- Scenario Referring To The Video Administer Medications To Patient Siu Sum Yi Illustrate A Procedure Manual For Your Ow 1 (87.77 KiB) Viewed 23 times
Evaluation Evaluation Rationale Documentation and reporting Documentation 1. MAR 2. Patient Progress Sheet Please write your documentation here: Reporting Please write your reporting here:
Name: Siu Sum Yi ID Number: A123456(7) Hospital Number: 153096 Sex: F Age: 60 Allergy / Alert Information Drug Allergy (1) No Known Drug Allergy Alert Nil Drug Allergy (1) No Known Drug Allergy SIU SUM YI Sex: F DOB: 01/01/1962 Alert Nil
Hospital No.: 153096 A123456(7) I.D.No. Name Siu Sum Yi Age: 60 Sex F NURSING ASSESSMENT FORM (ON ADMISSION) Chinese Name: 3A Ward: 1 Med Bed Dept.: Date 03/05/2022 # To be completed on every admission * Fill in or as appropriate Warded on: Time 07:00 Type of Admission: Clinical Emergency Transfer from other Hospital (specify If police case (Reg. No.: and Police Station) Mode of Admission: Ambulatory Wheelchair Stretcher Others Relatives Informed: Yes No, specify reason Accommodation: Lives alone OAH/Nursing Home Others Lives with family Doctor: Ivan Chan Diagnosis on Admission / Upon Transfer: Persistent cough on and off dizziness for 1/12 for further investigation Reason for Admission / Transfer: Fair DM control and drug compliance. informed Time: 07:15 Date: 03/05/2022 Past Health History: DM HT Iron deficiency anemia Smoker 7 Ex-smoker Social drinker Heavy drinker Ex-drinker Smoking: Non-smoker Drinking Non-drinker History of Allergy / Alert: (a) Medication: Not known (b) Food: Not known (c) Others: Specify: Yes, specify Yes, specify Initial Assessment: General Condition: Vital Signs: Temp. 36.9C SpO2 LMP (Female): Conscious Level: Language / Dialect: Speech Vision: Satisfactory Stable Serious Critical 138/80 Pulse/X/TX 90 min 20 Resp. min BP mmHg 98 02 L/min Body Weight 55 kg Height 160 cm BMI Date Alert Apathetic Confused Stuporous Comatose Cantonese Putonghua English Others: Clear Slurring Inappropriate Dumb Nil complaint Blurring (L/R) Blind (L/R) Prosthesis (L/R) Visual aid Normal Impaired (L/R) Deaf (L/R) Hearing aid (L/R) No Yes, specify location Normal Tachypnoeic Dyspnoeic Wheezing Stertorous Gasping Assistive Device: Nil Tracheostomy Tube / ETT Ventilator/BiPAP Home 02 L/min Hearing: Pain: Respiration:
Cough: Pedal oedema: Pulse: Productive (Sputum colour Dizziness: Nil Dry NO Yes Regular Irregular Warm No No Yes Yes Pacemaker in-situ: Extremities: Cold Others: Special diet / fluid DM diet Self care: Dependent Assisted Self care / Independent Mobility: Normal Hemiplegia (L/R) Paraplegia Quadriplegia O Bed-bound Chair-bound Contracture Deformity Assistive Device: Nil Yes, specify: Sleeping: Normal Shallow sleep Insomnia (Hypnotics: No /Yes Nutrition Diet as tolerated Soft diet Fluid diet Instant food thickener Food Restriction/Dislike Artificial Feeding NG tube feeding PEG Parenteral nutrition Others Denture: Nil Yes, Upper Row (Fixed/Detachable) Lower Row (Fixed/Detachable) Skin Colour: Normal Pale Jaundice Flushed Cyanotic Skin Texture: Normal Dehydrated Oedematous Clammy Skin Warmth: Warm Cold Skin Lesion: Bruise Rash Scar Pressure Ulcer Wound Others: Total no. as indicated Pressure ulcer risk score: Low risk High risk Pressure ulcer preventive measures: Not required Required Elimination - urinary Normal Frequent Dysuria Incontinence Urinary retention Haematuria Frequency Oliguria Others Assistive Device: No Yes (Catheter with size / Others Elimination - bowel: Normal Incontinence Constipation Diarrhoea PR Bleeding Stoma Haemorrhoid Others Medication used Emotional State: Calm D Anxious Depressed Restless Others Behavioural State: Co-operative Uncooperative Aggressive Others Fall risk score: Low risk High risk Fall preventive measures: Not required Required Remarks: Chris 03/05/2022 Assessed By: CHRIS WONG/RN 07:20 Signature Name in Block / Rank Date Time
Please use Block Letter or Affix Label Hospital No.: 153096 Name: Siu Sum Yi I.D. No.: A123456(7) PATIENT PROGRESS SHEET Sex: F Age: 60 Each entry must be signed and initialed page no. 1) Date/Time (discipline) 03/05/2022 07:30 (MEDICAL) Emergency admitted x persistent cough. GC stable. Afebrile. Past health history: Diabetes mellitus Hypertension Iron deficiency anemia Complaint of on and off dizziness x 1/52. Mx: Vital signs Q4H DM diet I&O chart DM chart with H'stix TDS Ivan Chan MO Dr. Ivan Chan (D246)
NURSING OBSERVATION CHART WITH MEWS (Affix Patient Particulars Label Here or Use Block Letter) Hospital No: 153096 ID No:A1234456(7) Name: Siu Sum Yi 姓名: Sex/Age: F/60 Ward: 3A Bed: Dept: Medical Arrived at (Emergency Clinical Transfer in) Date 03/05/2022 04/05/2022 11:00 Time 07
0019
003:07:00 15 >40 40 Date Time >240 240 2 220 39 200 3 38.5 180 1 160 38 140 120 Heart or Pulse Rate 37 * 100 180 0 160 36 40 11 1 20 2 35 2 <35 3 U 2 P 1 v V 0 A 22200 199 190 180 170 160 150 140 A 130 A Λ Λ 120 лл 110 100 90 80 V 2 70 60 3 50 40 <40 9 3 230 221-29 1 15-20 20 20 20 20 18 16 18 09.14 2 2 58 MEWS Tota! Bowel BW (kg) 55 Spa/%) 98 99 99 99 99 99 99 Oz (L/min) RA RA RA RA RA RA RA U 3 3 P2 V 1 1 А о 200 199 190 180 170 3 160 150 140 130 120 2 110 100 Pressure (mmHg) A Nursing Observation Chart with MEWS Heart or Pulse Rate Ý V V V ño 0 888888 50 1 2 230 30 21-29 22 15-20 1 9-140 S8 58 2 MEWS Total Urine Test Date WBC NIT ALB SUG RBC KET BH cm MR/KEC/GEN/001 MR/KEC/GEN/001 intake output Balance 04/10 DIABETIC CHART (Patient Gum Label) Patient Name: Siu Sum Yi I.D. no.: A123456(7) Hospital no.: 153096 Age: 60 Sex: F Date H'stix H'stix H'stix H'stix Before H'stix B'fast Tx(PRN) Before H'stix Lunch Tx(PRN) Before H'stix Dinner TX(PRN) ITDS Frea Before Bed Tx(PRN) Tx(PRN) Tx(PRN) Tx(PRN) 07:45 7.2 11:30 6.8 17:00 6.4 Time 3/5/2022 Sign Wong Wong Lee S Time 4/5/2025.me 07:00 7.6 Sign Lee S K K Time Sign 5 к Time Sign 5 K Time Sign S K Time Sign 5 K Time Sign K Remarks: H'stix Time: Before B'fast: 0630-0700 Before Bed: 2030-2100 Before Lunch: 1130-1200 Before Dinner: 1630-1700 Freq: Preset Time S = Urine Sugar K = Urine Ketone Monotard HM = MHM Protaphane HM = PHM Glucose Water = GW Actrapid HM = AHM
(Patient Labell Patient Name: Siu Sum Yi Hospital no.: 153096 1.D. no.: A123456(7) Age: 60 Sex: F FLUID BALANCE WORKSHEET INTAKE (ml) OUTPUT (ml) Date & & Time Amount Given Checked Amount Time Vomit/ Aspiration Urine Faeces Dr N Fluids Additive/ Dosage by by By mouth Tube Feed Nature Anore 4/5/2022 Total Daily Total Total Input ml Total Output ml Balance mil +/-
Medication Administration Record Allergy: NKDA ADR: Nil Patient Name: Siu Sum Yi Hospital no.: 153096 I.D.no.: A123456(7) Sex: F Dr. Signature & Code Age: 60 Dr. Ivan Chan D246 Chan Specialty: Med Ward: 3A DRUG DETAIL Time DATE / DR. Date Date 03/05/2022 Signature Date 04/05/2022 Signature Signature Order: 0800 Wong 03/05/2022 Dr. Sign.& code Dr. Ivan Chan D246 Cher Off Med: ORAL Betaloc 50 mg Daily 0800 Wong Order: 03/05/2022 Dr. Sign.& code Dr. Ivan Chan D246 Cher Off Med: ORAL Metformin 750 mg BD 1800 Lee 0800 Wong Order: 03/05/2022 Dr. Sign.& code Dr. Ivan Chan D246 Cher Off Med: ORAL MES 10 mL TDS 1200 Wong 2000 Lee Order: 03/05/2022 Dr. Sign.& code Dr. Ivan Chan D246 Chen 0800 Wong ORAL FeSO4 300 mg Daily Off Med: 04/05/2022 Dr. Ivan Chan ID 246 Cher