Skills Check-off Scenarios

Scenario I
The following scenarios were designed for the beginning of the semester skills check-offs
for the fourth semester students. The skills including vital signs, IV medications,
abbreviated physical assessments and catheterizations.

Objectives:
1. Assessment and recognition of the signs and symptoms of congestive heart failure
a. Assess for respiratory problems related to congestive heart failure
b. Assess vital signs related to congestive heart failure
c. Assess for dysrhythmias
d. Assess Intake and Output for other signs of fluid retention.
2. Initiate interdisciplinary collaboration in a hospital setting.
a. Report changes in the patient’s condition to the physician
b. Implement new orders received from the physician
c. Chart findings on the appropriate charting sheets
3. Select appropriate interventions
a. Check vital signs.
b. Oxygen – Apply 2-4 L/nasal cannula as ordered
c. Insert a Foley catheter
d. Complete an assessment specific to evaluate congestive heart failure.
e. Administer an IV medication
4. Monitor therapeutic response to interventions (Outcomes).
a. Monitor that patient will not have difficulty breathing and will maintain
oxygen saturations at > 90%.
b. Monitor urinary output

Case study: You are working the day shift at Butler Simulation Hospital. John Sims, a
seventy-five year old male was admitted to your unit with hypertension, peripheral edema
and shortness of breath. He has a past history of congestive heart failure. He was started
on oxygen at 4 L via nasal canula and given 40 mg furosemide IV in the ER. His chest x-
ray showed bilateral effusions in both lower lobes of his lungs. The ER doctor sent
preliminary orders and said his primary care doctor would be in to write further
medication orders. In report the ER nurse told you that John had taken his digoxin and
aspirin this AM. It is now 1300. Begin initiating the orders from the order sheet.
 Butler Clinical Learning Center Simulation Orders

ORDERED Name: John A. Sims DOB 5/11/32

DATE TIME
0730 ADMIT TO: ⌧Telemetry Floor Non-telemetry Floor
DIAGNOSIS: Diabetes, R/O Myocardial Infarction, ⌧CHF, S/P CABG, Chest Pain,
Head Injury, Stroke, GI Bleed, S/P Lung surgery______, S/P abdominal surgery____,
S/P ortho surgery_______, MVC________, HTN,
Cancer____________ Other_____________
ALLERGIES: ⌧No Yes If yes, list:

ACTIVITY: Bedrest ⌧ BRP Activity as tolerated Other:

I&O
VITAL SIGNS: ⌧ Every 4 hours Every shift Other:
⌧O2 Sats. Q shift
DIET: NPO Clear liquid ⌧2gm Low Na, low fat, 1800kcal ADA, 2000kcal ADA
Other _________________________________
⌧ IV: Saline Lock D51/2NS with 20mEq KCL TRA _______
0.9% Sodium Chloride IV TRA _____ Lactated Ringers TRA _______
Other: ________________________________
O2: None 2Liters/minute via Nasal Cannula Other: ___________
⌧ titrate to keep sats > 90%
MEDICATIONS:
⌧ Aspirin non enteric coated 325 mg po daily
Acetaminophen 650mg po q 6 hours prn pain or temp > 101.5 F.
⌧ laxative of choice
Zolpidem 5 mgs prn HS
⌧ NS flush IV BID and prn for IV flush
Others__Nitroglycerin 0.4 mg SL prn chest pain q 5 minutes x 3

Digoxin 0.5 mg po q. AM

Repeat furosemide 40 mg IV x1 after admission to floor

______________________________________________________________
(Treatments) ⌧ Place Foley to DD
Dressing Changes _______________________________
Place NG Tube
Other _________
LAB TESTS:
CBC Chem 7 Routine UA
Others________________________________
X-Rays: ⌧ chest x-ray in AM Other ________________________________
ECG stat if chest pain occurs, notify MD
Additional orders

Date________ Time_1115____ Signature: Dr. Chester Hart Patient ID

Developed by dms Butler Community College

 Butler Clinical Learning Center Medication Sheet

NURSING STATION WORKSHEET (MAR FORMAT)

ROOM- PATIENT DOB WT AGE/SEX ADM DATE ATTENDING

BED John A Sims 5/11/32 81 kg 75/male today PHYSICIAN
B5 Dr. Hart
DRUG ALLERGIES: No known allergies
MEDICATION ROUTE/SIG ORDERING DOSE 0800-1559 1600-2359 0000-0759

Furosemide IV on admission 40 mg
to floor

Digoxin po 0.5 mg 0900

Aspirin po 325 mg 0900

MOM po prn 30 ml

Nitroglycerin SL prn chest pain 0.4 mg

q 5 min. x 3

Normal Saline Flush IV bid and prn 0900 2100

Signature/Initials
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______

Developed by faculty Butler Community College

 LABORATORY REPORT

Date Time Exam Result

0845
CBC
RBC 5.2 mc/L
WBC 6400 mc/L
Hct. 42%
Hgb 13 gm/dL
Platelet 160,000 ul
MCV 84 f
MCH 28 pg/cell
MCHC 33 gm/dL

0845 BMP
Sodium 135 mEq/L
Potassium 2.9 mEq/L (L)
Chloride 96 mEq/l
Magnesium 2.1 mg/dL

0845 ABGs
pH 7.35
PaCO2 35 mm Hg
PaO2 77 mm Hg (L)
SO2 88 % (L)

Developed by dms at Butler cc

 REPORT OF MEDICAL HISTORY Date of Exam

Note: This information is for official and medically-confidential

MEDICAL RECORD
l use only and will not be released to unauthorized persons.
1. Name of Patient (First, Middle, Last) 2. Identification Number 3. Date of Birth
John A Sims 004303336 5/11/32
4a. Home street address 5. Examining Facility
511 Eleventh St. Butler Community College
4b. City State Zip Code Simulation Hospital
Yourcity KS 67042
6. Patient’s occupation 7a. Height b. Weight
Homemaker 5’10” 81 Kg
8. Current Used Medications at Home 9. Allergies ( include medications, latex, bee stings and food)
Digoxin 0.125 mg daily
Capoten 25 mg bid Penicillin

10. Past/Current Medical History

Check Each Item Yes No Don’t Check Each Item Yes No Don’t Check Each Item Yes No Don’t
Know Know Know
Household Contact with anyone x Shortness of Breath x Bone or join deformity x
with tuberculosis
Tuberculosis or positive TB test x Pain or Pressure in chest x Loss of finger or toe x
Blood in Sputum or when x Chronic Cough x Painful shoulder or elbow x
coughing
Excessive bleeding after injury or x Palpitation or pounding heart x Recurrent back pain or any x
dental work back injury
Suicide attempt or plans x Heart trouble x Knee injury x
Sleepwalking x High blood pressure x Foot trouble
Wear corrective lenses x Low blood pressure x Nerve injury x
Eye surgery to correct vision x Cramps in your legs x Paralysis x
Complete vision loss in either eye x Frequent Indigestion x Epilepsy or seizure x
Wears a hearing aid x Stomach, liver, or intestinal x Car, train, or sea sickness x
trouble
Stutters or Stammers x Gall bladder trouble x Frequent trouble sleeping x
Wears a brace or back support x Jaundice or Hepatitis x Depression or excessive x
worry
Scarlet fever x Broken bones x Loss of memory x
Rheumatic fever x Skin diseases x Nervous trouble of any sort x
Swollen or painful joints x Tumor, growth, cyst, or Cancer x Periods of unconsciousness x
Frequent or severe headache x Hernia x Parent/sibling with diabetes, x
Dizziness or fainting spells x Hemorrhoids or rectal Disease x cancer, stroke or heart
disease.
Eye Trouble x Frequent or painful urination x X-Ray or other radiation x
therapy
Hearing Loss x Bed wetting since age 12 x Chemotherapy x
Recurrent ear infections x Kidney stones or blood in urine x Asbestos or toxic chemical x
exposure
Chronic or frequent colds x Sugar or Protein in urine x Plate or pin in any bone x
Severe tooth or gum trouble x Sexually transmitted disease(s) x Been told to cut down or x
Sinusitis x Recent gain or loss of weight x criticized for alcohol use

Hay Fever or allergic rhinitis x Eating Disorder x Easily fatigued x

Head injury x Arthritis, Rheumatism, or x Used illegal substances x
Bursitis
Asthma x Thyroid trouble x Used tobacco x
11. Females only answer section 11
Check each item Yes No Don’t Know Date of last menstrual period Date of last pap smear Date of last mammogram
Treated for a female disorder
Change in menstrual pattern

Check each item. If “yes,” explain in blank space to right. List explanation by item number.
ITEM Yes No
12. Have you been refused employment or been unable
to hold a job or stay in school because of:
a. Sensitivity to chemicals? x
b. Inability to perform certain motions? x
c. Inability to assume certain positions? x
d. Other medical reasons? (If yes, give reasons.) x
13. Have you ever been treated for a mental condition? x Heart problems 2004
(If yes, describe and give age at which occurred.)
14. Have you had, or have you been advised to have, any x
operation? (If yes, describe and give age at which
occurred.)
15. Have you ever been a patient in any type of hospital? x
(If yes, specify when, where, why, and name of doctor
and complete address of hospital.)
16. Have you consulted or been treated by clinics, x
physicians, healers, or other practitioners within the past
5 years for other than minor illnesses? (If yes, give
complete address of doctor, hospital, clinic, and details.)
17. Have you ever been discharged from military service x
because of physical, mental, or other reasons? (If yes,
specify.)
18. Have you ever received, is there pending, or have x
you ever applied for pension or compensation for
existing disability? (If yes, specify what kind, granted by
whom, and reason.)
19. Have you ever been diagnosed with a learning x
disability? (If yes, give type and what is needed to help
overcome.)
20. List all immunizations received

Polio, Tetanus, Pneumonia

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors,
hospitals, or clinics and their staff that are directly providing management of my care to review and input data into the Medical Record in accordance with local, state,
and federal laws.
24a. Typed or Printed Name 24b. Signature 24c. Date
John Sims JohnSims
NOTE: THIS DOCUMENT WILL BE PLACED IN THE MEDICAL RECORD
25. Physician’s summary and elaboration of all pertinent data.

Chronic Heart Failure

Pleural effusion

26a. Typed or Printed Name of Physician or Examiner 26b. Signature 26c. Date Patient Label Here

Dr. Simulation Getwell Dr. Simulation

Getwell

Designed by mt revised by dms Butler Community College

 Skills Check-off Scenarios
Scenario II

The following scenarios were designed for the beginning of the semester skills check-offs
for the fourth semester students. The skills including vital signs, IV medications,
abbreviated physical assessments and catheterizations.

Objectives:
1. Assessment and recognition of the signs and symptoms of pulmonary edema
related to renal failure
c. Assess for respiratory problems related to pulmonary edema
d. Assess vital signs related to renal failure/pulmonary edema
e. Assess for respiratory distress
f. Assess Intake and Output for other signs of fluid retention.
2. Initiate interdisciplinary collaboration in a hospital setting.
g. Report changes in the patient’s condition to the physician
h. Implement new orders received from the physician
i. Chart findings on the appropriate charting sheets
3. Select appropriate interventions
j. Check vital signs.
k. Oxygen – Apply 2-4 L/nasal cannula as ordered
l. Insert a Foley catheter
m. Complete an assessment specific to evaluate pulmonary edema.
n. Administer an IV medication
4. Monitor therapeutic response to interventions (Outcomes).
o. Monitor that patient will not have difficulty breathing and will maintain
oxygen saturations at > 90%.
p. Monitor urinary output

Case study: It is shift change and you were assigned Joel A Sims who was admitted to
your unit yesterday with a new diagnosis of renal disease. The night nurse reports that
about one hour ago Joel had difficulty breathing and crackles in both lungs. His blood
pressure is steadily rising. At 0630 it was 172/114. She notified the physician. He
ordered stat Bumetanide and Hydralazine along with some other new orders. She gave
the Bumetanide and was waiting for the Hydralazine to arrive from the pharmacy. X-ray
was just completing the portable chest x-ray. The unit secretary calls that the hydralazine
has just arrived from pharmacy. Using the order sheet begin the care on your patient.
 Butler Clinical Learning Center Simulation Orders

ORDERED Name: Joel A. Sims DOB 12/23/32

DATE TIME
1500 ADMIT TO: ⌧Telemetry Floor Non-telemetry Floor
DIAGNOSIS: Diabetes, R/O Myocardial Infarction, CHF, S/P CABG, Chest Pain,
Head Injury, Stroke, GI Bleed, S/P Lung surgery______, S/P abdominal surgery____,
S/P ortho surgery_______, MVC________, HTN, Cancer____________ Other: renal
disease
ALLERGIES: ⌧No Yes If yes, list:

ACTIVITY: Bedrest ⌧ BRP Activity as tolerated Other:

I&O
VITAL SIGNS: ⌧ Every 4 hours Every shift Other:
⌧O2 Sats. Q shift
DIET: NPO Clear liquid 2gm Low Na, low fat, 1800kcal ADA, 2000kcal ADA
Other ___renal diet__800 ml per day fluid restriction
⌧ IV: Saline Lock D51/2NS with 20mEq KCL TRA _______
0.9% Sodium Chloride IV TRA _____ Lactated Ringers TRA _______
Other: ________________________________
O2: None 2Liters/minute via Nasal Cannula Other: ___________
⌧ titrate to keep sats > 90%
MEDICATIONS:
Aspirin non enteric coated 325 mg po daily
⌧ Acetaminophen 650mg po q 6 hours prn pain or temp > 101.5 F.
⌧ laxative of choice
Zolpidem 5 mgs prn HS
⌧ NS flush IV BID and prn for IV flush
Others______________________________
Bumetanide 1 mg IV now and repeat in four hours

hydralazine 40 mg IV now

______________________________________________________________
(Treatments) ⌧ Place Foley to DD now
Dressing Changes _______________________________
Place NG Tube
Other _________
LAB TESTS:
CBC ⌧ Chem 7 Routine UA
⌧ Others:_renal profile, serum creatine
X-Rays: ⌧ chest x-ray in AM Other ________________________________
ECG stat if chest pain occurs, notify MD
Additional orders

Date________ Time_1115____ Signature: Dr. Chester Hart Patient ID

Developed by dms Butler Community College

 Butler Clinical Learning Center Medication Sheet

NURSING STATION WORKSHEET (MAR FORMAT)

ROOM- PATIENT DOB WT AGE/SEX ADM DATE ATTENDING

BED Joel A Sims 12/23/32 81 kg 75/male today PHYSICIAN
B6 Dr. Hart
DRUG ALLERGIES: No known allergies
MEDICATION ROUTE/SIG ORDERING DOSE 0800-1559 1600-2359 0000-0759

Hydralazine IV now 40 mg

Normal Saline Flush IV bid and prn 0900 2100

Acetaminophen Po prn pain 650 mg

or temp > 101.5

MOM po prn 30 ml

Bumetanide IV now and 1 mg 1100

repeat in 4 hours

Signature/Initials
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______

Developed by second semester faculty Butler Community College

 LABORATORY REPORT

Date Time Exam Result

0845
CBC
RBC 5.2 mc/L
WBC 6400 mc/L
Hct. 42%
Hgb 13 gm/dL
Platelet 160,000 ul
MCV 84 f
MCH 28 pg/cell
MCHC 33 gm/dL

0845 BMP
Sodium 135 mEq/L
Potassium 2.9 mEq/L (L)
Chloride 96 mEq/l
CO2 20 mEq/L (L)
Magnesium 1.9 mg/dL

0845 BUN 22 mg/dL (H)

Creatinine 1.7 mg/dL (H)
Calcium 7.8 mg/dL (L)
Phosphorus 4.9 mEq/dL (H)

Created by dms Butler cc

 MEDICAL RECORD REPORT OF MEDICAL HISTORY Date of Exam

Note: This information is for official and medically-confidential use only and will not be released to unauthorized persons.
1. Name of Patient (First, Middle, Last) 2. Identification Number 3. Date of Birth
Joel A Sims 0023033375 12/23/32
4a. Home street address 5. Examining Facility
1932 North First Butler Community College
4b. City State Zip Code Simulation Hospital
Yourtown KS 67042
6. Patient’s occupation 7a. Height b. Weight
Retired electrical engineer 5’ 11” 81 Kg
8. Current Used Medications at Home 9. Allergies ( include medications, latex, bee stings and food)

Crestor 10 mg once daily

ASA 81 mg once daily NKA

10. Past/Current Medical History

Check Each Item Yes No Don’t Check Each Item Yes No Don’t Check Each Item Yes No Don’t
Know Know Know
Household Contact with anyone x Shortness of Breath x Bone or join deformity x
with tuberculosis
Tuberculosis or positive TB test x Pain or Pressure in chest x Loss of finger or toe x
Blood in Sputum or when x Chronic Cough x Painful shoulder or elbow x
coughing
Excessive bleeding after injury or x Palpitation or pounding heart x Recurrent back pain or any x
dental work back injury
Suicide attempt or plans x Heart trouble x Knee injury x
Sleepwalking x High blood pressure x Foot trouble x
Wear corrective lenses x Low blood pressure x Nerve injury x
Eye surgery to correct vision x Cramps in your legs x Paralysis x
Complete vision loss in either eye x Frequent Indigestion x Epilepsy or seizure x
Wears a hearing aid x Stomach, liver, or intestinal x Car, train, or sea sickness x
trouble
Stutters or Stammers x Gall bladder trouble x Frequent trouble sleeping x
Wears a brace or back support x Jaundice or Hepatitis x Depression or excessive x
worry
Scarlet fever x Broken bones x Loss of memory x
Rheumatic fever x Skin diseases x Nervous trouble of any sort x
Swollen or painful joints x Tumor, growth, cyst, or Cancer x Periods of unconsciousness x
Frequent or severe headache x Hernia x Parent/sibling with diabetes, x
Dizziness or fainting spells x Hemorrhoids or rectal Disease x cancer, stroke or heart
disease.
Eye Trouble x Frequent or painful urination x X-Ray or other radiation x
therapy
Hearing Loss x Bed wetting since age 12 x Chemotherapy x
Recurrent ear infections x Kidney stones or blood in urine x Asbestos or toxic chemical x
exposure
Chronic or frequent colds x Sugar or Protein in urine x Plate or pin in any bone x
Severe tooth or gum trouble x Sexually transmitted disease(s) x Been told to cut down or x
Sinusitis x Recent gain or loss of weight x criticized for alcohol use

Hay Fever or allergic rhinitis x Eating Disorder x Easily fatigued x

Head injury x Arthritis, Rheumatism, or x Used illegal substances x
Bursitis
Asthma x Thyroid trouble x Used tobacco x

11. Females only answer section 11

Check each item Yes No Don’t Know Date of last menstrual period Date of last pap smear Date of last mammogram
Treated for a female disorder
Change in menstrual pattern
 Check each item. If “yes,” explain in blank space to right. List explanation by item number.
ITEM Yes No
12. Have you been refused employment or been unable
to hold a job or stay in school because of:
a. Sensitivity to chemicals? x
b. Inability to perform certain motions? x
c. Inability to assume certain positions? x
d. Other medical reasons? (If yes, give reasons.) x 1933 repair of an inguinal hernia
13. Have you ever been treated for a mental condition? x
(If yes, describe and give age at which occurred.)
14. Have you had, or have you been advised to have, any x
operation? (If yes, describe and give age at which
occurred.)
15. Have you ever been a patient in any type of hospital? x
(If yes, specify when, where, why, and name of doctor
and complete address of hospital.)
16. Have you consulted or been treated by clinics, x
physicians, healers, or other practitioners within the past
5 years for other than minor illnesses? (If yes, give
complete address of doctor, hospital, clinic, and details.)
17. Have you ever been discharged from military service x
because of physical, mental, or other reasons? (If yes,
specify.)
18. Have you ever received, is there pending, or have x
you ever applied for pension or compensation for
existing disability? (If yes, specify what kind, granted by
whom, and reason.)
19. Have you ever been diagnosed with a learning x
disability? (If yes, give type and what is needed to help
overcome.)
20. List all immunizations received

Polio, Tetanus, Pneumonia

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors,
hospitals, or clinics and their staff that are directly providing management of my care to review and input data into the Medical Record in accordance with local, state,
and federal laws.
24a. Typed or Printed Name 24b. Signature 24c. Date
Joel Sims Joel Sims
NOTE: THIS DOCUMENT WILL BE PLACED IN THE MEDICAL RECORD
25. Physician’s summary and elaboration of all pertinent data.
History or hyperlipidemia
Recent symptoms of dull pain in right flank, 16 Kg weight gain, shortness of breath, blood in urine and
hypertension.
Diagnosis renal failure—unknown cause.

26a. Typed or Printed Name of Physician or Examiner 26b. Signature 26c. Date Patient Label Here

Dr. Chester Hart Dr. Chester Hart

Designed by mt revised by dms Butler Community College

 Skills Check-off Scenarios
Scenario III
The following scenarios were designed for the beginning of the semester skills check-offs
for the fourth semester students. The skills including vital signs, IV medications,
abbreviated physical assessments and catheterizations.

Objectives:
5. Assessment and recognition of the signs and symptoms of congestive heart failure
a. Assess for respiratory problems related to congestive heart failure
b. Assess vital signs related to congestive heart failure
c. Assess for dysrhythmias
d. Assess Intake and Output for other signs of fluid retention.
6. Initiate interdisciplinary collaboration in a hospital setting.
a. Report changes in the patient’s condition to the physician
b. Implement new orders received from the physician
c. Chart findings on the appropriate charting sheets
7. Select appropriate interventions
a. Check vital signs.
b. Oxygen – Apply 2-4 L/nasal cannula as ordered
c. Insert a Foley catheter
d. Complete an assessment specific to evaluate congestive heart failure.
e. Administer an IV medication
8. Monitor therapeutic response to interventions (Outcomes).
a. Monitor that patient will not have difficulty breathing and will maintain
oxygen saturations at > 90%.
b. Monitor urinary output

Case study: You are working the day shift at Butler Simulation Hospital. Sally Sims, a
seventy-two year old female was admitted to your unit with hypertension, peripheral
edema and shortness of breath. She has a past history of congestive heart failure. She
was started on oxygen at 4 L via nasal canula and given 40 mg furosemide IV in the ER.
Her chest x-ray showed bilateral effusions in both lower lobes of his lungs. The ER
doctor sent preliminary orders and said his primary care doctor would be in to write
further medication orders. In report the ER nurse told you that Sally had taken her
digoxin and aspirin this AM. It is now 1300. Begin initiating the orders from the order
sheet.
 Butler Clinical Learning Center Simulation Orders

ORDERED Name: Sally A. Sims DOB 4/30/36

DATE TIME
0730 ADMIT TO: ⌧Telemetry Floor Non-telemetry Floor
DIAGNOSIS: Diabetes, R/O Myocardial Infarction, ⌧CHF, S/P CABG, Chest Pain,
Head Injury, Stroke, GI Bleed, S/P Lung surgery______, S/P abdominal surgery____,
S/P ortho surgery_______, MVC________, HTN,
Cancer____________ Other_____________
ALLERGIES: ⌧No Yes If yes, list:

ACTIVITY: Bedrest ⌧ BRP Activity as tolerated Other:

I&O
VITAL SIGNS: ⌧ Every 4 hours Every shift Other:
⌧O2 Sats. Q shift
DIET: NPO Clear liquid ⌧2gm Low Na, low fat, 1800kcal ADA, 2000kcal ADA
Other _________________________________
⌧ IV: Saline Lock D51/2NS with 20mEq KCL TRA _______
0.9% Sodium Chloride IV TRA _____ Lactated Ringers TRA _______
Other: ________________________________
O2: None 2Liters/minute via Nasal Cannula Other: ___________
⌧ titrate to keep sats > 90%
MEDICATIONS:
⌧ Aspirin non enteric coated 325 mg po daily
Acetaminophen 650mg po q 6 hours prn pain or temp > 101.5 F.
⌧ laxative of choice
Zolpidem 5 mgs prn HS
⌧ NS flush IV BID and prn for IV flush
Others__Nitroglycerin 0.4 mg SL prn chest pain q 5 minutes x 3

Digoxin 0.5 mg po q. AM

Repeat furosemide 40 mg IV x1 after admission to floor

______________________________________________________________
(Treatments) ⌧ Place Foley to DD
Dressing Changes _______________________________
Place NG Tube
Other _________
LAB TESTS:
CBC Chem 7 Routine UA
Others________________________________
X-Rays: ⌧ chest x-ray in AM Other ________________________________
ECG stat if chest pain occurs, notify MD
Additional orders

Date________ Time_1115____ Signature: Dr. Chester Hart Patient ID

Developed by dms Butler Community College

 Butler Clinical Learning Center Medication Sheet

NURSING STATION WORKSHEET (MAR FORMAT)

ROOM- PATIENT DOB WT AGE/SEX ADM DATE ATTENDING

BED Sally A Sims 4/30/36 81 kg 72/female today PHYSICIAN
B4 Dr. Hart
DRUG ALLERGIES: No known allergies
MEDICATION ROUTE/SIG ORDERING DOSE 0800-1559 1600-2359 0000-0759

Furosemide IV on admission 40 mg
to floor

Digoxin po 0.5 mg 0900

Aspirin po 325 mg 0900

MOM po prn 30 ml

Nitroglycerin SL prn chest 0.4 mg

pain q 5 min. x 3

Normal Saline Flush IV bid and prn 0900 2100

Signature/Initials
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______

Developed by faculty Butler Community College

 LABORATORY REPORT

Date Time Exam Result

0845
CBC
RBC 5.2 mc/L
WBC 6400 mc/L
Hct. 42%
Hgb 13 gm/dL
Platelet 160,000 ul
MCV 84 f
MCH 28 pg/cell
MCHC 33 gm/dL

0845 BMP
Sodium 135 mEq/L
Potassium 2.9 mEq/L (L)
Chloride 96 mEq/l
Magnesium 2.1 mg/dL

0845 ABGs
pH 7.35
PaCO2 35 mm Hg
PaO2 77 mm Hg (L)
SO2 88 % (L)

Developed by dms Butler cc

 REPORT OF MEDICAL HISTORY Date of Exam

Note: This information is for official and medically-confidential

MEDICAL RECORD
l use only and will not be released to unauthorized persons.
1. Name of Patient (First, Middle, Last) 2. Identification Number 3. Date of Birth
Sally A Sims 004303336 4/30/36
4a. Home street address 5. Examining Facility
430 Corona St. Butler Community College
4b. City State Zip Code Simulation Hospital
Yourcity KS 67042
6. Patient’s occupation 7a. Height b. Weight
Homemaker 5’5” 81 Kg
8. Current Used Medications at Home 9. Allergies ( include medications, latex, bee stings and food)
Digoxin 0.125 mg daily NKA
Capoten 25 mg bid
Calcium 500 mg bid

10. Past/Current Medical History

Check Each Item Yes No Don’t Check Each Item Yes No Don’t Check Each Item Yes No Don’t
Know Know Know
Household Contact with anyone x Shortness of Breath x Bone or join deformity x
with tuberculosis
Tuberculosis or positive TB test x Pain or Pressure in chest x Loss of finger or toe x
Blood in Sputum or when x Chronic Cough x Painful shoulder or elbow x
coughing
Excessive bleeding after injury or x Palpitation or pounding heart x Recurrent back pain or any x
dental work back injury
Suicide attempt or plans x Heart trouble x Knee injury x
Sleepwalking x High blood pressure x Foot trouble
Wear corrective lenses x Low blood pressure x Nerve injury x
Eye surgery to correct vision x Cramps in your legs x Paralysis x
Complete vision loss in either eye x Frequent Indigestion x Epilepsy or seizure x
Wears a hearing aid x Stomach, liver, or intestinal x Car, train, or sea sickness x
trouble
Stutters or Stammers x Gall bladder trouble x Frequent trouble sleeping x
Wears a brace or back support x Jaundice or Hepatitis x Depression or excessive x
worry
Scarlet fever x Broken bones x Loss of memory x
Rheumatic fever x Skin diseases x Nervous trouble of any sort x
Swollen or painful joints x Tumor, growth, cyst, or Cancer x Periods of unconsciousness x
Frequent or severe headache x Hernia x Parent/sibling with diabetes, x
Dizziness or fainting spells x Hemorrhoids or rectal Disease x cancer, stroke or heart
disease.
Eye Trouble x Frequent or painful urination x X-Ray or other radiation x
therapy
Hearing Loss x Bed wetting since age 12 x Chemotherapy x
Recurrent ear infections x Kidney stones or blood in urine x Asbestos or toxic chemical x
exposure
Chronic or frequent colds x Sugar or Protein in urine x Plate or pin in any bone x
Severe tooth or gum trouble x Sexually transmitted disease(s) x Been told to cut down or x
Sinusitis x Recent gain or loss of weight x criticized for alcohol use

Hay Fever or allergic rhinitis x Eating Disorder x Easily fatigued x

Head injury x Arthritis, Rheumatism, or x Used illegal substances x
Bursitis
Asthma x Thyroid trouble x Used tobacco x

11. Females only answer section 11

 Check each item Yes No Don’t Know Date of last menstrual period Date of last pap smear Date of last mammogram
Treated for a female disorder x
Change in menstrual pattern x 1988 2/07 2/07

Check each item. If “yes,” explain in blank space to right. List explanation by item number.
ITEM Yes No
12. Have you been refused employment or been unable
to hold a job or stay in school because of:
a. Sensitivity to chemicals? x
b. Inability to perform certain motions? x
c. Inability to assume certain positions? x
d. Other medical reasons? (If yes, give reasons.) x Hysterectomy 1998 at Butler Simulation Hospital
13. Have you ever been treated for a mental condition? x
(If yes, describe and give age at which occurred.) Heart problems 2004
14. Have you had, or have you been advised to have, any x
operation? (If yes, describe and give age at which
occurred.)
15. Have you ever been a patient in any type of hospital? x
(If yes, specify when, where, why, and name of doctor
and complete address of hospital.)
16. Have you consulted or been treated by clinics, x
physicians, healers, or other practitioners within the past
5 years for other than minor illnesses? (If yes, give
complete address of doctor, hospital, clinic, and details.)
17. Have you ever been discharged from military service x
because of physical, mental, or other reasons? (If yes,
specify.)
18. Have you ever received, is there pending, or have x
you ever applied for pension or compensation for
existing disability? (If yes, specify what kind, granted by
whom, and reason.)
19. Have you ever been diagnosed with a learning x
disability? (If yes, give type and what is needed to help
overcome.)
20. List all immunizations received

Polio, Tetanus, Pneumonia

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors,
hospitals, or clinics and their staff that are directly providing management of my care to review and input data into the Medical Record in accordance with local, state,
and federal laws.
24a. Typed or Printed Name 24b. Signature 24c. Date
Sally Sims Sally Sims
NOTE: THIS DOCUMENT WILL BE PLACED IN THE MEDICAL RECORD
25. Physician’s summary and elaboration of all pertinent data.

Chronic Heart Failure

Pleural effusion
Osteophorosis

26a. Typed or Printed Name of Physician or Examiner 26b. Signature 26c. Date Patient Label Here

Dr. Simulation Getwell Dr. Simulation

Getwell

Designed by mt revised by dms Butler Community College

 Skills Check-off Scenarios
Scenario IV

The following scenarios were designed for the beginning of the semester skills check-offs
for the fourth semester students. The skills including vital signs, IV medications,
abbreviated physical assessments and catheterizations.

Objectives:
1. Assessment and recognition of the signs and symptoms of pulmonary edema
related to renal failure
c. Assess for respiratory problems related to pulmonary edema
d. Assess vital signs related to renal failure/pulmonary edema
e. Assess for respiratory distress
f. Assess Intake and Output for other signs of fluid retention.
2. Initiate interdisciplinary collaboration in a hospital setting.
g. Report changes in the patient’s condition to the physician
h. Implement new orders received from the physician
i. Chart findings on the appropriate charting sheets
3. Select appropriate interventions
j. Check vital signs.
k. Oxygen – Apply 2-4 L/nasal cannula as ordered
l. Insert a Foley catheter
m. Complete an assessment specific to evaluate pulmonary edema.
n. Administer an IV medication
4. Monitor therapeutic response to interventions (Outcomes).
o. Monitor that patient will not have difficulty breathing and will maintain
oxygen saturations at > 90%.
p. Monitor urinary output

Case study: It is shift change and you were assigned Sarah A Sims, a 78 year old female,
who was admitted to your unit yesterday with a new diagnosis of renal disease. The
night nurse reports that about one hour ago Sarah had difficulty breathing and crackles in
both lungs. Her blood pressure is steadily rising. At 0630 it was 172/114. The nurse
notified the physician. He ordered stat Bumetanide and Hydralazine along with some
other new orders. She gave the Bumetanide and was waiting for the Hydralazine to
arrive from the pharmacy. X-ray was just completing the portable chest x-ray. The unit
secretary calls that the hydralazine has just arrived from pharmacy. Using the order sheet
begin the care on your patient.
 Butler Clinical Learning Center Simulation Orders

ORDERED Name: Sarah A. Sims DOB 9/1732

DATE TIME
1500 ADMIT TO: ⌧Telemetry Floor Non-telemetry Floor
DIAGNOSIS: Diabetes, R/O Myocardial Infarction, CHF, S/P CABG, Chest Pain,
Head Injury, Stroke, GI Bleed, S/P Lung surgery______, S/P abdominal surgery____,
S/P ortho surgery_______, MVC________, HTN, Cancer____________ Other: renal
disease
ALLERGIES: ⌧No Yes If yes, list:

ACTIVITY: Bedrest ⌧ BRP Activity as tolerated Other:

I&O
VITAL SIGNS: ⌧ Every 4 hours Every shift Other:
⌧O2 Sats. Q shift
DIET: NPO Clear liquid 2gm Low Na, low fat, 1800kcal ADA, 2000kcal ADA
Other ___renal diet__800 ml per day fluid restriction
⌧ IV: Saline Lock D51/2NS with 20mEq KCL TRA _______
0.9% Sodium Chloride IV TRA _____ Lactated Ringers TRA _______
Other: ________________________________
O2: None 2Liters/minute via Nasal Cannula Other: ___________
⌧ titrate to keep sats > 90%
MEDICATIONS:
Aspirin non enteric coated 325 mg po daily
⌧ Acetaminophen 650mg po q 6 hours prn pain or temp > 101.5 F.
⌧ laxative of choice
Zolpidem 5 mgs prn HS
⌧ NS flush IV BID and prn for IV flush
Others______________________________
Bumetanide 1 mg IV now and repeat in four hours

hydralazine 40 mg IV now

______________________________________________________________
(Treatments) ⌧ Place Foley to DD now
Dressing Changes _______________________________
Place NG Tube
Other _________
LAB TESTS:
CBC ⌧ Chem 7 Routine UA
⌧ Others:_renal profile, serum creatine
X-Rays: ⌧ chest x-ray in AM Other ________________________________
ECG stat if chest pain occurs, notify MD
Additional orders

Date________ Time_1115____ Signature: Dr. Chester Hart Patient ID

Developed by dms Butler Community College

 Butler Clinical Learning Center Medication Sheet

NURSING STATION WORKSHEET (MAR FORMAT)

ROOM- PATIENT DOB WT AGE/SEX ADM DATE ATTENDING

BED Sarah A Sims 9/17/32 69 kg 78/female today PHYSICIAN
B2 Dr. Hart
DRUG ALLERGIES: No known allergies
MEDICATION ROUTE/SIG ORDERING DOSE 0800-1559 1600-2359 0000-0759

Hydralazine IV now 40 mg

Normal Saline Flush IV bid and prn 0900 2100

Acetaminophen Po prn pain 650 mg

or temp > 101.5

MOM po prn 30 ml

Bumetanide IV now and 1 mg 1100

repeat in 4 hours

Signature/Initials
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______

Developed by faculty Butler Community College

 LABORATORY REPORT

Date Time Exam Result

0845
CBC
RBC 5.2 mc/L
WBC 6400 mc/L
Hct. 42%
Hgb 13 gm/dL
MCV 84 f
MCH 28 pg/cell
MCHC 33 gm/dL

0845 BMP 135 mEq/L

Sodium 2.9 mEq/L (L)
Potassium 96 mEq/l
Chloride 20 mEq/L (L)
CO2 1.9 mg/dL
Magnesium

0845 BUN 22 mg/dL (H)

Creatinine 1.7 mg/dL (H)
Calcium 7.8 mg/dL (L)
Phosphorus 4.9 mEq/dL (H)

Developed by dms at Butler cc

 MEDICAL RECORD REPORT OF MEDICAL HISTORY Date of Exam

Note: This information is for official and medically-confidential use only and will not be released to unauthorized persons.
1. Name of Patient (First, Middle, Last) 2. Identification Number 3. Date of Birth
Sarah A Sims 0023033378 9/17/32
4a. Home street address 5. Examining Facility
1932 North First Butler Community College
4b. City State Zip Code Simulation Hospital
Yourtown KS 67042
6. Patient’s occupation 7a. Height b. Weight
Retired school teacher 5’ 4” 69 Kg
8. Current Used Medications at Home 9. Allergies ( include medications, latex, bee stings and food)

Crestor 10 mg once daily

ASA 81 mg once daily NKA

10. Past/Current Medical History

Check Each Item Yes No Don’t Check Each Item Yes No Don’t Check Each Item Yes No Don’t
Know Know Know
Household Contact with anyone x Shortness of Breath x Bone or join deformity x
with tuberculosis
Tuberculosis or positive TB test x Pain or Pressure in chest x Loss of finger or toe x
Blood in Sputum or when x Chronic Cough x Painful shoulder or elbow x
coughing
Excessive bleeding after injury or x Palpitation or pounding heart x Recurrent back pain or any x
dental work back injury
Suicide attempt or plans x Heart trouble x Knee injury x
Sleepwalking x High blood pressure x Foot trouble x
Wear corrective lenses x Low blood pressure x Nerve injury x
Eye surgery to correct vision x Cramps in your legs x Paralysis x
Complete vision loss in either eye x Frequent Indigestion x Epilepsy or seizure x
Wears a hearing aid x Stomach, liver, or intestinal x Car, train, or sea sickness x
trouble
Stutters or Stammers x Gall bladder trouble x Frequent trouble sleeping x
Wears a brace or back support x Jaundice or Hepatitis x Depression or excessive x
worry
Scarlet fever x Broken bones x Loss of memory x
Rheumatic fever x Skin diseases x Nervous trouble of any sort x
Swollen or painful joints x Tumor, growth, cyst, or Cancer x Periods of unconsciousness x
Frequent or severe headache x Hernia x Parent/sibling with diabetes, x
Dizziness or fainting spells x Hemorrhoids or rectal Disease x cancer, stroke or heart
disease.
Eye Trouble x Frequent or painful urination x X-Ray or other radiation x
therapy
Hearing Loss x Bed wetting since age 12 x Chemotherapy x
Recurrent ear infections x Kidney stones or blood in urine x Asbestos or toxic chemical x
exposure
Chronic or frequent colds x Sugar or Protein in urine x Plate or pin in any bone x
Severe tooth or gum trouble x Sexually transmitted disease(s) x Been told to cut down or x
Sinusitis x Recent gain or loss of weight x criticized for alcohol use

Hay Fever or allergic rhinitis x Eating Disorder x Easily fatigued x

Head injury x Arthritis, Rheumatism, or x Used illegal substances x
Bursitis
Asthma x Thyroid trouble x Used tobacco x

11. Females only answer section 11

Check each item Yes No Don’t Know Date of last menstrual period Date of last pap smear Date of last mammogram
Treated for a female disorder x 1979 2007
Change in menstrual pattern
 Check each item. If “yes,” explain in blank space to right. List explanation by item number.
ITEM Yes No
12. Have you been refused employment or been unable
to hold a job or stay in school because of:
a. Sensitivity to chemicals? x
b. Inability to perform certain motions? x 1984 Hysterectomy, cystocele repair
c. Inability to assume certain positions? x
d. Other medical reasons? (If yes, give reasons.) x
13. Have you ever been treated for a mental condition? x
(If yes, describe and give age at which occurred.)
14. Have you had, or have you been advised to have, any x
operation? (If yes, describe and give age at which
occurred.)
15. Have you ever been a patient in any type of hospital? x
(If yes, specify when, where, why, and name of doctor
and complete address of hospital.)
16. Have you consulted or been treated by clinics, x
physicians, healers, or other practitioners within the past
5 years for other than minor illnesses? (If yes, give
complete address of doctor, hospital, clinic, and details.)
17. Have you ever been discharged from military service x
because of physical, mental, or other reasons? (If yes,
specify.)
18. Have you ever received, is there pending, or have x
you ever applied for pension or compensation for
existing disability? (If yes, specify what kind, granted by
whom, and reason.)
19. Have you ever been diagnosed with a learning x
disability? (If yes, give type and what is needed to help
overcome.)
20. List all immunizations received

Polio, Tetanus, Pneumonia

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors,
hospitals, or clinics and their staff that are directly providing management of my care to review and input data into the Medical Record in accordance with local, state,
and federal laws.
24a. Typed or Printed Name 24b. Signature 24c. Date
Sarah Sims Sarah Sims
NOTE: THIS DOCUMENT WILL BE PLACED IN THE MEDICAL RECORD
25. Physician’s summary and elaboration of all pertinent data.
History or hyperlipidemia
Recent symptoms of dull pain in right flank, 16 Kg weight gain, shortness of breath, blood in urine and
hypertension.
Diagnosis renal failure—unknown cause.

26a. Typed or Printed Name of Physician or Examiner 26b. Signature 26c. Date Patient Label Here

Dr. Chester Hart Dr. Chester Hart

Designed by mt revised by dms Butler Community College

 Skills Check-off Scenarios
ScenarioV
The following scenarios were designed for the beginning of the semester skills check-offs
for the fourth semester students. The skills including vital signs, IV medications,
abbreviated physical assessments and catheterizations.

Objectives:
9. Assessment and recognition of the signs and symptoms of congestive heart failure
a. Assess for respiratory problems related to congestive heart failure
b. Assess vital signs related to congestive heart failure
c. Assess for dysrhythmias
d. Assess Intake and Output for other signs of fluid retention.
10. Initiate interdisciplinary collaboration in a hospital setting.
a. Report changes in the patient’s condition to the physician
b. Implement new orders received from the physician
c. Chart findings on the appropriate charting sheets
11. Select appropriate interventions
a. Check vital signs.
b. Oxygen – Apply 2-4 L/nasal cannula as ordered
c. Insert a Foley catheter
d. Complete an assessment specific to evaluate congestive heart failure.
e. Administer an IV medication
12. Monitor therapeutic response to interventions (Outcomes).
a. Monitor that patient will not have difficulty breathing and will maintain
oxygen saturations at > 90%.
b. Monitor urinary output

Case study: You are working the day shift at Butler Simulation Hospital. Chad Sims, a
seventy-seven year old male was admitted to your unit with hypertension, peripheral
edema and shortness of breath. He has a past history of congestive heart failure. He was
started on oxygen at 4 L via nasal canula and given 40 mg furosemide IV in the ER. His
chest x-ray showed bilateral effusions in both lower lobes of his lungs. The ER doctor
sent preliminary orders and said his primary care doctor would be in to write further
medication orders. In report the ER nurse told you that Chad had taken his digoxin and
aspirin this AM. It is now 1300. Begin initiating the orders from the order sheet.
 Butler Clinical Learning Center Simulation Orders

ORDERED Name: Chad A. Sims DOB 8/27/31

DATE TIME
0730 ADMIT TO: ⌧Telemetry Floor Non-telemetry Floor
DIAGNOSIS: Diabetes, R/O Myocardial Infarction, ⌧CHF, S/P CABG, Chest Pain,
Head Injury, Stroke, GI Bleed, S/P Lung surgery______, S/P abdominal surgery____,
S/P ortho surgery_______, MVC________, HTN,
Cancer____________ Other_____________
ALLERGIES: ⌧No Yes If yes, list:

ACTIVITY: Bedrest ⌧ BRP Activity as tolerated Other:

I&O
VITAL SIGNS: ⌧ Every 4 hours Every shift Other:
⌧O2 Sats. Q shift
DIET: NPO Clear liquid ⌧2gm Low Na, low fat, 1800kcal ADA, 2000kcal ADA
Other _________________________________
⌧ IV: Saline Lock D51/2NS with 20mEq KCL TRA _______
0.9% Sodium Chloride IV TRA _____ Lactated Ringers TRA _______
Other: ________________________________
O2: None 2Liters/minute via Nasal Cannula Other: ___________
⌧ titrate to keep sats > 90%
MEDICATIONS:
⌧ Aspirin non enteric coated 325 mg po daily
Acetaminophen 650mg po q 6 hours prn pain or temp > 101.5 F.
⌧ laxative of choice
Zolpidem 5 mgs prn HS
⌧ NS flush IV BID and prn for IV flush
Others__Nitroglycerin 0.4 mg SL prn chest pain q 5 minutes x 3

Digoxin 0.5 mg po q. AM

Repeat furosemide 40 mg IV x1 after admission to floor

______________________________________________________________
(Treatments) ⌧ Place Foley to DD
Dressing Changes _______________________________
Place NG Tube
Other _________
LAB TESTS:
CBC Chem 7 Routine UA
Others________________________________
X-Rays: ⌧ chest x-ray in AM Other ________________________________
ECG stat if chest pain occurs, notify MD
Additional orders

Date________ Time_1115____ Signature: Dr. Chester Hart Patient ID

Developed by dms Butler Community College

 Butler Clinical Learning Center Medication Sheet

NURSING STATION WORKSHEET (MAR FORMAT)

ROOM- PATIENT DOB WT AGE/SEX ADM DATE ATTENDING

BED Chad A Sims 8/27/31 81 kg 77/male today PHYSICIAN
B3 Dr. Hart
DRUG ALLERGIES: No known allergies
MEDICATION ROUTE/SIG ORDERING DOSE 0800-1559 1600-2359 0000-0759

Furosemide IV on admission 40 mg
to floor

Digoxin po 0.5 mg 0900

Aspirin po 325 mg 0900

MOM po prn 30 ml

Nitroglycerin SL prn chestpain 0.4 mg

q 5 min. x 3

Normal Saline Flush IV bid and prn 0900 2100

Signature/Initials
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______
___________________________/ / ______

Developed by faculty Butler Community College

 LABORATORY REPORT

Date Time Exam Result

0845
CBC
RBC 5.2 mc/L
WBC 6400 mc/L
Hct. 42%
Hgb 13 gm/dL
Platelet 160,000 ul
MCV 84 f
MCH 28 pg/cell
MCHC 33 gm/dL

0845 BMP
Sodium 135 mEq/L
Potassium 2.9 mEq/L (L)
Chloride 96 mEq/l
Magnesium 2.1 mg/dL

0845 ABGs
pH 7.35
PaCO2 35 mm Hg
PaO2 77 mm Hg (L)
SO2 88 % (L)

Developed by dms at Butler cc

 REPORT OF MEDICAL HISTORY Date of Exam

Note: This information is for official and medically-confidential

MEDICAL RECORD
l use only and will not be released to unauthorized persons.
1. Name of Patient (First, Middle, Last) 2. Identification Number 3. Date of Birth
Chad A Sims 004303336 8/27/31
4a. Home street address 5. Examining Facility
430 Corona St. Butler Community College
4b. City State Zip Code Simulation Hospital
Yourcity KS 67042
6. Patient’s occupation 7a. Height b. Weight
Retired Baker 5’10” 81 Kg
8. Current Used Medications at Home 9. Allergies ( include medications, latex, bee stings and food)
Digoxin 0.125 mg daily NKA
Capoten 25 mg bid

10. Past/Current Medical History

Check Each Item Yes No Don’t Check Each Item Yes No Don’t Check Each Item Yes No Don’t
Know Know Know
Household Contact with anyone x Shortness of Breath x Bone or join deformity x
with tuberculosis
Tuberculosis or positive TB test x Pain or Pressure in chest x Loss of finger or toe x
Blood in Sputum or when x Chronic Cough x Painful shoulder or elbow x
coughing
Excessive bleeding after injury or x Palpitation or pounding heart x Recurrent back pain or any x
dental work back injury
Suicide attempt or plans x Heart trouble x Knee injury x
Sleepwalking x High blood pressure x Foot trouble
Wear corrective lenses x Low blood pressure x Nerve injury x
Eye surgery to correct vision x Cramps in your legs x Paralysis x
Complete vision loss in either eye x Frequent Indigestion x Epilepsy or seizure x
Wears a hearing aid x Stomach, liver, or intestinal x Car, train, or sea sickness x
trouble
Stutters or Stammers x Gall bladder trouble x Frequent trouble sleeping x
Wears a brace or back support x Jaundice or Hepatitis x Depression or excessive x
worry
Scarlet fever x Broken bones x Loss of memory x
Rheumatic fever x Skin diseases x Nervous trouble of any sort x
Swollen or painful joints x Tumor, growth, cyst, or Cancer x Periods of unconsciousness x
Frequent or severe headache x Hernia x Parent/sibling with diabetes, x
Dizziness or fainting spells x Hemorrhoids or rectal Disease x cancer, stroke or heart
disease.
Eye Trouble x Frequent or painful urination x X-Ray or other radiation x
therapy
Hearing Loss x Bed wetting since age 12 x Chemotherapy x
Recurrent ear infections x Kidney stones or blood in urine x Asbestos or toxic chemical x
exposure
Chronic or frequent colds x Sugar or Protein in urine x Plate or pin in any bone x
Severe tooth or gum trouble x Sexually transmitted disease(s) x Been told to cut down or x
Sinusitis x Recent gain or loss of weight x criticized for alcohol use

Hay Fever or allergic rhinitis x Eating Disorder x Easily fatigued x

Head injury x Arthritis, Rheumatism, or x Used illegal substances x
Bursitis
Asthma x Thyroid trouble x Used tobacco x
11. Females only answer section 11
Check each item Yes No Don’t Know Date of last menstrual period Date of last pap smear Date of last mammogram
Treated for a female disorder
Change in menstrual pattern

Check each item. If “yes,” explain in blank space to right. List explanation by item number.
ITEM Yes No
12. Have you been refused employment or been unable
to hold a job or stay in school because of:
a. Sensitivity to chemicals? x
b. Inability to perform certain motions? x
c. Inability to assume certain positions? x Repair of inguinal hernia 1987
d. Other medical reasons? (If yes, give reasons.) x
13. Have you ever been treated for a mental condition? x Heart problems 2004
(If yes, describe and give age at which occurred.)
14. Have you had, or have you been advised to have, any x
operation? (If yes, describe and give age at which
occurred.)
15. Have you ever been a patient in any type of hospital? x
(If yes, specify when, where, why, and name of doctor
and complete address of hospital.)
16. Have you consulted or been treated by clinics, x
physicians, healers, or other practitioners within the past
5 years for other than minor illnesses? (If yes, give
complete address of doctor, hospital, clinic, and details.)
17. Have you ever been discharged from military service x
because of physical, mental, or other reasons? (If yes,
specify.)
18. Have you ever received, is there pending, or have x
you ever applied for pension or compensation for
existing disability? (If yes, specify what kind, granted by
whom, and reason.)
19. Have you ever been diagnosed with a learning x
disability? (If yes, give type and what is needed to help
overcome.)
20. List all immunizations received

Polio, Tetanus, Pneumonia

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors,
hospitals, or clinics and their staff that are directly providing management of my care to review and input data into the Medical Record in accordance with local, state,
and federal laws.
24a. Typed or Printed Name 24b. Signature 24c. Date
Chad Sims Chad Sims
NOTE: THIS DOCUMENT WILL BE PLACED IN THE MEDICAL RECORD
25. Physician’s summary and elaboration of all pertinent data.

Chronic Heart Failure

Pleural effusion

26a. Typed or Printed Name of Physician or Examiner 26b. Signature 26c. Date Patient Label Here

Dr. Simulation Getwell Dr. Simulation

Getwell

Designed by mt revised by dms Butler Community College

 Scenario References

Black, J. & Hawks, J (2005) Medical Surgical Nursing Clinical Management for Positive
Outcomes 7th ed. Elsevier Saunders, St Louis

Hopper, J. & Vallerand, A (2005) Davis’s Drug Guide for Nurses 10th ed. F.A. Davis,
Philadelphia

Palm Skyscape (2006) Drug Guide Skyscape, Inc.

Potter, P. & Perry, A. (2007) Basic Nursing Essential for Practice 6th ed. Mosby Elsevier,
St. Louis

Reviewed and edited by Faculty at Butler community College