Pt. name: Dale Mayman Admitting Physician: Dr. S Phillips
Age: 51 DOB: 11/13/xx Bed: ER Bed 2
Admitting diagnosis: Confusion bleeding gums
Pt. ID # 542768 Med Rec #: 78543
Wt. lbs: 172 kg: 78 Ht.: 71 inches Race:Caucasian
Major Support: Wife
Religion:Not stated
Immunizations: current
Allergies: Ace inhibitors (angioedema)
Nursing Map of Care |
Complete Patient Assessment |
Current MAR
Medication History:
Order # |
Med/dose |
Route/schedule |
Reason |
Date started |
|---|---|---|---|---|
#1 |
100 mg PO Daily |
diuretic |
||
#2 |
40 mg PO Daily |
diuretic |
||
#3 |
Inderal (hold if HR<60, SBP < 100) |
10 mg PO BID |
Blood Pressure |
|
#4 |
1 tab PO Daily |
Muti-vitamin |
||
#5 |
30 mL PO Daily | elevated ammonia levels |
||
#6 |
1 gram IVPB Q 12 hrs |
antibiotic |
||
#7 |
3.375 mg IVPB Q 6 hrs |
antibiotic | ||
| #8 | ||||
#9 |
||||
#10 |
||||
#11 |
||||
#12 |
|
| ||
