nr 342 pharmacology template

• Name: Kirby BaxterAge: 36 yearsProvider: M. McCall MDAllergies: NKDACode Status: Full CodeAdmit Wt: 190 lbs (86.2 kg)BMI: 27.3
• Other

09/30 0800Client Information:

Medical History: Transient ischemic attack, type 2 diabetes, depression, pulmonary embolism

Social History: Smokes 1 pack/day cigarettes

• Name: Kirby BaxterAge: 36 yearsProvider: M. McCall MDAllergies: NKDACode Status: Full CodeAdmit Wt: 190 lbs (86.2 kg)BMI: 27.3r
• Lab & Diagnostics
• Other

DIAGNOSTIC TEST RESULTSDateDiagnostic TestFindings09/30 0920
Computed Tomography (CT)
Focal cord enlargement at the level of trauma on sagittal T4. Suggested MRI (magnetic resonance imaging) for more detailed imaging.

• Provider
• Lab & Diagnostics
• Other

PROVIDER PRESCRIPTIONS & NOTES09/30 0802Prescriptions:

• Insert two large-bore peripheral IVs
• 650 mg of acetaminophen by mouth q6h PRN for pain
• Apply 100% oxygen via nonrebreather mask
• Complete full neurologic exam
• Electrocardiogram now
• Insert indwelling urinary catheter
• Out of bed to chair three times daily
• Regular diet

09/30 0925Prescriptions:

• Morphine 2 mg IV push q3h PRN for pain
• 0.9% NS 1000 mL IV fluid bolus – infuse over one hour
• Collect urine sample
• Orthostatic vital signs – once
• CBC level
• Lower the head of the bed
• Flowsheets
• Provider
• Lab & Diagnostics
• Other

VITAL SIGN TRENDDate TempHRRRBPSpO2O209/30 074598.0 °F
(36.7 °C)462888/5299%2L/NC09/30 0930 98.0 °F
(36.7 °C)5816 100/80 99% RA 

Age: 36 years

Provider: M. McCall MD

Allergies: NKDA

Code Status: Full Code

Admit Wt: 190 lbs (86.2 kg)

BMI: 27.3

• Nursing
• Flowsheets
• Provider
• Lab & Diagnostics
• Other

NURSING ASSESSMENT & NOTES09/30 0750

Neuro/Cognitive: Alert, oriented to person, place, time, and situation. Slow to answer questions.

Cardiovascular: S1 and S2 sounds present. Denies chest pain. Sinus bradycardia.

Respiratory: Breathing rapid. Equal chest rise and fall.

Genitourinary: 16 F indwelling urinary catheter draining yellow, clear urine.

Neurovascular: Numbness and tingling along with decreased sensation to lower extremities.

Pain: Rates 9/10 pain. “My neck is killing me!”

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