June 22, Monday, Day Shift

9:30 am: Maureen is awake.

She was very sweaty.

We gave her few sips of water via swab.

We placed Maureen in an upright position.

9:50 am: Administered 75mcg of Levothyroxine with apple sauce.

6 oz of water (with thickener)

10:00 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 Cavilon cream on inner thighs.

10:20 am: Shelly - the nurse visited Maureen

Temperature is 98.2°

Blood pressure 130/68

Pulse is 82

Respirations 18

Good bowel sounds and lungs are clear.

Shelly’s recommendations are …

• Wound wash on left breast where it is discharging, twice a day. Change shirt as needed.

• we use the Triamcinolone cream twice a day on right foot.

• A different allergy medication is being prescribed, should be here this afternoon.

Cough medication should be tomorrow.

10:55 am: We washed Maureen’s left breast (warm water with Cetaphil Cleanser)

We applied Triamcinolone Cream on her right foot.

11:10 am: We transferred Maureen to the living room.

11:15 am: Nebulizer.

11:30 am: Breakfast: waffle with butter and jelly, kiwi.

Administered 10 mg of Loratadine with applesouce.

12:20 pm: Oral care.

12:30 pm: Face routine.

1:15 pm: lunch: Soup with thickener. Yogurt.

5 oz of sparkling water with thickener.

1:45 pm: Oral care.

2:00 pm: We took Maureen to the bedroom for the one hour break.

The diaper was very wet. Large formed B/M. We cleaned and changed her.

3:20 pm - 4:05 pm : We were outside.

5 oz of water with thickener.

4:20 pm: Nebulizer.

Dry diaper.

4:35: Dinner: Spagetti.

11 oz of water with thickener.

5:15 pm: Administered 12,5 ml of Vimpat and 5 mg of Olanzapine with applesouce.

5:40 pm: Oral Care.

5:50 pm: Transferred Maureen to the bedroom.

Little wet diaper. Medium brown discharge.

Cleaned and changed.

Applied Cavilon cream.

We applied Cetaphil lotion to face, hands and feet.

We washed Maureen’s left breast (warm water with Cetaphil Cleanser). We noticed that is hoter and harder.

We applied Triamcinolone Cream on her right foot.

Positioned Maureen on her left side.

Vitals:

T-96.3

O2-110

P-92

6:25 pm: Maureen is in bed.