July 20, Monday, Day Shift

9:30 am: Maureen is sleeping.

10:00 am: still sleeping.

10:15 am: Carolyn, Colleen and Shelly (the nurse) visited Maureen.

BP 114/69

Pulse - 84

R 18

Lungs - good.

Shelly recommends - important:

Follow Maureen’s cues - for example:

• if she sleeps let her sleep

• If she doesn’t feel like eating or drinking - don’t force her

Inform Shelly if Maureen stops eating altogether.

We are stopping the administration of Miralax.

We are administering Bisacodyl suppositories every other day.

10:50 pm: We placid Maureen in an upright position and administered 75mcg of Levothyroxine with apple sauce.

2 oz of water with lemon by swap.

11:00 am: Me and Martha washed Maureen’s upper body with warm purple wipes.

Dry diaper. Medium 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.

11:30 am: We transferred Maureen to the living room.

11:40 am: Nebulizer/albuterol

11:55 am: Breakfast: Scramble egg with cheese, tomato and some banana.

Administered 10 mg of Cetirizine Hcl with a little apple souce.

Coughing- 2 times

Suctioning- 2 times

12:30 pm: NAP - 1:45 pm

6 oz of sprite with thickener

2:15 pm: We transferred Maureen to the bedroom for break rest.

Medium wet diaper.

We cleaned and changed.

Positioned on her right side.

2:45 pm: a lot of coughing

We used the suction machine four times.

Maureen started moaning; it looks like she's in pain.

We administered Tylenol with applesauce.

Repositioned her on the left side.

3:50 pm: Dry diaper.

We transferred Maureen to the living room.

4:15 pm: Nebulizer/ Albuterol

4:30 pm: Dinner: Orange chicken and avocado

2 oz of sprite water by swap

5:00 pm: Administred: 12,5 ml of Vimpat with thickener and 5 mg of Olanzapine with apple sauce.

Coughing- 4 times

Section- 3 times

5:30 pm: Oral Care.

5:45 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-97.5

O2-97

P-102

6:15 pm: Maureen is in bed.