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create a nurse’s note that details the client’s pressure injury and the prescribed treatment plan in paragraph form. A nurse is caring for Allen Johnson, an 87-year-old client who is postoperative. The client has developed a pressure injury. The nurse has obtain vital signs, assessed the client, provided the provider with an SBAR report and implemented interventions. Allen Johnson Male, 87 years MRN: 8502262 Attending: Bernard Robinson, MD Allergies: Code Status: Full code Comments: none Inpatient Patient Summary Patient Information Results Provider Allergies & Home Medications Immunization Record Notes Flowsheets Screenings MAR Orders Patient Education SBAR Care Plan Discharge Barcode EXPAND Patient Summary Primary Concern: Stage 3 pressure injury The Patient Summary is read only! To add or edit data you must open another page by clicking the appropriate tab to the left. Vital Signs 01/28/2024 2319 Heart Rate 90 Blood Pressure 152/90 Respirations 20 Temperature 99.9°F (Oral) SpO2 (%) Pain Allergies Allergy Date Noted Reaction Orders Type of order to view: All Search: Show 10 entries Previous 1 Next Start Date Order Details Status All 01/29/2024 0004 Dressing Change Written order Frequency: Other-See Administration Instructions Start Date: 01/29/2024 0004 Dressing change to sacral/coccyx wound. Type of Dressing: Alginate dressing in wound bed covered by hydrocolloid dressing. Change every 3 days or as needed. Active 01/29/2024 0004 Wound Care Written order Start Date: 01/29/2024 0004 Clean with normal saline prior to dressing change. Active Showing 1 to 2 of 2 entries Previous 1 Next Labs Lab Range 01/28/2024 0019 Hematology White blood count (WBC) (x th cells/μL) 4.0-10.0 11.9 Red Blood Cell (mil/uL) female-4.00-5.20 male-4.50-5.90 Hemoglobin (g/dL) male-13.5-17.5 female-12-16 15 Hematocrit (%) male-42-54 female-37-47 46% Mean corpuscular volume (MCV) (fL) 80-100 fL Pediatric: Mean corpuscular hemoglobin (MCH) (g/dL) 26-35 g/dL Mean corpuscular hemoglobin concentration (MCHC) (gdL) 32-36 g/dL Platelet count (x th/μL) 150-350 x th/μL 90,000 Neutrophils 40%-60%, 2500-8000 Lymphocytes 20%-40%, 1000-4000 Monocytes 2%-8%, 100-700 Eosinophils 1%-4%, 50-500 Basophils 0.5%-1%, 25-100 Band 0%-3% Absolute Neutrophil Count (ANC) (cells/mm3) 1500-8000 Name Allen Johnson Sex Assigned at Birth Male Gender Identity Male Pronouns Pronouns DOB 87 years Provider Bernard Robinson, MD Code Status Labs TL 01/28/2024 0019 Hematology White blood count (WBC) (x th cells/μL) 11.9 Red Blood Cell (mil/uL) Hemoglobin (g/dL) 15 Hematocrit (%) 46% Mean corpuscular volume (MCV) (fL) Mean corpuscular hemoglobin (MCH) (g/dL) Mean corpuscular hemoglobin concentration (MCHC) (gdL) Platelet count (x th/μL) 90,000 Chief Complaint & History of Present Illness TL 01/28/2024 2319 Admission Problems Chief Complaint Non-healing wound on sacral/coccyx area Primary Concern – Admission Diagnosis Stage 3 pressure injury Other Problems/Diagnosis 12 days postoperative ORIF of the left hip Family History Other-See below Coronary artery disease Family members affected: Pt’s Mother, Pt’s Father Social/Environmental Safety Screening Patient lives: Alone Comments Client has been a widower for the past 2 years; adult children live in a different state. TL 01/28/2024 2319 Allergies Date allergy noted: Home Medication List Advair diskus 1 puff BID, Inhaled Ordered by: Reason: COPD Start Date: End Date: Is patient taking medication? Unknown Last taken: Merformin 500 mg BID, Oral Take with meals Ordered by: Reason: Type 2 DM Start Date: End Date: Is patient taking medication? Unknown Last taken: Lisinopril 20 mg daily, Oral Ordered by: Reason: Hypertension Start Date: End Date: Progress note: 87-year-old client, 12 days postoperative ORIF of left hip, seen for evaluation of sacral wound. Stage 3 pressure injury in sacral/coccyx area with subcutaneous tissue exposed, no necrosis or eschar noted. Moderate pain in the area of the wound,
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HEALTH SCIENCE
NURSING

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