just complete the template.
| 5/4 2000 | Neuro/Cognitive: Alert, oriented x 4. Speech clear. Obeys commands. Pupils pinpoint. Cardiovascular: S1, S2 heart sounds. HR regular and even. No edema. Respiratory: Breathing regular, even, unlabored. Integumentary: Hands swollen/puffy, red. Skin warm, dry. Slightly raised discolorations were noted on linear aspects of both forearms in various stages of healing. Psychosocial: Mood irritable. Arms folded, states, “Everybody treats me like a drug addict. I’m in pain!” Pain: Rates 8/10 sharp back pain. |
| 5/4 2000 | Nursing Note: Client presents from home with thoracic back pain onset today while in her home. States she was lifting a heavy box and felt a twinge in her back. States she took oxy IR without relief and used a heating pad. |
| 5/4 2000 | Client Information: Surgical History: Spinal surgery with internal fixation and decompression laminectomy, open reduction, and internal fixation of femur fracture Home Medications:
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| Date | Temp | HR | RR | BP | SpO2 | O2 |
| 5/4 2000 | 98.8 °F | 102 | 16 | 142/84 | 98% | RA |
| 5/4 2000 | Neuro/Cognitive: Alert, oriented x4. Speech clear. Obeys commands. Pupils pinpoint. Cardiopulmonary: S1, S2 heart sounds. HR regular and even. No edema. Respiratory: Breathing regular, even, unlabored. Integumentary:Hands swollen/puffy, red. Skin warm, dry. Slightly raised discolorations were noted on linear aspects of both forearms in various stages of healing. Psychosocial: Mood irritable. Arms folded, states, “Everybody treats me like a drug addict. I’m in pain!” Pain: Rates 8/10 sharp back pain. | |
| 5/4 2000 | Nursing Note: Client presents from home with thoracic back pain onset today while in her home. States she was lifting a heavy box and felt a twinge in her back. States she took oxy IR without relief and used a heating pad. | |
| 5/4 2110 | Nursing Note: Provider at the bedside. 24-gauge in R thumb after multiple attempts by staff. Ketorolac administered. The client states, “I don’t know why I bothered. That won’t do anything.” Client to and from imaging without complications. | |
| 5/4 2150 | Nursing Note: Client requesting additional pain medication. Dr. McDoyle is aware. No new prescriptions. | |
| 5/4 2230 | Nursing Note: Client pacing in room. States, “What kind of place is this that they don’t take care of your pain?” RN offering repositioning, heat therapy, distraction techniques. | |
| 5/4 2315 | Nursing Note: RN to bedside to give discharge instructions. The client states, “So he’s not giving me anything? How am I supposed to sleep? This is ridiculous!” The client rips out an IV and throws it at the nurse’s face. The client ambulates with a steady gait out of dept—discharge instructions mailed to the client's address. | |
| 5/7 1000 | Nursing Note: The client presents to the pain clinic and is tearful. States, “I behaved so horribly the other night in the ED. They are pressing charges. I don’t blame them... I deserve it. I need to get better. This has all spiraled out of control.” The client states that she began crushing her pain medications and injecting them approximately 1 year ago. The client is agreeable to speaking with case management. | |
| 5/4 2110 | Provider Prescriptions:
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| 5/4 2315 | Discharge Prescriptions:
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| Date | Diagnostic Test | Findings |
| 5/4 2250 | CT Thoracic Spine without Contrast | Bones: Vertebral body height and alignment are normal. |
Case Management Consultation Note: The client reports a motor vehicle accident five years ago with a significant injury that required opioid analgesia. The client states she developed a tolerance that grew into an addiction to medication. States she has tried to stop but becomes scared of withdrawal symptoms. The client reports starting to inject medication intravenously x1 year ago. Reports occasionally sharing needles when unable to obtain clean ones. Verbalizes financial concerns and inability to keep a job due to frequent call-offs for pain and withdrawal symptoms.
Client agreeable to receiving long-term treatment for drug rehabilitation. The client is to be prescribed naltrexone. Clarified allergy to naloxone. The client states, “It makes me nauseous.” The client was educated on symptoms as an anticipated response to the medication. The client was set up for 5/10 admission to Bright Horizons drug rehabilitation.
| 5/4 2000 | Client Information: Surgical History: Spinal surgery with internal fixation and decompression laminectomy, open reduction, and internal fixation of femur fracture Home Medications:
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Name: Jasmine Gelnett
Age: 26 years
Provider: A. McDoyle MD
Allergies: naloxone
Code Status: Full Code
Admit Wt: 118 lbs (53.5 kg)
BMI: 19.0
