just complete the template.

12/04 2240

Neuro/Cognitive: Alert, oriented x 4, PERRLA – 3mm bilaterally, responding appropriately to questions.
Cardiovascular: Regular, S1& S2 present. No edema.
Respiratory: Clear breath sounds, regular rate, diminished breath sounds in lower lobes with shallow breathing.
Gastrointestinal: Abdomen guarded, tender to palpation, bowel sounds hypoactive, present in all four quadrants.
Genitourinary: Voiding without difficulty, reported blood in urine.
Integumentary: Skin warm and dry. 2 cm x 0.5 cm laceration to R lower lip. Moderate bleeding. Scattered superficial abrasions to face. Ecchymosis to R periorbital region. +bruising to L abdomen.
Psychosocial: Client apprehensive, appeared “jumpy” with room noises, intermittently tearful.
Pain: 4/10

12/05 0500Nursing Note: Lying in stretcher in Short Stay Unit for observation. Very restless, slept intermittently throughout the night. Ice to left ear and lip. Sipping clear liquids. Rates pain 4/10 and unable to get comfortable. Acetaminophen 1000 mg administered at 2245, acetaminophen 650 administered at 0450.12/05 0500

Situation: Alex DeChilds came to the emergency department last night after being injured at home.

Background: Alex’s husband was intoxicated and became abusive. They required laceration repair, various diagnostic tests, and is here for a 16-hour admission for observation. The labs have come back negative, and there was scant blood in the last urine.

Assessment: They had a restless night taking only acetaminophen for pain. They are not able to swallow pills.

Recommendation: I would recommend a one-time dose of codeine with acetaminophen elixir so Alex can get some sleep.

12/05 0950Teaching Plan:

Care of sutures and lacerations
No lifting or exertion for one week
Pain management-acetaminophen 650 mg by mouth q6h PRN for pain, not to exceed three doses daily
Domestic violence hotline and review of safety plan
Options for follow-up counseling and support groups
Return to primary care provider in 10 days for suture removal and follow-up

12/05 1010Nursing Note: Pain reported to decrease, 3/10. Client tearful when discussing safety plan. Reports they have been married for six years and “this has only happened 2 or 3 times. I don’t want to leave him. I love him, and our relationship is good. Good thing we don’t have any children.” Last two voids tested negative for blood. Discharge teaching conducted.

VITAL SIGN TREND
Date	Temp	HR	RR	BP	SpO2	O2
12/04 2240	98.9 °F (37.2 °C)	110	20	114/76	94%	RA

PROVIDER PRESCRIPTIONS & NOTES

12/04 2250

Prescriptions:

Labs – CBC, CMP, Urinalysis
Kidneys, Ureters, Bladder x-ray
Chest x-ray
CT abdomen and pelvis without contrast
Admit to Short-Stay Unit for sixteen-hour observation
Consult reconstructive surgical NP for wound suturing
Consult Trauma Counselor -domestic violence/crisis counseling
Diet: nothing by mouth, once cleared – progress to clear liquids and regular diet
Start peripheral IV
0.9% normal saline 1000 mL infusion - 75 mL/hour
Acetaminophen 1000 mg by mouth once
Acetaminophen 650 mg by mouth q6h PRN for pain
Wound care for minor lacerations
Ice to wounds and abdomen as tolerated
>Repeat UA in the morning
Discharge at 1500 if no blood in urine, no increase in pain

12/05 0505

Prescriptions:

Codeine with acetaminophen oral elixir 15 mL by mouth one-time dose
Resume acetaminophen after one-time dose of elixir

LAB RESULTS
Date	Lab	Normal	Result
12/05 0030	Complete Blood Count
	RBC	4.2-5.9 calls/L	4.2
	Hgb	12-17 g/dL	14.1
	Hct	36-51%	34% L
	WBC	4,000-10,000 mm3	9.6
	Platelets	150,000-350,000 mm3	203,000
	CMP
	BUN	8-20 mg/dL	18
	Creatinine	0.7-1.3 mg/dL	0.8
		3.5-5.0 mEq/L	3.9
	Na	136-145 mEq/L	141
	Ca	9-10.5 mg/dL	9.1
	Cl	98-106 mEq/L	102
	Glucose	70-100 mg/dL	79
	Albumin	3.5-5.0 g/dL	5.6 H
	CO2	18-29 mm3	26

DIAGNOSTIC TEST RESULTS
Date	Diagnostic Test	Findings
12/05 0030	Urinalysis	Moderate blood
12/05 0030	KUB	Negative - No masses, fluid collection, or lesions noted.
12/05 0030	CXR	No evidence of injury, scattered infiltrates in lower lobes bilaterally.
12/05 0030	Abdomen CT	Normal size, contour, and placement of right and left kidneys. No masses or obstructions noted in abdomen. No fluid or bleeding. Negative for renal hematomas or contusions.

COLLABORATIVE CARE12/05 0930Counselor Note: Met with Alex. Established contract for safety. Alex denies intentions to hurt themself or others. Stated this was not the first episode of abuse, though is the first episode requiring hospitalization. Alex affirms that their husband is not abusive unless intoxicated and that spouse’s drinking is sporadic and uncommon. Denies acceleration of violence in the recent past and denies sexual assault. Discussed safety plan and sources of support and community resources. Alex denies follow-up or referral to crisis counselor. Repeated their personal requests not to press assault charges or to contact law enforcement.

12/05 0505

Hospital Formulary

Codeine with acetaminophen oral elixir available 2.4 mg/mL of codeine; 24 mg/mL of acetaminophen

12/04 2240

Client Information:
Gender Identity: Non-Binary
Social Background:

Preferred pronouns: They/Them