Wednesday, June 2, 2010

Nurse's Case Notes

Rudee, this one is for you, babe.

Bed 1, Harry C., male, 13yrs
Dx: Fracture L 3rd metatarsal
Radiology: repeat X ray 3 june 2010; Orthopedic surgeon to review fracture and remove pins.
Nursing notes: Harry woke at 0700hrs. Pleasant mood as usual. Fed self. Performed self care & hygiene tasks using Right hand. Eating and drinking normally. Attended school. Refrained from jumping off anything high. Nil complaints voiced.

Bed 2, Jerome C., male, 11yrs
Dx: Recent Ear Infection and Gastroenteritis
Haemotology: blood draw, test for possible glandular fever following exposure to infected classmates.
Nursing notes: Jerome woke at 0800hrs. Temp. 37.5 degrees (normal). Complained of tiredness & Sore leg muscles following overexertion at rugby training. Requested assistance to travel to school. This was triaged as low priority. Jerome withdrew request after completing his homework quickly. Legs made a mircaulous recovery when older brother Harry was witnessed to be standing by the front door, ready to walk to school. Fed self; toileted. Encouraged oral hydration ++. Pt Neglected to attend to oral hygiene. Night staff: please request patient to complete an Oral Hygiene Contract this PM !!!!

Bed 3, Layne V., male, 38 yrs
Admitted for: Tiredness
Psychiatry: Consultant Psychiatrist Dr Gillies visited today; Dx = overworked teacher syndrome; Rx = analgesia + 20 hours of mindless escapism (liberal access to computer games)+ copious physical affection + days off work.
Medication: 40 mg ibuprofen STAT (administered 1100 hrs, 2 June 2010);
Additional Medication Charted: 10mg temazepam nocte; 500mg paracetamol as required
Dermatology: pls review ring-shaped rash on patient's lips (? caused by playing trombone?)
Nursing Notes: patient woke at 7am. Complained of tiredness. Eating and drinking normally.Attended to hygiene. Did not want to go to work. Complained of irritated mood and aural pain caused by large numbers of noisy teenagers. Patient encouraged ++ to go to work. Patient returned home at 15oo hrs. Played on Playstation 3. Patient d/charged self A.M.A to attend band rehearsal at 1800 hrs. Due to return at 2100 hrs.
Social Work: Mr V. has accrued a phenomenal 74 days of sick leave entitlement, due to never taking a sick day in the past decade. He should be encouraged to take a sick day once in a while.

Also in Bed 3 (it's a large bed!)
Mrs M. V., female, 41 yrs
Dx: Excessive creativity
Psychiatry: Consultant Psychiatrist Dr Gillies Dx: Hypercreativity Syndrome. Rx: Patient should be allowed to write, knit, and play musical instruments for most of the day. Light housework only. Advised patient re: self-care activities - exercise routine, and exposure to sunlight
Medications: efexor 225mg daily; oral vitamin D supplement
Nursing notes: Patient woke at 0750 hrs. Was observed to feed all other patients before feeding herself. Wrote using her laptop. Did housework. Drove car to gym. Spent 1 hour on treadmill. Showered. Joined husband at a cafe for lunch. Went to the bank. Returned home. Did housework. Rested for 45 minutes. Taught 3 students. Practised trumpet. Fed other patients again. Assisted Jerome C. with homework. Showed signs of irritation with Jerome. Wrote on laptop again. Fed Layne V. (grumpy) on his return from Band practice. Patient looks tired.
Social Work: Patient may be a potential referral for day spa, or 2-day cruise (therapeutic).

9 comments:

  1. Did you used to be a nurse or have you just read a LOT of patients' charts? LOL - this is awesome. Rudee [who is a nurse] did one of these [today] on a pair of socks she is knitting.

    I think my RX is the same as yours with a generous serving of PIE. heehee.

    Hope you have a great day tomorrow [suspect you are in dreamland right now. :D]

    Love ya!

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  2. Prescription

    Name: Mrs. M. V.
    Age: 41

    Rx: A getaway, preferably in the company of nobody with testosterone as a primary hormone, i.e., girlfriends.

    Directions: Gather aforementioned girlfriends and make a run for it. May repeat as necessary until feeling sane again.


    Refills: 12

    Signature: Dr. Rudee

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  3. Oh. I like Skippy's solution of pie as well. Perhaps we should all runaway to her house.

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  4. Pie is generally good, but for the tough adult cases, two fingers of a good single malt works nicely, as well.

    Cheers.

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  5. Love it! A very creative look into your day :)

    That Mrs. M. V. in bed 3 sure is one busy lady!!! I'm surprised she isn't suffering from fatigue! Patient should be checked for Energizer Bunny syndrome :)

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  6. *lmao* that was too cute!
    Where can I get the same Rx from Dr. Rudee????

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  7. make my pie cherry please! ha ha ha

    smiles, bee
    xoxoxoxoxoxo

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  8. LOVES It! I will call you over to the states when I need a prescription for my days :)

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