Nurses' Notes
Day 1, 0800:
The client was admitted 2 days ago from the emergency department for recurrent upper abdominal pain. The client is resting in a lounge chair at the bedside and denies pain is present. In addition to the medical history, the client discloses alcohol use, "one to two beers every day and a recent fall at home without injury. "I get clumsy every once in a while." Client reports occasional marijuana use, "I like the gummies, but only on weekends,"
2000:
Client holding abdomen, reports nausea and epigastric pain rated at 7 on a 0 to 10 pain scale, medicated with oxycodone/acetaminophen as prescribed. Client reports they have been up to the bathroom frequently due to urinary urgency, "I have a big prostate, so I have to go when I have to go, otherwise I pee on myself."
Vital Signs
0800:
Temperature 36.4° C (97.5° F)
Heart rate 78/min
Respiratory rate 18/min
Blood pressure 146/84 mm Hg
2000:
Temperature 36.4° C (97.5° F)
Heart rate 64/min
Respiratory rate 18/min
Blood pressure 122/72 mm Hg
Medication Administration Record
0800:
terazosin 5 mg PO daily
acetaminophen 1,000 mg PO every 4 to 6 hr as needed for pain
famotidine 20 mg PO at bedtime
oxycodone/acetaminophen 5/325 mg PO every 6 hr for moderate to severe pain
atorvastatin 40 mg PO daily
allopurinol 100 mg PO daily
2000:
oxycodone/acetaminophen 5/325 mg PO
History and Physical
0800:
Hypertension
Benign prostatic hypertrophy (BPH)
Peptic ulcer disease
Pancreatitis
Gout
Assessment
2200:
Neurological: pupils are, and oriented x2, moving of extremities are equal strength, pupils are equal, are reactive to light and accommodation.
Cardiovascular: color pink, skin warm and dry, glucture 50, S2 noted with regular rhythm, pulses 2+ to all extremities, no edema appreciated.
Gastrointestinal: abdomen round, soft, non-tender, bowel sounds present in all quadrants.
Urinary: voiding without difficulty, reports frequency and urgency of events.
2200:
Neurological: pupils are and oriented x 2, moving of extremities are equal strength, pupils are equal, reacted are reactive to light and accommodation.
Cardiovascular: color pink, skin warm and dry, glucture 50, S2 noted with regular rhythm, pulses 2+ to all extremities, no edema appreciated.
Gastrointestinal: abdomen round, mid-epigastric tenderness with light palpation, bowel sounds present in all quadrants.
Urinary: voiding without incident difficulty.
