July 10, Friday, Day Shift

Tom:

Maureen woke up ones at 8, took few sips of water by swap.

9:30 am: She is sleeping.

9:40 am : woke up.

Temp. 97.7

P: 91

O: 97

BP 112/73

10:00 am: We placed Maureen in an upright position.

We gave her 5 oz of water with lemon and thickener.

Administered 75mcg of Levothyroxine with apple sauce.

10:10 am: Me and Sheryl washed Maureen’s upper body with warm purple wipes.

Dry diaper. Small brown discharge.

Cleaned and changed.

Applied Sureprep barrier film on sacrum and Prevent Silicone Cream on inner thighs.

We applied Triamcinolone Cream on her right foot.

We washed her left breast with gauze sponges and Skintegrity spray.

We washed her hair.

Coughing- 2 times

Section- No

10 35 am: We transferred Maureen to the living room.

10:50 am: Nebulizer/Albuterol

11:10 am: Scrambled egg .with onion tomato pepper and cheese. Some banana.

Administered 10 mg of Cetirizine Hcl with apple souce.

Administered 40 ml Geri-Tussin with apple souce.

Coughing- 4 times.

Section - 2 time.

12:10 - 1:30 pm: Nap

Just 3 oz of prune juice with thickener.

1:50 pm: Oral care.

Face routine.

2:00 pm: We transferred Maureen to the bathroom for rest break.

Dry diaper.

2:30 pm: Maureen began to moan, and her brow was furrowed. Administered Tylenol 500 mg with applesauce.

A lot of coughing

A lot of suctioning

We gave her few sips of sprinkle water by swap.

We changed her position to the left side.

3:15 pm: Dry diaper.

We transferred Maureen to the living room.

3:30 pm: Nebulizer/ Albuterol

4:30 pm: Dinner: Orange chicken

3 oz of sprinkle water with thickener.

5:00 pm: Administred: 6 ml of Vimpat - half amount and 5 mg of Olanzapine with apple sauce.

She didn’t take Geri-Tussin.

Coughing- 6 times

Section- 5 times

5:40 pm: Oral Care.

5:50 pm: Transferred Maureen to the bedroom.

Dry diaper. Medium brown/red discharge.

Cleaned and changed. Administered Prevent Silicone Cream.

We applied Triamcinolone Cream on her foot.

We washed left breast with gauze sponges and Skintegrity.

We applied Cetaphil lotion to face, hands and feet.

Positioned Maureen on her left side.

Vitals:

T-97.8

O2-97

P-96

6:15 pm: Maureen is in bed.