Skin/Wounds: (Skin turgor; presence of any skin breakdown; incisions; wounds.) Subjective: patient denies any skin breakdowns. Objective: leg skin is shiny and has several enlarged veins, otherwise, skin is pale and evenly pigmented, no lesions or excoriations, good turgor. Nails are light pink, adhere to nail bed with 160-degree angle. Hair is grey, shiny and full; amount and distribution Activity Level: walker Fall risk assessment: 11 (High risk) Oxygen: room air Side rail status: X2 Call light status: within reach Pressure ulcer risk: 24 (No risk)
Medications (Include only prn’s that you administer) Name (generic/trade) Dosage Route Frequency Administration times Atrovent (Ipratropium bromide) 0.5 mg/2.5 mL HHN q.4.h. 0700 1100 Ventolin (Albuterol sulfate) 2.5mg/3mL HHN q.4.h. 0700 1100 Zofran (Ondansentron) 4mg/2mL IV q.4.h. prn 0805 Ranolazine (Ranexa) 1,000 mg PO BID 0800 Ditropan (oxybutuin chloride) 5 mg PO BID 0800 Imdur (Isosorbide mononitrate) 30 mg (2 tabs) PO Daily 0800 Prednisone (Orazone) 20 mg PO Daily 0800 Norco (Hydrocodone acetaminophen) 325 mg PO q.4.h. 0800 Ditropan (Oxybutynin) 5 mg PO TID 1230 Neurontin (Gabapentin) 300 mg (2 caps) PO q.8.h. 1230
Intravenous Fluids Time Solution Rate Amt in bag Site Bag change due/time hung Tubing type N/A NONE N/A N/A N/A N/A N/A
Pertinent Lab & Diagnostic Test Results Test Result
INR 5.0 (H)
PT 54.3 (H)
X-ray Mild cardiomegaly
PSYCHOSOCIAL/CULTURAL: Primary & secondary languages: English. Religious beliefs/spirituality/values: Christian. Marital status: married. Family/support system: husband, brother, friends. Home/housing status: lives with her husband and
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