just complete the template

10/19 0715

Neuro/Cognitive: Alert, oriented x 4. Speech clear. Calm but somewhat disoriented, cooperative with staff. Pupils 4 mm PERRLA bilaterally. GCS: 15.

Cardiovascular: S1/S2 sounds present. HR regular, even. +2 pitting edema from feet to thighs. +pedal pulses with doppler, +2 radial pulses. 

Respiratory: Dyspnea on exertion and with lying supine. Breathing nonlabored when sitting upright. Lung sounds diminished bilaterally. No cough. 

Gastrointestinal: BS present x 4 quadrants, normoactive. Abdomen soft, round, distended, non-tender. States abdomen is more distended than normal.

Integumentary: Yellowing of sclera and skin. Skin turgor elastic. Skin warm, dry. Red/purple bruising noted from ankles to pretibial region. 

Lines/Drains: 20-gauge IV site in R hand. Patent, intact. Dressing clean, dry, intact.

Date

Temp

HR

RR

BP

SpO2

O2

10/19 0800

98.2 °F 
(36.8 °C)

92 

22

142/82

95% 

RA 

OTHER TRENDING DATA

Date

Weight

10/19 0715

234.2 lbs (106.2 kg)

10/17 2310

Admission Prescriptions:

• Daily weights

• CBC, CMP, albumen – am draw – daily

• AST, ALT level – once

• Ammonia level - once

• Diet: low sodium

• Supplemental protein shakes with meals

• Vital signs every shift

• Spironolactone 50 mg by mouth three times daily

• Furosemide 10 mg IV push daily

• Potassium chloride ER 40 mEq daily

10/19 0900

Prescriptions:

• Interventional radiology – therapeutic paracentesis

• Albumen 25%- 50 g/50 mL IV infusion – administer over 1 hour

Date

Lab

Normal

Result

10/19 0830

Complete Blood Count (CBC)

Red Blood Cells (RBC)

4.2 - 5.9 cells/L

4.2 

Hemoglobin (Hgb)

12 - 17 g/dL 

12.8 

Hematocrit (Hct)

36% - 51% 

38

White Blood Cells (WBC)

4,000 - 10,000 mm3

7,200

Platelets

150,000 - 350,000 mm3 

89,000 L

10/19 0830

BMP

 Blood Urea Nitrogen (BUN)

8 - 20 mg/dL 

19 

Creatinine

0.7 - 1.3 mg/dL 

1.2 

Potassium (K)

3.5 - 5.0 mEq/L 

4.1 

Sodium (Na)

136 - 145 mEq/L 

138 

Calcium (Ca)

9 - 10.5 mg/dL 

9.9 

Chloride (Cl)

98 - 106 mEq/L 

102 

Glucose

70 - 100 mg/dL 

89 

Albumin

3.5 - 5.0 g/dL

2.9 L

10/19 0830

Aminotransferase, Alanine (ALT)

0 - 35 U/L

132 H

10/19 0830

Aminotransferase, Aspartate (AST) 

0 - 35 U/L

79 H

Medical History: Hepatic steatosis, alcoholism, hypertension

Social History: 

• Former drinker – approximately 12-12oz beers daily. 

• Denies smoking history or recreational drug use. 

10/19 1630

Procedural Note:
Therapeutic Paracentesis: Written informed consent obtained before intervention. Client placed with HOB at 30 degrees. Left lower abdomen cleansed with iodine solution. 1% lidocaine administered to site of insertion for local anesthetic. 16-gauge needle inserted and attached to vacuum-seal bottles for fluid collection. 7.8 L of translucent, pale-yellow fluid. Needle removed. Simple gauze dressing applied. Client tolerated procedure well.

10/19 2000

Client Education:

What: Home Management

• Maintain low sodium diet below 2 g. 

  • Teach about food label reading. Seasoning with alternate spices. 

• Reduce oral fluid intake to 1200 mL/day.

• Daily weights.

• Take home diuretics as prescribed.

• Report changes in weight and monitor for shortness of breath or fatigue with activity.

• Maintain alcohol cessation.

• Reduction for bleeding: observe for epistaxis, bleeding gums. 

  • Avoid high contact physical activities, prevent falls.

• Follow-up with family provider for monitoring.

• Refer for counseling.