3 days ago:

Client presents to the surgical center for perioperative teaching and instructions. Client is scheduled for a cholecystectomy next week. Preoperative teaching reinforced regarding respiratory and physical functioning, anticipated length of stay, surgical preparation, and management of pain. Labs, vital signs, and ECG obtained. Provider obtained consent for surgery. Client is to return to surgical center in 3 days for scheduled surgery.

Today, 0900:
Client presents to surgical center for scheduled cholecystectomy. Client reports anxiety, and pain as 2 on a scale of 0 to 10. Client is requesting information about risks and benefits of surgery. Client is alert to person, place, time, and situation. Client reports last meal was this morning at 0730 and consisted of toast, coffee, and scrambled eggs. Client reports performing chlorhexidine shower this morning. Heart rate regular and fast, no murmurs or gallops. Radial pulse +3 bilaterally. Respirations even and nonlabored. Lungs clear anterior and posterior. Abdomen soft, rounded, and nondistended, no tenderness. Bowel sounds active in all 4 quadrants. Client reports formed bowel movement yesterday. Bladder nondistended; continent. Reports no difficulty with urinating. Skin warm, dry, and intact. Capillary refill less than 2 seconds. Turgor without tenting. No edema present.

Day 1, 1100:

Client admitted from emergency department with a new diagnosis of pneumonia. Confirmed by chest x-ray and laboratory results. Client reports dyspnea and exhibits shortness of breath at rest. Client is hypoxic, confirmed by oxygen saturation. Placed on oxygen at 2 L/min via nasal cannula. Congested cough, sputum specimen obtained and sent to the laboratory. Crackles heard on auscultation, breath sounds diminished. IV initiated in left forearm with 22-gauge angiocath for intermittent antibiotic therapy and further treatment.

Day 2, 1500:

Client remains hypoxic. Less dyspnea noted at rest, extreme shortness of breath noted on exertion. Receiving intermittent IV medications. IV site without manifestations of infection or infiltration.

Day 1:

Collecting client data on food safety. Raw meats and raw vegetables are prepared together on one cutting board. Refrigerator is set to 6.70 C (440 F) Leftovers are discarded after 7 days in refrigerator. Frozen foods are defrosted on the countertop. Client washes hands for 10 seconds before cooking. Leftovers are refrigerated after sitting on the countertop for 3 Reinforced client teaching about food safety. Follow-up visit scheduled in 2 weeks.

Day 14:

At client's home to collect follow-up data on food safety. Uses one cutting board to prepare raw meats and a different cutting board to prepare raw vegetables. The refrigerator is set to 5.60 C (420 F). Leftovers are discarded after 2 days in refrigerator. Frozen foods are defrosted in the refrigerator. Client washes hands for 1 5 seconds before cooking. Leftovers are refrigerated after sitting on the countertop for 2 hr.

Day 1, 1630:

Medication Administration Record

Metoprolol 50 mg PO BID

Simvastatin 40 mg PO daily at bedtime

Medication Administration Record

Metoprolol 50 mg PO BID

Simvastatin 40 mg PO daily at bedtime

6 months ago:

Client present today for annual examination. Reports lack of

sleep and increased stress due to moving and starting a new

job.

Today, 1400:

Client presents to office today with reports of fatigue. Client

states they have difficulty sleeping without drinking four or five

beers a night. Client reports, "l sometimes get headaches along  

with nausea and vomiting. I have been busy with my new job, so

I have been eating a lot of fast food, and I've gained 15 pounds."

Today, 1445:

Provider notified of laboratory results.

1 050:

Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the mid abdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify, rebound tenderness noted. Client reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea. Peripheral IV to the left forearm with IV fluids infusing.

1 200: Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expresses concerns about potential complications that could result from the surgery.

0800:

The client is alert and oriented to person, place, and time.

Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.

1000:

Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.

1 004:

Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen  3 L/min via nasal cannula. Oxygen saturation 95%.