Admission - Mel LaFleur - Simulated Client Records

Admission History

Admit Date	Discharge Date	Location	Reason for Visit
Current Admission	NA	TRU Simulation Hospital	#Rt fracture hip, ALOC, Pneumonia
21/05/2017	22/05/2017	TRU Simulation Hospital	back pain
10/04/2010	11/04/2010	TRU Simulation Hospital	COPD exacerbation

Source of Information	Daughter via phone
Reason for Visit	#Rt Hip- Fell at home, cognitive concerns when found, brought by ambulance
Health History	COPD Diabetes Type 2 Osteoarthritis Atrial Fibrillation Hypertension Depression
Medications	BPMH Bottles Pharmacy delivered
Height	150	cm	Weight	80	kg
Allergies	Penicillin	Reaction type		Hives
Language Spoken	English		Reading/Writing		English
Family History	Depression
Previous Illnesses	Dry eyes
ARO Screening	completed	MRSA:	negative	CPO:	negative	Close contact with someone positive:	no
Isolation Precautions	Type:
Surgical History
Wounds
Aggressive Behavior Screening	History of Violence:	no	Physically violent:	no	Verbally Aggressive:	no	AGG FORM	no
Dietary History	low sodium		Diet Type:	diabetic diet	Consistency:	normal
Substance Use	Type: Cigarettes			Last Used:	1 year ago, on smoking cessation program
Substance Use	Type:			Last Used:
Housing	Independent in home	Barriers:	Frequent Falls		Community Support:
Pharmacy	Save On Foods Northshore	Blister Pack: Crush:	No	Comments:	Delivered

Pain Management:	Independent	Yes	Comments:	uses hand held massager at home
Medication Management:	Independent	Yes	Comments:	Bottles, pharmacy delivers
Cognitive Functioning:	Independent	Yes	Comments:	Family reports periods of forgetfulness
Psychosocial:	Independent	Yes	Comments:	Daughter lives in Alberta, Son in Victoria, used to be active in church group
Nutrition/Swallowing:	Independent	Yes	Comments:	Prepares own meals
Bowel/Bladder Management:	Independent	Yes	Comments:	Incontinent product used in case they don’t get to bathroom in time
Functional Mobility:	Independent	Yes	Comments:	Walker
Discharge Considerations: Lives Independently						Estimated Discharge date: 7 days after admission
Patient/Family Goals:					Date:
Patient/Family Goals:					Date:

General: 2 Person Assist with care in bed, hip # precautions
Vital Signs: BP 164/88, P 86, R24, O2 88%RA, T36.7
HEENT: Glasses for reading, PERLA adequate.
Integumentary: Skin appears intact, sl redness to coccyx
Cardiovascular: Apical strong, with regular rhythm and pattern
Respiratory: Decreased air entry to bases, wheezing throughout, occasional wet cough, productive
Gastrointestinal: Diabetic Diet and low sodium, no choking hazard, decreased appetite
Genitourinary: Pull up on, found incontinent
Musculoskeletal: Shortened and externally rotated Rt Foot, unable to dorsi and planter flex rt foot. No limitations to Left leg and foot.
Neurologic: Alert and orientated x 1 name only, hard to get responses. Pain to Rt Hip (10/10, ongoing, sharp, radiating)
Developmental:
Endocrine: Type 2 Diabetes
Lymphatic:
Gynecology/Urology: Foley placed in ED

SMART GOAL:	Pain management

Interventions:	regular pain control, positioning, non pharmaceutical, ice

Plan:	Orientate to call bell, have within reach on every bedside visit
	Regularly scheduled analgesic as ordered, with PRN for breakthrough
	Assess pain q30mins, assess for effectiveness of analgesics and side effects
	Implement non pharmaceutical interventions q1 hr: Repositioning, ICE, Distractions, Warm blankets
Provider:	RN
Day:	day of admission
Time:	1400

Last Name:	First Name:	Middle Name:	Age:	DOB:	Sex:	Marital Status:	Ethnicity:	Religion:
Lafleur	Mel		70	01/02/ 1954		Widowed (2 years) Spouse: Jo Lafleur	Caucasian	Protestant
Address:	Street			Apt. #	City	Province	Postal Code	MRP
Address:	500 Speed way				Windy	BC	V2BK2D	Dr. Eve
Home Phone:	903-322-9090		Cell Phone:			Indigenous	Spouse was Metis
Guarantor/Legal Guardian of Minor (If different from patient)
Last Name:	First Name:	Middle Name:	Age:	DOB:	Sex:	Relation:

Address:	Street			Apt. #	City	Province:	Postal Code
Address:
Home Phone			Cell Phone
Employer Information
Name
Address	Street			Suite #	City	Province:	Postal Code
Address
Primary Insurance Information
Name of Insurance Company:			Medicare		Phone:
Policy #	1245466		33333
Group name:	ABC Care
Group Number:	1234
Insured:	Last:		First:		MI:
	Sex:		Relation:		DOB:
Emergency Contact
Name:	Debbie Lafleur			Relationship:	Daughter
Address:	3336	Canuck way		City:	Calgary
Phone:	416-320-8888			Province:		Postal: