SBAR

Initial Observation at 0730

Goro positioned supine in bed with the head of the bed elevated to 30 degrees and siderails up. Eyes closed and unresponsive to verbal stimuli.

On 2 liter flow of oxygen by nasal cannula with SpO2 94%. Shallow respiratory effort. Peripheral IV of D5NS with KCL at 100 ml/hr via infusion pump. Urinary condom catheter draining small amount of clear amber urine. Family at bedside with call light within reach.

 

Room: 505

Patient: Goro Oishi

 

Allergies: NKA

Age: 66

 

Physician’s Orders

Weight: 165 lbs

Day/Time        Orders Signature

Mon 0700        Order Type:

Admit: Hospice care, Do Not Resuscitate.

Diagnosis: Intracerebral hemorrhage.

Allergies: None known to food or medications.

Diet: NPO

Activity: Bed rest with head of bed elevated 30 degrees. Turn and position every 2 hours.

Monitoring: Neurologic assessment to include Glasgow Coma Scale every 4 hours.

Vital signs every 4 hours.

Intake and Output every 8 hours.

Notify physician of neurologic changes, respiratory distress, and systolic BP >150 or <110.

Respiratory therapy: Oxygen at 2L per nasal cannula, titrate to keep O2 sat >93%.

Pulmonary toilet per routine. Suction prn.

IV D5 NS with 20 mEq KCl @ 100 mL/hr.

Medications: Famotidine 20 mg IVPB every 12 hours.

Artificial tears 2 drops to both eyes every 2 hours PRN.

Acetaminophen suppository 650 mg every 4 hours PRN temp greater than 101 F.

Elimination: Condom catheter to gravity drainage.

Range of motion to all extremities TID.

Nurse’s Notes

Wed 0600        Oldest son arrived from out of town after physician left. Will arrange a meeting between oldest son and physician to discuss prognosis and plan of care. Mr. Oishi’s condition remains unchanged.            Rebecca Atkins, RN

 

Pacific View Regional Hospital

6475 E. Duke Avenue

MRN: 1868042            Room: 505

Patient: Goro Oishi

Sex: Male        Age: 66

Physician: Gerald Moher, M.D.

Nurse’s Notes

Day/Time        Notes   Signature

Tue 1910         Assumed care of the patient. See EPR for assessment and care. Physician discussed with the family inserting a feeding tube and initiating enteral nutrition and discontinuing the IV therapy and IV medication. Mrs. Oishi requested more time to think about the change in therapy. Condom catheter in place to gravity drainage with adequate urine output. Range of motion done TID to all extremities.      Rebecca Atkins, RN

 

Pacific View Regional Hospital

6475 E. Duke Avenue

MRN: 1868042            Room: 505

Patient: Goro Oishi

Sex: Male        Age: 66

Physician: Gerald Moher, M.D.

Nurse’s Notes

Day/Time        Notes   Signature

Tue 1800         No change in condition.          Rubeye Nasir, RN

 

Pacific View Regional Hospital

6475 E. Duke Avenue

MRN: 1868042            Room: 505

Patient: Goro Oishi

Sex: Male        Age: 66

Physician: Gerald Moher, M.D.

Nurse’s Notes

Day/Time        Notes   Signature

Tue 0800         Assumed care of patient. See EPR for assessment and care. Family at bedside. Condom catheter in place to gravity drainage with adequate urine output. Range of motion done to all extremities.            Rubeye Nasir, RN

 

Pacific View Regional Hospital

6475 E. Duke Avenue

MRN: 1868042            Room: 505

Patient: Goro Oishi

Sex: Male        Age: 66

Physician: Gerald Moher, M.D.

Nurse’s Notes

Day/Time        Notes   Signature

Tue 0600         Family went home to rest at 2000 and will return at 0800. Mr. Oishi’s condition remains unchanged. Condom catheter in place to gravity drainage with adequate urine ouptut.     Rebecca Atkins, RN

 

Pacific View Regional Hospital

6475 E. Duke Avenue

MRN: 1868042            Room: 505

Patient: Goro Oishi

Sex: Male        Age: 66

Physician: Gerald Moher, M.D.

Nurse’s Notes

Day/Time        Notes   Signature

Mon 1900        Assumed care of patient. No change in condition. See EPR for assessment and care. Wife and youngest son at the bedside.  Rubeye Nasir, RN

 

Pacific View Regional Hospital

6475 E. Duke Avenue

MRN: 1868042            Room: 505

Patient: Goro Oishi

Sex: Male        Age: 66

Physician: Gerald Moher, M.D.

Nurse’s Notes

Day/Time        Notes   Signature

Mon 1800        Mr. Oishi’s wife and youngest son have been present all day. The youngest son would like his mother to reconsider withholding all invasive treatments and providing only palliative care. Physical assessment unchanged. Condom catheter in place to gravity drainage-adequate urine output. Range of motion done TID to all extremities.   Rubeye Nasir, RN

 

Pacific View Regional Hospital

6475 E. Duke Avenue

MRN: 1868042            Room: 505

Patient: Goro Oishi

Sex: Male        Age: 66

Physician: Gerald Moher, M.D.

Nurse’s Notes

Day/Time        Notes   Signature

Mon 0800        Assumed care of patient. See the electronic patient record for assessment and care. Minimum data set (MDS) initiated. MDS coordinator notified. Condom catheter in place to gravity drainage.

 No Laboratory Reports

 

Pastoral Care Spiritual Assessment

Date: Wednesday        Room No.: 505

Gender: Male

Age Group: Geriatric

Care Settings: Long-term care, hospice

Nature of Chaplain’s Visit: Death/dying

Primary Service to: Spouse/significant other, family

Response: Urgent

Speed of Response: Within 24 hours

Referral by: RN

Source of Hope/Hope Factors: Family

Spirituality/Faith Factors:

Faith group: Buddhist

Religious/Faith Practice:

Perception of God:

Relationship with God:

Effects of illness on spirituality:

Key Psychosocial Factors: Terminal illness/awareness of mortality

Pastoral Interventions: Ethical deliberation, counseling/dialogue, affirmation/comfort/ministry of presence, decision support/advance directives/organ donation

Outcomes: Not helpful–family is Zen Buddhist

Referral to: Zen Buddhist spiritual advisor     Accomplished?: no

Time In: 1100  Time Out: 1200

Chaplain’s Name: Alan Joyce

Chaplain’s Signature: Alan Joyce

 

Patient Education

oal #    ITEM TAUGHT PERSON TAUGHT        INITIAL TEACHING       TEACHING REINFORCEMENT  TEACHING REINFORCEMENT

DATE   LEVEL  DATE   LEVEL  DATE   LEVEL

1          Palliative care S, OF    Mon     2          Tue      2          Wed     3

2          Turn and position        S, OF    Mon     2          Tue      2          Wed     3

2          Artificial tears S, OF    Mon     2          Tue      2          Wed     3

2          Oxygen therapy           S, OF    Mon     2          Tue      2          Wed     3

2          Pulmonary toilet         S, OF    Mon     2          Tue      2          Wed     3

2          Medications    S, OF    Mon     2          Tue      2          Wed     3

2          IV         S, OF    Mon     2          Tue      2          Wed     3

2          Diagnosis         S, OF    Mon     2          Tue      2          Wed     3

 

Chief Complaint:

“Worst headache of his life”

History of Present Illness:

On Sunday afternoon while Mr. Oishi was at home visiting with his wife and the family of his youngest son, he experienced a sudden, severe headache which he described to his wife and son as “the worst headache of his life.” Within minutes, he experienced numbness and weakness of his left face, arm, and leg and was having increasing difficulty speaking and understanding simple statements. His wife called 911, and by the time the ambulance arrived, his level of consciousness was declining and he was making incomprehensible sounds. He met all six criteria on the Los Angeles prehospital stroke scale. IV and oxygen therapy were initiated, and Mr. Oishi was transported to the Emergency Department. Upon arrival to the Emergency Department, Mr. Oishi was found to have a Glasgow Coma Scale of 4 (does not open eyes with painful stimuli, abnormal extension of right extremities to painful stimuli, no movement of the left extremities, and no verbal response). His pupils were unequal with the left pupil 1 mm larger than the right pupil 4 mm/3 mm, and both pupils had a sluggish reaction to light. His blood pressure was 190/110, and pulse oximetry was 93% on oxygen therapy of 2 liters per nasal cannula. His CT scan revealed a large right internal capsule intracerebral hemorrhage. EKG showed a normal sinus rhythm, left axis deviation with right bundle branch block. PA CXR showed heart size and pulmonary vasculature within normal limits. No opacification or pleural effusions. Labs done during acute care admission: RBC 4.01, WBC 4.6, Hgb 14.2, Hct 45, platelets 300, glucose 104, Na 139, K 4.5, Cl 105, CO2 28, CHOL 211, triglycerides 180, HDL 39, LDL 117, HDL/LDL 5.41, PT 11.6, INR 1.0, PTT 35, blood alcohol 100. Prognosis and treatment options were discussed with Mr. Oishi’s wife and youngest son. Mrs. Oishi, in light of a poor prognosis, declined any treatment that includes invasive procedures. The youngest son disagrees with his mother and has requested more aggressive therapy. Mr. Oishi was transferred to the ICU Sunday night while arrangements could be made for hospice care in a Skilled Nursing Facility. Mr. Oishi received Nitroprusside 50 mg in 250 mL D5W to titrate systolic BP <140 >110, Mannitol 25% solution to decrease intracranial pressure, Famotidine 20 mg IV to prevent stress ulcers, and IV therapy of D5 NS with 20 mEq KCl at 100 mL per hour. On Monday morning, Mr. Oishi’s blood pressure stabilized to a systolic BP of 140-150. The Nitroprusside and Mannitol were discontinued. He was transferred to skilled nursing for hospice care.

Allergies:

None known to food or medication.

Past Medical History:

Hypertension for the past 10 years which has been controlled by medication (Amlodipine/ Benazepril 2.5/10 mg every morning) until the past year when he began experiencing a high degree of stress over his company failing. Hyperlipidemia for the past 5 years controlled by medication (Atorvastatin 20 mg at bedtime). No hospitalizations.

Surgical History:

None

Gyn History:

N/A

OB History:

N/A

Social History:

Mr. Goro Oishi has been married to Mrs. Hiroko Oishi for 40 years. He enjoys a close and happy relationship with his wife. He has 2 married sons age 32 and 37. His youngest son lives in town and his oldest son lives out of town. Mr. Oishi is the owner and CEO of a small electronics company that up until a year ago was doing well. This past year the company has been failing. Mr. Oishi has been under a great deal of stress. He has been abusing alcohol for the past 6 months and has been hiding it from his wife and sons. His wife has suspected that he was abusing alcohol, but never confronted him. Mr. Oishi has been discussing retiring and having his youngest son take over the position of CEO of the company. Now that the business is failing he fears he will have no way to support his family and nothing left to leave his sons.

Family History:

Deferred

Medications:

Amlodipine/Benazepril 2.5/10 mg every morning

Atorvastatin 20 mg at bedtime

Review of Systems:

Other than mentioned in the HPI, noncontributory

 

Physical Exam:

GENERAL:

Comatose

VITAL SIGNS:

BP 140/70

P 72

R 20

T 98.8 (tympanic)

O2 sat 94% on oxygen at 2 liters per nasal cannula

HEENT:

The head is normocephalic without masses or lesions. Eyes deviate to the right. Pupils are unequal 4 mm/3 mm with the left pupil 1 mm larger than the right. Both pupils have a sluggish reaction to light. Sclera are nonicteric. Tympanic membranes are clear. Oral cavity is pink and moist and there are no masses or lesions. Neck is supple. No thyromegaly, lymphadenopathy, or masses. Tonsils are present.

LUNGS:

Chest expansion is shallow but symmetrical. Breath sounds are relatively clear with scattered rhonchi and diminished breath sounds both bases.

HEART:

S1 S2. Regular rate and rhythm. No gallops. No murmurs.

ABDOMEN:

Soft with no hepatosplenomegaly. No palpable masses. Bowel sound hypoactive in all four quadrants.

EXTREMITIES:

No movement on the left. Decerebrate rigidity to painful stimuli on the right. No clubbing, cyanosis or edema. Peripheral pulses present and 2+.

SKIN:

Cool and dry. No gross lesions.

BACK:

No kyphosis noted.

GENITALIA:

No skin lesions in perineal region. No masses. Stool negative for occult blood. Sphincter tone diminished. Prostate exam deferred.

NEUROLOGIC:

Glasgow Coma Scale = 4. Does not open eyes with painful stimuli, no movement on the left, decerebrate rigidity to the right exteremities, no verbal response. Negative Babinski.

Impression:

1. Intracerebral hemmorrhage right internal capsule.
2. Coma.

Plan:

1. Admit Skilled Nursing Unit for hospice care.
2. Do Not Resuscitate.
3. See admission orders. History and Physical

 

 

Acute Care Kardex

Medical Diagnosis:      Intracerebral hemorrhage–hospice care

DATE INITIATED          PROBLEMS      OUTCOMES

Bladder/Bowel Elimination

Patient will have adequate bowel and bladder function.

Bone Marrow Transplant

Patient/Family will achieve understanding of tests, pretransplant conditioning, procedures, illness condition, prognosis, and plan of care.

Cardiac

Patient/Family will maintain stable cardiac status.

Chemotherapy

Patient/Family will achieve understanding of their disease process and effects of chemotherapy.

Patient will achieve optimal effects of chemotherapy without severe side effects.

Comfort/Pain

Patient will have reduced or minimal pain.

Development

Patient will maintain or progress along in the developmental continuum during hospitalization.

Discharge

Patient/Family will be discharged possessing the necessary knowledge and skill to meet their continuing care needs.

Fluid/Volume/Electrolyte Imbalance

Patient will maintain fluid and electrolyte balance.

Hematology

Patient will participate in ADLs with minimal discomfort.

Patient/Family will achieve understanding of their disease process.

Infection

Patient will be free of signs and symptoms of infection.

Neuro

Patient will achieve optimal neurobehavior functioning.

Nutrition

Patient will demonstrate optimal nutritional intake.

Patient will demonstrate improved oral motor, swallowing, feeding ability.

Monday           Psychosocial

Patient/Family will be fostered to optimize bonding and attachment.

Monday           Respiratory

Patient will demonstrate optimal respiratory function.

 

DATE INITIATED          PROBLEMS      OUTCOMES

Monday           Safety

Patient will be provided with safe environment of care, avoiding any accidental injury.

Monday           Skin Integrity

Patient will be free of signs and symptoms of impaired skin integrity.

Monday           Spiritual/Cultural

Patient/Family will be provided an environment which supports their spiritual and cultural needs.

Monday           Thermoregulation

Patient will maintain temperature within normal range.

 

 

 

 

 

 

 

ADMISSION INFORMATION

Admitting Diagnosis:

Intracerebral hemorrhage

History:

Hypertension, hyperlipidemia

SURGERY

Date    Type

 

 

 

MONITORING

Code Status:

Full

Partial

DNR

VS: q4h            NVS: GCS q4h

Cardiac Monitor Limits:

 

MD Order

Per Protocol

Heart Rate:      Resp Rate:

Pulse Ox: continuous   Apnea Mon:

Weight:

Daily:                Weekly:

Pain Management

PCA/NCA:

Drug:

Concentration:

Continuous Dose:

Intermittent Dose:

Lockout:

4 Hour Maximum Dose:

Epidural:

Drug(s):

Rate:

Location:

PATIENT INFORMATION

Primary Language: English

Physical Impairments: Comatose with no movement left extremities

Assistive Devices:

ALLERGIES/REACTIONS

Drugs: None

Foods: None

Blood Products: None

ISOLATION/PRECAUTIONS

Date    Type

 

 

 

FLUID/NUTRITION

Diet:

NPO

IV Therapy:

 

Peripheral

PVC

CVC

 

Midline

PICC

Date    Site      Solution           mL/hr

Mon     R FA     D5 NS with 20 mEq KCl           100

 

 

ELIMINATION

I/O: Every 8 hours

Ostomy:

Foley: Condom catheter         Size:

Intermittent Cath:       Size:

NGT/OGT (Date):

Suction:

G-Tube:

ACTIVITY

 

Bedrest

BRP

Chair

 

Ambulate

Out of Bed

 

Other

Mode of Transportation:

 

A

W

S

C

 

RESPIRATORY

FiO2: Keep sat >93%   O2 Device: Wall O2

Mode: Nasal cannula  Rate: 2L flow

PEEP/Pressure:

TV:       IS:

CPT:       Freq:

Tx:         Freq:

CPAP/BiPAP:

Trach Branch:  Size:

Date Changed:

Chest Tube #1:   cm    H20Seal:

Chest Tube #2:   cm    H20Seal:

LABS

Time    Scheduled

QAM

Q6H

Q12H

 

Time    Bedside Testing

 

 

SCH      ORD                 DONE

 

 

 

 

 

 

 

PRIMARY TEAM

Attending:       Gerald Moher, M.D.

 

 

FAMILY CONTACTS

Name  Phone

Hiroko Oishi (wife)      555-623-0245

Nimashi Oishi (son)     555-434-3809

Kiyoshi Oishi (son)       555-623-1206

INTERVENTIONS

Date

Mon     Range of motion exercises TID

Mon     Notify physician of neurological changes, respiratory distress, and systolic BP >150 or <110

Mon     Keep head of bed elevated 30 degrees

Wed     Family conference to discuss plan of care

 

SCH      ORD                 DONE

 

 

DIAGNOSTIC PROCEDURES

SCH      ORD                 DONE

 

 Current Medications

Mon

0700

Famotidine

20 mg

IV

every 12 hours            0800

Mon

0700

Dextrose 5% in NS w/ 20 mEq Potassium chloride

1000 mL

IV

Continuous

PRN Medication Administration Record

Wednesday

Acetaminophen

650 mg

suppository/ per rectum

every 4 hours PRN temp greater than 101 F

Mon

0700

Artificial tears

2 drops

to both eyes

every 2 hours PRN

 

 

 

Current vital sign

 

BP 171/85,  oxygen 91, temperature  101.5,  heart rate 90 ,  Respiration rate 21 , pain 0