Mike Murphy     DOB 7/6/59                       Medical record 0001234123     

Mike Murphy     DOB 7/6/59                       Medical record 0001234123                                                                   Admitting physician: Dr. DooleAllergies: penicillinHeight 6’2″ Weight 189 lbs. Home Medications: Aspirin 81 mg po q day                                               Digoxin 0.25mg po q day                                Benazepril HCL 20 mg po BID             Metoprolol 50 mg po BID  Hydrochlorothiazide 25 mg po q am              Klor-Con 8 mEq po q day Mike Murphy, a 62-year-old white male, presented to the emergency department with altered mental status. He has a past medical history of hypertension, and mild congestive heart failure which have been well controlled with medication and diet. Vital signs: temp 102.8, BP 94/66, P- 98, R-24, and O2 Sat 97%. Examination and labs indicated UTI and Sepsis.  Mike Murphy was admitted to PCU yesterday at 1800. VS at Midnight temp 101.8, BP 110/78, P- 90, R-22, and O2 Sat 98 %VS at 0400 temp 102.8, BP 100/66, P- 92, R-20, and O2 Sat 97 % He has had an uneventful night shift. He denies pain and SOB. His lung sounds at the am assessment were clear. Vital signs at 0730 am were Temp-100.1, BP- 102/64, P 102, R 18, O2 Sat 97% on RA.You are his day shift nurse and it is time to administer his 10 am medications.              Physicians Orders Mike Murphy DOB 7/6/59                                                                Allergies: PenicillinMedical record 0001234123Dr. Doole Admit Day  1730  hoursAdmit to PCU: Diagnosis AMS, UTI w/ sepsis            Labs:  UA with C & S, CBC, BMP, BNP, Lactic acid and Blood CulturesIVF LR 1000ml over 1 hour for one bag followed by 0.9% NACL at 100 ml per hour Vital signs q 2 hoursCiprofloxacin 200 mg IV q 6 hoursAcetaminophen 650 mg PO q 8 hours PRN for temperature greater than 100.4            Diet 2g low Na            Continue home meds            Bed rest with BR privileges with assistance             Mike Murphy                                     DOB 7/6/59                            Medical record 0001234123Dr. Doole UA positive for bacteriaTime                       1700             2100Lactic Acid               7. 6               7.2WBCs                      16,000HGB                           14.2BNP                            285Bld glu                     132K +                            5.2BUN                         20Creatinine                 1.2            MAR  Mike Murphy DOB 7/6/59                                                                                        Allergy: penicillinMedical record 0001234123                                                                                 Dr. Doole   Drug     Date            TimeInitialsAspirin 81mg po q day                                                       ####1000 Digoxin 0.25 mg po q day              ####1000 Metoprolol 50 mg po BID ####1000 2200 Benazepril HCL 20 mg po BID                                                               ####1000 2200 Hydrochlorothiazide 25 mg po q day                                                                    ####1000 Klor-Con 8 mEq po q day                              ####1000 Ciprofloxacin 200 mg IV q 6 hours                                             ####1000 1600 2200 0600            Student Assignment:Review all paperwork related to simulation. Fill in SBAR. Review Apollo and medication station videos. Look up all medications and review the nine rights of medication administration. Be prepared to administer medications and recognize lab values pertinent to the patient. Learning Objectives: Demonstrate the ability to use the medication administration system with minimal assistance (Cognitive)Incorporate the medication administration system into the scenario to promote patient safety (Psychomotor)Apply the nine rights of medication administration during patient care (Cognitive & Psychomotor)Recognize cues and labs that may indicate the need to withhold or continue to give a medication (Cognitive)Communicate with the healthcare provider information pertinent to the patient chart. (Affective) Health Science Science Nursing NURSING 210 Share EmailCopy link Comments (0)

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