- Patient Description Name Ruiz Eliana September 30 1940 Dob 76 Years Age Weight 121 Lbs 55 0 Kg 5 2 Height Gender Fe 1 (170.7 KiB) Viewed 290 times
- Patient Description Name Ruiz Eliana September 30 1940 Dob 76 Years Age Weight 121 Lbs 55 0 Kg 5 2 Height Gender Fe 2 (181.14 KiB) Viewed 290 times
- Patient Description Name Ruiz Eliana September 30 1940 Dob 76 Years Age Weight 121 Lbs 55 0 Kg 5 2 Height Gender Fe 3 (122.18 KiB) Viewed 290 times
Patient Description Name Ruiz, Eliana September 30, 1940 DOB 76 years Age Weight 121 lbs = 55.0 kg 5'2" Height Gender Female Background: History of Present Complaint Medical Record # 49730 Ethnicity Hispanic Eliana Ruiz is an elderly woman with a non-healing wound on her right upper leg where a femoral-popliteal bypass graft was performed two weeks ago. She is diabetic and injured her left ankle by tripping on a curb on the way to the hospital. She is anxious about not being able to care for herself when she returns home. She lives alone but has a daughter close by, and no health insurance. Past medical history is significant for HTN and type 1 DM. Setting/Location: Medical-surgical unit Patient Information: History Type 1 diabetes mellitus, HTN, Appendectomy 40 years ago. Recent Medical History Right leg popliteal bypass surgery 10/20/2020. Sprained left ankle as a result of tripping on a curb on the way to the hospital today. Urinary incontinence. Lives alone; has daughter that lives nearby. Has no health insurance. Social History Medications NHP insulin, Sliding scale Regular insulin, Keflex, acetaminophen, morphine sulfate Allergies & Reaction No known allergies Primary Care Provider Dr. Martha Stoneham Primary admitting diagnosis Non-healing upper right leg wound post femoral-popliteal bypass surgery Scenario start day: Day 1 Scenario start time: To be announced Chief complaint upon Right upper leg non-healing wound, Left ankle sprain, Anxiety admission: Primary diagnosis: Non-healing infected graft wound site
PATIENT INFORMATION: SIMCARE HEALTH SYSTEM ALLERGIES: NKA PHYSICIAN'S ORDER FORM ELIANA RUIZ ADM: 11/3/2020 BD: 9/30/1940 MR # 49730 DATE/TIME 11/3/2020 Admit to floor 0800 Vital signs with pulse oximetry twice a day Up with assistance three times a day Diet 1200 calorie ADA Accu-Chek ac & bedtime Regular insulin subcutaneous ac & bedtime per sliding scale: 151 - 200 = 2 unit 201 - 250 = 4 units 251 - 300 = 6 units 301-350 = 8 units 351 - 399 = 10 units; greater than 400 call physician for orders; Notify healthcare provider if less than 50 NPH Insulin 30 units subcutaneous every AM Keflex 250 mg po every 6 hours Acetaminophen 600 mg every 4 - 6 hours prn mild pain or fever greater than 38° C; not to exceed 3000 mg/24 hours Morphine sulfate 3 mg IM every 3 - 4 hours prn severe pain or prior to dressing change Insert Foley catheter for incontinence Change dressing every 24 hours bypass graft site using sterile technique and sterile normal saline Apply elastic bandage to left ankle for sprain using figure eight Incentive spirometer 10 times every shift while awake as needed Notify healthcare provider if BP greater than 180/100; HR greater than 100; RR greater than 30 or temperature greater than 38.3°C Dr. Martha Stoneham
Eliana Ruiz DOB: 9-30-1940 MR # (49730) MEDICATION ADMINISTRATION RECORD ALLERGIES: No known allergies ORDER 0701 - 1500 1501 - 2300 2301 - 0700 0830 1630 Regular insulin subcutaneous -ac & bedtime sliding scale: 151 - 200 = 2 unit 201 - 250 = 4 units 251 - 300 = 6 units 301-350 = 8 units 351 - 399 = 10 units 1130 2000 Greater than 400 call physician for orders 0830 1630 Accu-chek ac & bedtime 1130 2000 NPH Insulin 30 units subcutaneous every a.m. 0900 0830 Keflex 250 mg po every 6 hours 1430 2030 0200 Morphine 3 mg IM every 3-4 hours prn dressing change and severe pain Acetaminophen 600 mg every 4-6 hours prn mild pain or fever above 38° Celsius Signature Initials Title Signature Initials Title Page 1 of 1