TIME PATIENT PROGRESS RECORD
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PATIENT
EDUCATION
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LEARNING NEED
PT./S.O. INSTRUCTED ACCORDING TO/TOOLS USED:
TEACHING PROTOCOL VIDEO
CLASS HAND-OUTS
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WAS S.O. PRESENT? YES NO RELATIONSHIP
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OUTCOMES:
VERBALIZED UNDERSTANDING YES NO
DEMONSTRATED SKILLS YES NO
REQUIRES FOLLOW-UP / REFERRAL YES NO
8P Patient extremely;y agitated and confused
having incoherent conversation with person
or persons MD present Patient unaware
of present physical location Patient believes
he is home. Ativan 4mg given without
good results
9P Patient continue(s) with increased agitation attempting to
climb out of bed Heart Rate 128-132 MD
aware
10:45 Patient still very agitated MD aware
extremely verbal (loudly) Confused speaking
incoherently still climbing Out of Bed Dr. Mayer
made aware. Order for Ativan 6mg IVP
given with good results.
12MN Patient sleeping much quieter vital sign
per flow sheet
2A 2A(M) Ativan held patient sleeping
4A Patient sleeping
6A AM care given Patient agitated Ativan 4mg
given Patient (?tolerance) status unchanged
Esmira (?Johnson) RN
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