accommodation. Drainage: No discharge or drainage. Dentures Full Partial No denture Upper CARDIOVASCULAR Hearing aid Glasses: Patient does not wear glasses or contact. Lower RATE 2 Heart Sounds S1S2 Regular Irregular Capillary Refill < 3 sec. Minor pressure was put on nailbed it was pink in color and return in less than 2sec after pressure was removed. >3 sec absent Pulses RATE Check one per column ALL LUE RU E L L E RLE 77 Absent X x x X x Murmur S3 S4 Murmur is heard on the left side of the heart anterior Edema AL LU L E RU E LL RLE E Present in Absent all extremitie s. Intermittent Trace +1 1+ +2 2+ +3 3+ Bounding 4+ Non pitting Ede ma pres ent on the righ t arm Pitting RESPIRATORY 3 Clear RUL LU L L L L RM L RLL Rate X X x x X 19 Additional comments Rales Crackles Rhonchi Wheeze Diminished Respiratory symptoms Cough nonproductive productive Sputum 🡪 Patient is not coughing. SOB Hypoventilating hyperventilating cyanosis Not using of accessory muscle Dyspnea Nasal drainage other GI Bowels sounds ALL LU Q RU Q RLQ LLQ GI Symptoms Present X X x x x Constipation Hypoactive X x x x x Diarrhea Hyperactive Abd pain: Patient rated pain 5 on a scale of 0-10. She has abdominal binder in place Absent Flatulence Incontinence Distention Bloody stool Tenderness No distention or tenderness. Bowel sound was heard in all four quadrant.

The sound heard was hypoactive because patient had surgery done in June, debridement in sept 23rd and wound closure sept 29th GU 4 Urinary Symptoms Urine color Character Elimination Dysuria Yellow clear Voiding w/o difficulty: Patient can walk to the bathroom without assist. No hematuria or dysuria Frequency Amber cloudy Voiding with difficult Oliguria Orange concentrated Indwelling catheter Polyuria Brown sediment Inability to void Anuria Red bloody Condom catheter Incontinence Pink Clots Suprapubic catheter Odor Urostomy Hematuria Nephrostomy tube Dialysis Ileal conduit Output Intake Diet IV lines Patient NPO Anorexia Nausea Vomiting Tolerate Dysphagia Other🡪 She is on heart healthy diet bur states she preferred to be drinking lemonade for now Patient has 22 gauge on her right upper arm. Saline lock. The site is intact, no swelling, redness. No infiltration or phlebitis. INTEGUMENTARY Sensory Perception Nutrition Activity Mobility Completely limited Patient she does not have good appetite. Bedrest: Intact complete immobile Very limited Inadequate OOB to chair redden Limited Slightly limited Adequate BRP: Patient walks to the No limitation 5 bathroom by herself No impairment Excellent Ambulate: . Bruises No bruises on patient skin Lesions No lesions Masses No masses Wounds 🡪 Abdominal wound with right and left JP drains; serosanguinous drainage. JP drain 10 mL on left and 30 mL on the right. MUSCULOSKELETAL pain Pain Scale: 5 Swelling Location Stiffness Onset Contractures Duration Deformities Frequency Weakness Aggravating factor amputation Alleviating factor When supported lying in bed Fractures Quality Patient states it is shooting pain Cast Devices On the abdomen Walker Cane Patient wear no cast. ALL LUE RUE LLE RLE Muscle strength x X X x x Full ROM x X X x x Impaired ROM x x x x x LABS Pt Results High/low Reason for abnormality WBC 7.92 normal Normal range 4.5-11.

WBC are immune system cells that protect the body against diseases and foreign invaders like bacteria, viruses, and germ. When there is an invader, the number increase to fight the infection. Patient value is normal 6 Hemoglobin 8.3 Low Hgb Normal range Men: 13.5 to 17.5 grams per deciliter, for women: 12.0 to 15.5 grams per deciliter. Hbg is a protein in red blood cells that carries iron, this iron holds oxygen, making hemoglobin an essential component of the blood. Low Hgb levels lead to anemia which causes symptoms like fatigue and trouble breathing. Patient level is low because of breast cancer. Hematocrit 27.4 Low Hematocrit normal range for men 41% to 50% and women ranges from 36% to 48%. This test is done to check for proportion of red blood cells. Hct can tell if someone is anemic, too many or too few red blood cells can indicate certain nutritional deficiencies or diseases. Patient level is low because is anemic as result of disease process Platelet count 363 normal Normal platelet count ranges from 150,000 to 450,000 platelet per microliter of blood. When it is lower than 150,000 platelets patient is said to have thrombocytopenia and when is more than 450,000 platelets is a condition called thrombocytosis. Patient level is normal RBC 3.13 Low Normal RBC count for men is 4.7 to 6.1 million cells/mcl and women 4.2 to 5.4 million cells/mcl. Red blood cells are cells that circulate in the blood and carry oxygen throughout the body.

RBCs make up to about 40% of the blood volume. RBCs contain hemoglobin, a protein that binds to oxygen and enables RBCs to carry oxygen from the lungs to the tissues and organs of the body. When RBC is low in the body, it may implies that some vitamins like B6,B12 or folate are deficient or there is a bleeding, overhydration, kidney disease or pregnancy. A high RBC count tells that there has been an increase in oxygencarrying cells in the blood. In some cases, it may indicate that the body is compensating for some condition that is depriving the body oxygen, in others, the 7 cause may be related to diseases or drugs that alter the production of RBCs. BUN 7.0 normal Normal BUN levels: Adult men 8 to 24 mg/dl, women: 6 to 21 mg/dl. Blood urea nitrogen (BUN) test is used to determine how well your kidneys are working. It does this by measuring the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that is created in the liver when the body breaks down proteins. BUN levels tend to increase when the kidneys or lever are damaged. Having too much urea nitrogen in the blood can be a sign of kidney or lever problem.

Patient level is normal Glucose 74 Normal Glucose is a test that it is done to identify blood glucose level and diabetic in a patient. A blood sugar level less than 130 and greater than 70 is normal. Patient level is normal Creatinine 0.8 Normal A creatinine test is a measure of how well your kidneys are performing their job of filtering waste from the blood. An increased level of creatinine may be a sign of poor kidney function. Normal range for adult men: 0.74 to 1.35 mg/dl. For adult women: 0.59 to 1.04 mg/dl .Patient level is normal Cholesterol Triglyceride Total cholesterol levels less than 200 milligrams per deciliter are considered desirable for adults. A reading between 200 and 239 mg/dl is borderline and a reading of 240 mg/dl and above is considered high. 149 Normal Normal less than 150 milligrams per deciliter. Triglycerides stores unused calories and provide your body with energy. Nursing Generic Patient Report Paper.

High triglycerides may contribute to hardening of the arteries or thickening of the 8 LDL 90 Normal Potassium 3.8 Normal Sodium 140 Normal artery walls which increases the risk of stroke, heart attack and heart disease. Patient value is normal Low-density lipoproteins levels should be less than 100 mg/dl. It is also called bad cholesterol because it collects in the walls of the blood vessels raising chances of health problems like heart attack or stroke. Normal range 3.5 to 5.0. It is an electrolyte that helps the nerve to function and muscles to contract. It also helps the heartbeat to stay regular. The normal value ranges from 135145. The test is done to check the fluid volume. When the volume is high in the blood. It is called hypernatremia and low is hyponatremia. Patient value is normal Diagnostic tests /results CT of The Abdomen and Pelvis with Contrast FINDINGS:

9 Clinical History: 60 year old woman, history of DIEP flap, abdominal seroma Visualized portions of the lower lung fields. Unremarkable Technique: Multidetector axial CT images of the abdomen and pelvis were obtained after the uneventful administration of 100 mL Omnipaque 350 intravenous contrast. Oral contrast was administered. Nursing Generic Patient Report Paper.

Sagittal and coronal reconstructions were obtained. The following dose reduction techniques were utilized: automated exposure control and/or adjustment of the mA and/or kV according to patient size, and the use of iterative reconstruction technique. Liver: Normal in size, contour, and attenuation. Gallbladder: Status post cholecystectomy. Pancreas: Normal in size, contour, and attenuation. Adrenals: Normal in size, contour, and attenuation. COMPARISON: CT of the abdomen and pelvis performed 01/21/2020 SBAR Communication Worksheet This is not part of the medical record Patient Initials: __L.M___________ Patient Date of Birth: __12/17/1960_____________________________ Room Number ___31____________ Date: __09/30/2021_______________ Time: __12pm____Inova Alexandria__________ Location: _____________________________________________ Pre-call preparation: Gather the following information: Patient’s name; age; chart. Rehearse in your mind what you plan to say. Run it by another nurse if unsure. If calling about pain, when and what was last pain medication? If calling about fever, what was the most recent temperature? If calling about an abnormal lab, what was the result of the last test? What is the goal of your call? Remember to start by introducing yourself by name and location. Use area below as a checklist to gather your thoughts and prepare. Situation: Briefly describe the current situation. Give a clear, succinct overview of pertinent issues : _______Hello Dr, Mich this is nurse Xty calling from Inova North 4.

The reason for my call is to inform you that Ms. L.M your patient in room 31 is complaining of pain around the abdominal area. She states that the pain persists at the site of previous seromas, located to the right to midline and rated pain 5 out of 10 on the scale of 0 to 10, ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________ B ackground: Briefly state the pertinent history. What got us to this point?: ______Ms. L.M is 60 year old female who presents for percutaneous drainage and possible drain placement of abdominal wall seroma versus abscess status post bilateral mastecomies with DIEP flap reconstruction on 6/15/2021. Patient has been seen by Dr. Gab and has had multiple drainage abdominal wall seroma. 10 CT abdomen pelvis perfomed on 9/17/2021 demonstrated persistent abdominal wall seroma and patient sent for elective drain placement. She states that since 9/17/21 she has experienced fevers and lethargy. Last fever was yesterday evening and was 103.6 F.

She has been taking Tylenol which helped in controlling the fever. Patient denies any antiplatelet or anticoagulant use. Denies current chest pain, shortness of breath, dysuria, cough. She is on 2 antibiotics but does not know the name._______________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ _________________________________________________________________________________________________________ A ssessment: Summarize the facts and give your best assessment. What is going on? Use your best judgement: _____Ms T.J vital signs are BP 120/79, Temp 97 F Pulse 77 Resp 19 oxygen saturation 98 room air. Her H & H are low with hemoglobin 8.3 and hematocrit 27.4 She has 22 gauge in eight upper arm and saline lock, no redness, infiltration or phlebitis, sinus rhyme, no accucheck, she wears abdominal binder , She is bathroom privilege with minimal assist and JP drainage in place with Right 30 mL and Left 10 mL.________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________ R ecommendation: What actions are you asking for? What do you want to happen next? __I would recommend will continue to monitor her labs, control her pain, at adequate level as identified by patient, prevent fall and infection during her hospital stay. Is there anything you would like me to do?_________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Follow-up Action (Next Steps): Document the call and “read back” orders to ensure accuracy. Is there a change in the plan of care? Yes No ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ List of Problems can be actual, risk or potential with supporting subjective or objective data Risk for infection related to abscess formed at the abdominal cavity as evidenced by collection of pus in the peritoneum. Acute pain related to trauma to tissues as evidenced by patient verbalization of pain on the abdomen and rated pain 5 out of 10 Nursing Diagnosis with supporting objective/subjective data Risk for infection related to abscess formed at the abdominal cavity as evidenced by collection of pus in the peritoneum. 11 Goal with expected outcome should be (S specific, M measurable, A achievable, R reality based, T time oriented)

• Patient will be able to avoid the development an infection during her hospital stay Nursing actions to meet goals Rational for each nursing action (EBP) 1. Assess vital signs observe for any signs of To assess for the evidence of ongoing infection. Sepsis or infection of the blood may develop from peritonitis, and can be evidenced by fever accompanied by respiratory distress. infection as well as for signs of respiratory distress, and gastrointestinal problems such as diarrhea, nausea, and vomiting. 2. Perform a focused assessment on the abdominal region, particularly checking for Peritonitis is a serious complication of pancreatitis, diverticulitis, trauma, liver disease, or kidney disease. Nursing Generic Patient Report Paper.

It is evidenced by abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness. pain, abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness. 3. Administer antibiotics as prescribed To treat the underlying infection with broad spectrum antibiotics, then switch with the type of antibiotics to which the causative bacteria are sensitive. Nursing Generic Patient Report Paper.

This is also done to prevent the risk of developing sepsis in patient with peritonitis. Evaluation of outcome Goal met. Patient was free from infection at during hospital and was discharge with no infection Educational Nursing Diagnosis with supporting objective/subjective data Deficient knowledge related to how past medical history of diverticulitis caused present illness of abdominal wall abscess as evidenced by patient inaccurate follow through of instruction. Nursing Generic Patient Report Paper.

Goal with expected outcome should be (S specific, M measurable, A achievable, R reality based, T time oriented) Patient will identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors during my 12 hour shift Nursing actions to meet goals Rational for each nursing action (EBP) 12 1. Nursing Generic Patient Report Paper.

Review underlying disease process and Provides knowledge base from which patient can make informed choices. recovery expectations 2. Identify signs and symptoms requiring Early recognition and treatment of developing complications may prevent more serious illness and injury. medical evaluation: recurrent abdominal pain and distension, vomiting, fever, chills or presence of purulent drainage, swelling, erythema of surgical incision. 3. Demonstrate aseptic dressing change, Reduces risk of contamination. Provides opportunity to evaluate healing process. wound care. Evaluation of outcome Goal met. Patient verbalized understanding of how her history diverticulitis caused her present diagnosis of abdominal wall abscess. 13 Stratford University School of Nursing Medication Administration Record NSG 240/245/ 430 (Attach I have confirmed I have the right patient, drug, dose, If not administered, route, and time. Select a reason for not administering I have completed my THREE checks (i.e. medication safety retrieved/pulled, when I am preparing/pouring the medication, and right before I give the medication to the patient) Patient Secondary ID Check Full name 1 Refused 2 NPO 3 Nauseated 4 Unable to swallow 5 Off unit 6 Wasted/ Dropped 7 Drug not available 8 Other Birth Date Medication /classification Dosage /route/ Reason for frequency administration Nursing consideration/ Side effects Administer Acetaminophen(Tylen ol)/Analgesics 500 To relieve mg/oral/every 6 pain/fever hours scheduled Nursing consideration: Do not exceed 4g of acetaminophen per day to limit risk for liver, renal, and cardiac damage Administer ed Not Administer Enter code Side Effect: Nausea, stomach pain, loss of appetite, dark urine, claycolored stools or jaundice. Acyclovir(Zovirax) capsule/Antivirals 200 mg/oral/daily Used to decrease pain and speed the healing of sores or blisters in people who have varicella(chickenp ox), prophylaxis for genital herpes simplex Nursing consideration: Monitor for signs and symptoms of reinfection in pregnent patients. Acyclovir induced neurologic symptoms in patients with history of neurologic problems; drug resistance in immunocompromised patient receiving prolonged or repeated therapy; acute

Administer ed 14 renal failure with concomitant use with other nephrotoxic drugs or preexisting renal disease. Side Effects: Malaise, nausea, headache, abdominal pain, diarrhea. Carvedilol(Coreg) tablet/Beta blocker 6.25 To treat high Nursing consideration: mg/orally/every blood pressure and Monitor blood pressure and 12 hours heart failure pulse frequently during dose adjustment period and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position Monitor intake and output ratios and daily weight. Side effects:

Tiredness, weakness, lightheadedness, dizziness, nausea, vomiting, diarrhea. Ceftriaxone(Rocephin) 1g : 200 /Cephalosporin mL/hr/intraven antibiotics ous/ every 24 hours It is used to treat infections caused by bacteria, pelvic inflammatory disease. Nursing consideration: Watch for seizures, monitor signs of pseudomembranous colitis, including diarrhea, abdominal pain, fever, pus or mucus in stools and other severe or prolonged GI problems(Nausea, vomiting, heartburn) Side effects: sore throat, shortness of breath, swollen gland, unusual bleeding or bruising, fever, chills, chest pain, black tarry stool. Lactobacillus/streptoco 1 ccus(Risaquad) capsule/oral/dai capsule/Antidiarrhea ly Agent It is a probiotic that is used to help maintain the number of healthy bacteria in the stomach and intestines. Nursing consideration: Monitor CBC periodically during therapy, assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Side effects: Trouble breathing, puffiness or swelling of the eyelids, face, Administer ed Not Adminis tered Administer ed 15 tongue or lips, tightness in the chest, dizziness, cough, fast heartbeat, bloating, flatulence. Levothyroxine(Synthro 50 id)/Thyroid products mcg/orally/dail y at 0600 It is administered to treat an underactive thyroid gland(hypothyroid ism). It is taken to replace the missing thyroid hormone. Nursing consideration: Should be taken on an empty stomach with water, at least 1 hour before eating. Even coffee has been shown to interfere with the absorption of T4. And levothyroxine is incompatible with many other medications, so it should be taken alone. Side effects: Weight gain or loss, headache, fever, changes in appetite, sensitivity to heat, changes in menstrual cycle. Not Adminis tered Mirtazapine(Remeron) 15 mg/oral/at /Antidepressants bedtime

It is given to treat depression Nursing consideration: Assess changes in motor activity or muscle function. Assess dizziness and drowsiness that might affect gait, balance and other functional activities. Report severe or problematic twitching, increased muscle tone, or changes in muscle activity and motor abnormalities(hyperkinesia, hypokinesia) Side effects: Severe sedation, constipation, drowsiness, increased serum cholesterol, weight gain, fatigue, insomnia, and decrease appetite. Not Adminis tered Montelukast(Singulair) 10 mg/oral/at /Leukotriene receptor bedtime antagonists To treat mild asthma and can stop it from getting worst. Nursing consideration: Patient should be instructed to take medications at the same time each day and at least two hours prior to exercise. They should not discontinue medications Not Adminis tered 16 without notifying the provider. Side effect: Upper respiratory infection, fever, headache, sore throat, cough, earache or ear infection, flu, runny nose and sinus infection. Administer ed Polyethylene 17 g/oral/daily glycol(Miralax)/ Nursing Generic Patient Report Paper.

constipation Nursing considerations. Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Assess color, consistency, and amount of stool produced. Advise patient to notify provider if unusual cramps, bloating, or diarrhea occurs. Side effect: Nausea, vomiting, irritation of the rectum, excessive thirst, stomach cramps, abdominal bloating, malaise. Vitamin D(Cholecalciferol)/Vit amin D analogs To maintain proper bone structure. To treat and prevent vitamin D deficiency. Nursing consideration: Adminis Monitor for manifestations tered of hypercalcemia, if hypercalcemia occurs, discontinue. Report fall in serum alkaline phosphatase as this usually signal onset of hypercalcemia. Measure urinary calcium and phosphorus level q24h. Side effects: High blood calcium level, constipation, na

Nursing Generic Patient Report Paper.