Delirium and Altered Liver Function due to Excessive Alcohol Intake

QUESTION

Do short progress note for each scenario 

Scenario 1: Mr Girish Chandrin, 62 years old is admitted with delirium and altered liver function secondary to excessive alcohol intake. Patient is prescribed IV medication to be commenced. You are required to administer the medications prescribed.

Scenario 2: Mrs Catherine Osborne, 38 years old is admitted with gastritis and anaemia. Patient is prescribed IV PPI to be commenced asap. You are required to administer the medications prescribed.

Scenario 3: Mr Luigi Presso, 56 years old is admitted with congestive heart failure. Patient is fluid overloaded and is prescribed IV diuretics to be commenced asap. You are required to administer the medications prescribed.

ANSWER

Scenario 1 Progress Note

Patient: Mr. Girish Chandrin
Age: 62 years
Diagnosis: Delirium and Altered Liver Function due to Excessive Alcohol Intake
Medication: IV Medication (Prescribed)

Progress:
Administered prescribed IV medication to Mr. Chandrin as ordered. Patient’s vital signs monitored before and after administration. Patient remained stable throughout the process. Nursing assessment performed post-administration, and no immediate adverse reactions observed. Informed patient about the medication and its purpose, addressing any concerns. Documented administration details in the patient’s electronic health record (EHR) accurately. Noted the importance of patient education on alcohol cessation and its impact on liver function.

Scenario 2 Progress Note

Patient: Mrs. Catherine Osborne
Age: 38 years
Diagnosis: Gastritis and Anaemia
Medication: IV Proton Pump Inhibitor (PPI) (Prescribed)

Progress:
Administered prescribed IV PPI medication to Mrs. Osborne promptly, following the healthcare provider’s instructions. Ensured patient comfort during the process and monitored vital signs before and after administration. No immediate adverse reactions observed. Communicated with Mrs. Osborne about the medication’s purpose, emphasizing the importance of adherence. Instructed the patient to report any discomfort or changes. Recorded the administration details accurately in the EHR. Nursing team coordinated with the dietary department to provide appropriate nutrition considering the gastritis diagnosis.

Scenario 3 Progress Note

Patient: Mr. Luigi Presso
Age: 56 years
Diagnosis: Congestive Heart Failure (CHF)
Medication: IV Diuretics (Prescribed)

Progress

Administered prescribed IV diuretics to Mr. Presso as part of his CHF management. Monitored patient closely before, during, and after medication administration. Patient’s fluid status assessed to ensure appropriate diuretic dosage. No immediate adverse effects observed. Educated Mr. Presso about the importance of fluid balance management in CHF and encouraged adherence to prescribed treatment. Assisted in positioning the patient comfortably to facilitate fluid removal. Documented medication administration details accurately in the EHR. Coordinated with the healthcare team to monitor the patient’s response to diuretics and adjust treatment plan if necessary.