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COLORS:  RED - PAIN   ORANGE - AGITATION   GREEN - TERMINAL

Ellen Anderson  Nursing Staff Notes   
12/29/95
1600 to 2330		   New admit.
Behavior - Patient admitted in company of daughter from care center. Deteriorating over the past 3 weeks. Not sleeping. Crying and screaming inconsolably, even when family is present. Has been taking Benadryl at care center for a rash in recent weeks. Long prior history of dementia, this exacerbation is an acute change from baseline. Care center unable to manage patient needs. 
Intervention - Orient family to anticipated treatment interventions and use of medication. Morphine Sulfate 10 mg IM at 2000 for severe pain (patient becomes rigid and screams when touched) related to profound osteoporosis given to patient per order Dr. Weitzel. 
Response - Patient calmer 2 hours after Morphine Sulfate injection; very needy of staff attention. Screams when left alone, if awake speech becomes inarticulate
Plan - Please see master treatment plan.
L. Wilson, RN
     
     
                                                                   
12/30/95
0100
 

0315

0330

0630
 

0730

                                                                                                                                                 Patient's respirations have been very erratic and ranging form 8 to 16 per minute. Blood pressure 70/50. Pulse 120. Dr. Weitzel paged and nursing supervisor informed of patient's condition.
T. Scholl, RN
Patient awakened. Thrashing arms and attempting to throw body. Patient moaning and screaming. Dr. Weitzel paged again. 
Dr. Weitzel returned page, informed of patient's condition. Morphine Sulfate 10 mg. IM given per doctor's order. T. Scholl, RN
Patient has appeared to sleep since receiving Morphine Sulfate - respirations remain erratic. EKG and Chest x-ray done. Side rails up x 2. Bed check monitor in place. T. Scholl, RN

Patient resting in bed. Vital signs: temperature 97.9, respirations 12, pulse 60.Unable to get blood pressure. Patient not responsive to verbal and tactile touch. Patient able to blink eyes. Family notified in Brigham City of patient's decline but get answering machine and left message to contact Davis (continued)
Bonnie Hardy, RN
     
12/30/95
0855
 

0920

1120

1320

    

(Continued) hospital. Bonnie Hardy, RN  
Patient with no respirations, no heart rate for 5 minutes. Dr. Weitzel notified. Nursing supervisor notified. Awaiting return call from only relative listed in chart with phone number. 
Family member returned call, notified of patient's condition. Family stated they were on their way and hung up phone. Bonnie Hardy, RN
Family arrived, gathered personal belongings. Requested body be sent to Meyers Mortuary in Brigham City. Arrangements made. Bonnie Hardy, RN
Mortician arrived and transported body and signed for receipt of body. 
Bonnie Hardy, RN

Psych Eval   Discharge Summary   Living Will / Medical Treatment Plan

Physician's Orders   Progress Notes    Nursing Staff Notes   Nursing Admission Assessment

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