Question

290 UNIT 5 Medication Administration Documentation Exercise Scenario: Question 59 refers to this scenario. Today is April 24, 2022. You are administering medications to Ms. Ebonie Washington, a 51-year-old patient with a diagnosis of coronary artery disease and hypertension who was admitted on April 22, 2022. She is in Room 409, and her hospital ID number is 4982376. Her date of birth is February 7, 1971. At 9:00 a.m. you give Ms. Washington her oral medications: amiodarone 200 mg PO, amlodipine 10 mg PO, and valsartan 320 mg PO. You also must change her nitroglycerine (Nitroderm) patch. You note that her blood pressure is a little high, at 166/88. She complains that she was awake much of the night with a severe headache, so you check to see if she has anything ordered for pain. She has a prn order for Lortab 5 mg for moderate to severe pain. You return to her room about 9:20 a.m. and give her the Lortab. At that time, you also provide a cold cloth for her head, dim the lights, and close the door. At 10:00 am, you check back to see how she is feeling. She says the headache is getting better and she thinks she can sleep for a while now. 59. Document the medications you have given on the appropriate place on the medication administration record (MAR: Fig. 35.1). Document any pertinent information on the nurse's note form (Fig. 35.2).

Answer 1

Name of patient :- Ms. Ebonie Washington

Hospital ID :- 4982376

Date of admission:- April 22, 2022

Room No. :-409

Date of birth :- February 7, 1971

Diagnosis :- coronary artery disease, hypertension

Medication chart

Date ordered	date record	drug	dose	route	frequency	administration time
April 22, 2022	April 24, 2022	Tab. Amiodarone	200mg	p.o ( oral)	OD	9 am
	24/4/2022	Tab. Amlodipine	10mg	p.o	OD	9am
	24/4/2022	Tab. Valsartan	320mg	p.o	OD	9am
	24/4/2022	Tab. Lortab	5mg	p.o	prn	9.20am

Signature/ shift indicates

nurse administering medications

Nurse's note

24/4/2022

9.00 am :- Assessed patient

Due medications given as per doctor's order

Removed nitroglycerin patch, assessed the site. No redness or other reactions observed

Patient complained of severe headache and sleeplessness at night

BP checked and recorded, BP- 166/88 mm/Hg

9.20 am :- Administered Tab. Lortab 5 mg as per prn order

Provided cold compress on forhead

Provided proper environment ( dim lights, closed door)

10.00am :- Reassess the patient.

Patient verbalised as her headache relieved to some extent.