Robert Caudill is a 72-year-old male admitted from his provider's office today. His daughter
noticed a decrease in mental status with some sweating and agitation. He was seen in the office
and found to have hypoglycemia and hypertension. He has a history of coronary artery disease,
hypertension, type 2 diabetes, and early Alzheimers disease.
You have 10 minutes to complete this phase.
Press the Pause button when not actively charting.
To exit SimChart, press the Logout button in the upper-right corner of the screen.
The charge nurse has started the admission process on Mr. Caudill. She asks you to obtain the
patient's height and weight. You assist Mr. Caudill to the bedside scale. He comments his feet
have been bothering him with numbness and tingling. His weight is 150 lbs, and his height is
5'7". His daughter states "Wow, dad you have lost some weight." You record the height and
weight and review the chart to gather information to start your plan of care.
[LEARNER ACTION: Document the height and weight. Review the patient's admission orders,
history and physical, and patient assessment. In a Misc. Nursing note describe your findings from
this review that are important to note.]
weight is 150 lbs 5'7". lost some weight
Completing the admission assessment for mr. Caudill, I noticed he is observing signs of diabetic
neuropathy with a new onset of numbness and tingling in his feet. The client has a past medical
history of type 2 diabetes, coronary artery disease, and hypertension. His daughter mentioned
weight loss.
You start a peripheral intermittent lock in the median vein in the right forearm as ordered; the
insertion site is clean and dry, a transparent dressing was placed over the site and dated, and the
IV is patent and flushes easily.
[LEARNER ACTION: Document your care in the EHR in the IV form.]
When you have completed the above tasks, you may click Complete this Phase.
, Diagnosis: hypertension, hypoglycemia
Full Code
Diet: Low Carbohydrate 1800 cal diet
Activity: Bathroom privileges with assistance
Monitoring:
1. Vital signs every hour until blood pressure less than 160/90
2. Intake and output every shif
3. Heparin lock for intermittent medication, peripheral site
4. Fingerstick glucose upon admission and every 4 hours; notify physicain if blood sugar is less
than 60 or greater than 180
Medications:
1. Labetalol 20 mg IV every 15 minutes until blood pressure less than 160/90 (max total of 300
mg)
2. Donepezil 10 mg PO daily
Labs:
1. Complete blood count
2. Basic metabolic panel
3. Urinalysis
hypertension
DM
Chart:System Assessments Thu 17:30
Entry Time:Thu 17:30
Entered By:P Jaynes, RN
Cardiovascular Assessment
noticed a decrease in mental status with some sweating and agitation. He was seen in the office
and found to have hypoglycemia and hypertension. He has a history of coronary artery disease,
hypertension, type 2 diabetes, and early Alzheimers disease.
You have 10 minutes to complete this phase.
Press the Pause button when not actively charting.
To exit SimChart, press the Logout button in the upper-right corner of the screen.
The charge nurse has started the admission process on Mr. Caudill. She asks you to obtain the
patient's height and weight. You assist Mr. Caudill to the bedside scale. He comments his feet
have been bothering him with numbness and tingling. His weight is 150 lbs, and his height is
5'7". His daughter states "Wow, dad you have lost some weight." You record the height and
weight and review the chart to gather information to start your plan of care.
[LEARNER ACTION: Document the height and weight. Review the patient's admission orders,
history and physical, and patient assessment. In a Misc. Nursing note describe your findings from
this review that are important to note.]
weight is 150 lbs 5'7". lost some weight
Completing the admission assessment for mr. Caudill, I noticed he is observing signs of diabetic
neuropathy with a new onset of numbness and tingling in his feet. The client has a past medical
history of type 2 diabetes, coronary artery disease, and hypertension. His daughter mentioned
weight loss.
You start a peripheral intermittent lock in the median vein in the right forearm as ordered; the
insertion site is clean and dry, a transparent dressing was placed over the site and dated, and the
IV is patent and flushes easily.
[LEARNER ACTION: Document your care in the EHR in the IV form.]
When you have completed the above tasks, you may click Complete this Phase.
, Diagnosis: hypertension, hypoglycemia
Full Code
Diet: Low Carbohydrate 1800 cal diet
Activity: Bathroom privileges with assistance
Monitoring:
1. Vital signs every hour until blood pressure less than 160/90
2. Intake and output every shif
3. Heparin lock for intermittent medication, peripheral site
4. Fingerstick glucose upon admission and every 4 hours; notify physicain if blood sugar is less
than 60 or greater than 180
Medications:
1. Labetalol 20 mg IV every 15 minutes until blood pressure less than 160/90 (max total of 300
mg)
2. Donepezil 10 mg PO daily
Labs:
1. Complete blood count
2. Basic metabolic panel
3. Urinalysis
hypertension
DM
Chart:System Assessments Thu 17:30
Entry Time:Thu 17:30
Entered By:P Jaynes, RN
Cardiovascular Assessment
