Topics

Facesheet
History & Physical
Physician Orders
Nursing admission & History
Physician Notes
Pastoral Consult
Nursing notes
Laboratory
Advanced Directive
Kardex
Flowsheets
Medication Record
Pacific View Regional Hospital MRN: 1868042

6475 E. Duke Avenue Patient: Goro Oishi

Sex: Male

Physician: Gerald Moher, M.D.

Authority for Admission

PART I
ADMIT TO UNIT ROOM NO.
Hospice 505
ADMIT DATE ADMIT TIME
Monday 730
DIAGNOSIS #1 ICD 9
Intracerebral hemorrhage--internal
431
capsule

SCHEDULED PROCEDURE #1 PROCEDURE CODE #1

SCHEDULED PROCEDURE #2 PROCEDURE CODE #2

PART II: PATIENT INFORMATION

NAME, LAST FIRST
Oishi Goro
PATIENT'S HOME ADDRESS (Street)
APT/CONDO NO.
777 West 1st Street
CITY STATE
Generation CA
HOME PHONE WORK PHONE
(555) 623-0245 (555) 623-3265
IF BEING ADMITTED FOR CHILDBIRTH,
WHAT NUMBER CHILD WILL THIS BE?
1st 1st       2nd 2nd       3rd 3rd
      4th 4th       5th 5th       Other:  
MARITAL STATUS

 Married    

RACE ETHNIC BACKGROUND

Asian Asian
PART III: INSURANCE INFORMATION (ATTACH COPY OF PROOF OF INSUR
NAME, LAST FIRST
Oishi Goro
COMPLETE ADDRESS
777 W. 1st Street, Generation, CA
95555

INSURANCE COMPANY NAME

Blue Cross & Blue Shield

PART IV: EMERGENCY DATA OF PRIMARY NEXT OF KIN
NAME (Last, First, Middle) Relationship
Hiroko Oishi Wife
ADDRESS (Street)
777 West 1st Street
CITY STATE
Generation CA
PART V: ACCIDENT/INJURY INFORMATION
DID YOUR ACCIDENT/INJURY OCCUR:
  AT HOME    

WERE YOU TRANSFERRED FROM

ANOTHER HOSPITAL?   NO

PART VI: CONDITIONS OF ADMISSIONS

Initials
ADVANCE DIRECTIVE ACKNOWLEDGMENT - Please read and ch
the appropriate below.
I have executed an advance directive.
I have provided the hospital with a copy
of the advance directive.
I HAVE NOT executed an advance
directive. I have been provided with
HO written material on my rights to accept
or refuse to forumulate an advanced
directive.
Acting as a representative of the
patient, I am not aware of whether the
patient has or has not executed an
advance directive.
I HAVE READ AND UNDERSTAND THE CONDITIONS OF ADMISSION. I HAVE RECEIVED A COPY AND A
AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS AGREEMENT. WHERE APPLICABLE,
PAYOR HAS BEEN COMPLETED.

Hiroko Oishi
Patient/Proxy Name (Print)

Hiroko Oishi
Patient/Proxy Signature

Relationship to Patient (Check One)

patient PATIENT    parent PARENT    authorized party AUTHORIZED PARTY
Jolene Roberts
Witness Name (Print)

Jolene Roberts
Witness Signature
 Room: 505

Age: 66

(Check One) MEDICAL RECORD NO.

ROUTINE 1868042
ADMITTING SERVICE ADMITTING PHYSICIAN
IM Gerald Moher, M.D.

NFORMATION

MIDDLE

ZIP CODE
95555
AGE SEX
66 Male

RELIGION

Buddhist
CH COPY OF PROOF OF INSURANCE)
MIDDLE
Yoshiro
 PRIMARY NEXT OF KIN

ZIP CODE HOME PHONE

95555 555-623-0245
RY INFORMATION

SIONS

WLEDGMENT - Please read and check

I HAVE RECEIVED A COPY AND AM THE PATIENT OR AM

GREEMENT. WHERE APPLICABLE, UNIVERSAL SECONDARY

Monday
Date

ARTY
Monday
Date
MRN: 1868042
Patient: Goro Oishi
Sex: Male
Physician: Gerald Moher, M.D.
History and Physical
Chief Complaint:
"Worst headache of his life"
History
On Sunday of Present
afternoonIllness:
while Mr. Oishi was at home visiting with his wife and the
family of his youngest son, he experienced a sudden, severe headache which he
described to his wife and son as "the worst headache of his life." Within minutes, he
experienced numbness and weakness of his left face, arm, and leg and was having
increasing difficulty speaking and understanding simple statements. His wife called
911, and by the time the ambulance arrived, his level of consciousness was declining
and he was making incomprehensible sounds. He met all six criteria on the Los
Angeles prehospital stroke scale. IV and oxygen therapy were initiated, and Mr. Oishi
was transported to the Emergency Department. Upon arrival to the Emergency
Department, Mr. Oishi was found to have a Glasgow Coma Scale of 4 (does not open
eyes with painful stimuli, abnormal extension of right extremities to painful stimuli,
no movement of the left extremities, and no verbal response). His pupils were
unequal with the left pupil 1 mm larger than the right pupil 4 mm/3 mm, and both
pupils had a sluggish reaction to light. His blood pressure was 190/110, and pulse
oximetry was 93% on oxygen therapy of 2 liters per nasal cannula. His CT scan
revealed a large right internal capsule intracerebral hemorrhage. EKG showed a
normal sinus rhythm, left axis deviation with right bundle branch block. PA CXR
showed heart size and pulmonary vasculature within normal limits. No opacification
or pleural effusions. Labs done during acute care admission: RBC 4.01, WBC 4.6, Hgb
14.2, Hct 45, platelets 300, glucose 104, Na 139, K 4.5, Cl 105, CO2 28, CHOL 211,
triglycerides 180, HDL 39, LDL 117, HDL/LDL 5.41, PT 11.6, INR 1.0, PTT 35, blood
alcohol 100. Prognosis and treatment options were discussed with Mr. Oishi's wife
and youngest son. Mrs. Oishi, in light of a poor prognosis, declined any treatment
that includes invasive procedures. The youngest son disagrees with his mother and
has requested more aggressive therapy. Mr. Oishi was transferred to the ICU Sunday
night while arrangements could be made for hospice care in a Skilled Nursing Facility.
Mr. Oishi received Nitroprusside 50 mg in 250 mL D5W to titrate systolic BP <140
>110, Mannitol 25% solution to decrease intracranial pressure, Famotidine 20 mg IV
to prevent stress ulcers, and IV therapy of D5 NS with 20 mEq KCl at 100 mL per
hour. On Monday morning, Mr. Oishi's blood pressure stabilized to a systolic BP of
140-150. The Nitroprusside and Mannitol were discontinued. He was transferred to
skilled nursing for hospice care.
Allergies:
None known to food or medication.
Past Medical History:
Hypertension for the past 10 years which has been controlled by medication
(Amlodipine/ Benazepril 2.5/10 mg every morning) until the past year when he
began experiencing a high degree of stress over his company failing. Hyperlipidemia
for the past 5 years controlled by medication (Atorvastatin 20 mg at bedtime). No
hospitalizations.
Surgical History:
None
Gyn History:
N/A
OB History:
N/A
Social History:

Mr. Goro Oishi has been married to Mrs. Hiroko Oishi for 40 years. He enjoys a close
and happy relationship with his wife. He has 2 married sons age 32 and 37. His
youngest son lives in town and his oldest son lives out of town. Mr. Oishi is the owner
and CEO of a small electronics company that up until a year ago was doing well. This
past year the company has been failing. Mr. Oishi has been under a great deal of
stress. He has been abusing alcohol for the past 6 months and has been hiding it
from his wife and sons. His wife has suspected that he was abusing alcohol, but
never confronted him. Mr. Oishi has been discussing retiring and having his youngest
son take over the position of CEO of the company. Now that the business is failing he
fears he will have no way to support his family and nothing left to leave his sons.

Family History:
Deferred
Medications:
Amlodipine/Benazepril 2.5/10 mg every morning
Atorvastatin 20 mg at bedtime
Review of Systems:
Other than mentioned in the HPI, noncontributory

Physical Exam:
GENERAL:
Comatose
VITAL SIGNS:
BP 140/70
P 72
R 20
T 98.8 (tympanic)
O2 sat 94% on oxygen at 2 liters per nasal cannula
HEENT:

The head is normocephalic without masses or lesions. Eyes deviate to the right.
Pupils are unequal 4 mm/3 mm with the left pupil 1 mm larger than the right. Both
pupils have a sluggish reaction to light. Sclera are nonicteric. Tympanic membranes
are clear. Oral cavity is pink and moist and there are no masses or lesions. Neck is
supple. No thyromegaly, lymphadenopathy, or masses. Tonsils are present.

LUNGS:
Chest expansion is shallow but symmetrical. Breath sounds are relatively clear with
scattered rhonchi and diminished breath sounds both bases.
HEART:
S1 S2. Regular rate and rhythm. No gallops. No murmurs.
ABDOMEN:
Soft with no hepatosplenomegaly. No palpable masses. Bowel sound hypoactive in all
four quadrants.
EXTREMITIES:
No movement on the left. Decerebrate rigidity to painful stimuli on the right. No
clubbing, cyanosis or edema. Peripheral pulses present and 2+.
SKIN:
Cool and dry. No gross lesions.
BACK:
No kyphosis noted.
GENITALIA:
No skin lesions in perineal region. No masses. Stool negative for occult blood.
Sphincter tone diminished. Prostate exam deferred.
NEUROLOGIC:
Glasgow Coma Scale = 4. Does not open eyes with painful stimuli, no movement on
the left, decerebrate rigidity to the right exteremities, no verbal response. Negative
Babinski.
Impression:
1. Intracerebral hemmorrhage right internal capsule.
2. Coma.
Plan:
1. Admit Skilled Nursing Unit for hospice care.
2. Do Not Resuscitate.
3. See admission orders.
Room: 505

Age: 66
MRN: 1868042 Room: 505
Patient: Goro Oishi
Sex: Male Age: 66
Physician: Gerald Moher, M.D.
   Weight: 165 lbs

Day/Time Orders
Order Type:

Wed 1130
1. Increase oxygen therapy to 4L/min.

Day/Time Orders

Order Type:

1. Admit: Hospice care, Do Not

Resuscitate.

2. Diagnosis: Intracerebral
hemorrhage.

3. Allergies: None known to food or

medications.
4. Diet: NPO
5. Activity: Bed rest with head of bed
elevated 30 degrees. Turn and
position every 2 hours.
6. Monitoring: Neurologic assessment
to include Glasgow Coma Scale every
4 hours.
7. Vital signs every 4 hours.

8. Intake and Output every 8 hours.

Mon 0700 9. Notify physician of neurologic

changes, respiratory distress, and
systolic BP >150 or <110.
10. Respiratory therapy: Oxygen at 2L
per nasal cannula, titrate to keep O2
sat >93%.

11. Pulmonary toilet per routine.

Suction prn.
12. IV D5 NS with 20 mEq KCl @ 100
mL/hr.
13. Medications: Famotidine 20 mg
IVPB every 12 hours.
14. Artificial tears 2 drops to both
eyes every 2 hours PRN.
15. Acetaminophen suppository 650
mg every 4 hours PRN temp greater
than 101 F.
16. Elimination: Condom catheter to
gravity drainage.
17. Range of motion to all extremities
TID.
 Signature

Gerald Moher, M.D.

Signature

Gerald Moher, MD
MRN: 1868042 Room: 505

Patient: Goro Oishi
Sex: Male Age: 66
Physician: Gerald Moher, M.D.
Nursing Admission and History
1. How to be addressed: Mr. Oishi
2. Admission date: Monday
3. Reason for this admission as stated by patient/chief complaint:

Information given by wife.

Hospice care after suffering a large stroke.
4. Diagnosis:
Intracerebral hemorrhage-internal capsule

5. Allergies and Reactions:

a. Drugs: None

b. Food: None

c. Other: None

6. Armband name verified: Yes, on left wrist

7. Patient instructed in the use of:
a. Call light: Family instructed
b. Bed rails: Family instructed
c. Smoking policies: Family instructed
d. Visiting hours: Family instructed
8. Age: 66
9. Sex: Male

10. T (°F): 98.8 tympanic

11. Blood pressure (systolic/diastolic): 140/70
12. Pulse: 72
13. Respiratory rate: 20
14. Height (ft/in): 5' 8"
15. Weight (lbs/kg): 165 lbs/75 kg
16. Current medications:
Medications Dosage Physician
Amlodipine/Benazepril 2.5 mg/10 mg daily G. Moher
Atorvastatin 20 mg at bedtime G. Moher
17. Any medications brought into the hospital:

Medications Disposition

None

18. Religion or spirituality: Buddhist

19. Valuables:

Yellow metal necklace, yellow metal ring, yellow metal watch

20. Disposition of valuables:

Wearing yellow metal ring, other valuables given to wife
21. Anticipated needs for support at time of discharge:
Grief and bereavement for family

HEALTH PROMOTION

1. Describe your general health:

Good until his stroke
2. Medical/psychiatric problems:
High blood pressure and high cholesterol. Started drinking alcohol 6 months ago and was trying to hi
it from his family.
3. Usual BP:
130/70 on antihypertensive

4. Surgeries, injuries, fractures:

None
5. Immunizations:
Up to date
6. Flu shots:

None

7. TB test:

Last year

8. Family HX:
Father and mother living, no illnesses. Brother died in a car accident at age 16.
9. Is there anything that interferes with your ability to follow health advice or medication
schedule:
Was experiencing a great deal of stress. Stopped following diet.
10. Use of alcohol, caffeine, tobacco, recreational drugs:
Abused alcohol past six months. No tobacco use.
11. Do you use any alternative complimentary therapies?
Yes, meditation
12. Describe any changes that have occurred in your lifestyle due to your medical condition
Comatose
13. Do you
Regularly conduct a breast self-
No
exam
Get a mammogram Does Not Apply 
Get a Pap smear Does Not Apply 
14. Do you
Regularly conduct a testicular
No
self-exam
Have your prostate examined Yes 
15. Do you use
Car seat belts Yes
Helmet when riding a bicycle Does Not Apply 
16. What questions, fears, or concerns do you have about your health:
Family fears that Mr. Oishi will die.

17. Do you have an advance

Yes
directive:
NUTRITION/METABOLIC

1. Usual appetite:

Good
2. Current appetite:
NPO
3. Do you have any dietary restrictions or problems we should know
about:
N/A

4. Have you had any recent weight gains or losses:

No
5. Oral cavity:

a. Teeth/dentures: Own dentition
b. Dental caries: None

c. Gums: Pink
d. Oral mucosa: Pink
e. Lesions: None
f. Altered taste: Unable to determine

6. Eating patterns:

a. Food preferences, allergies, intolerances: None

b. Number of meals/day: 3

c. Special diets: Low fat

d. Dietary supplements: None

e. Difficulty swallowing or chewing: Comatose, unable to swallow or chew

f. Fluid intake: IV intake only

g. Can you eat independently: No

h. Do you need help preparing meals: Family is independent.

i. Can you afford food and utilities for cooking: Family is able.

j. Appetite changes (describe): Unable to determine

k. Nausea and vomiting (describe precipitating/relieving factors): Unable
to determine
7. Any history of GI, liver, or endocrine problems: No
8. Skin assessment:
a. Integrity: Intact
b. Turgor: Skin elastic
c. Rash, incisions (describe location, size, healing): None
d. Varicosities: None
e. Poor wound healing: No
f. Drainage: None
g. Bruising: None
h. Lesions: None
i. Petechiae: None
j. Lymph node assessment as indicated: Deferred

k. Condition of hair and nails: Good

 ELIMINATION

1. Last bowel movement:

Unknown
2. Stool characteristics:

Unknown
3. What is your pattern of bowel movements:
Unknown
4. Laxatives or bowel elimination aids:
None

5. Any surgeries pertinent to bowel elimination:

None
6. Abdominal examination:
a. Inspection: Slightly rounded
b. Auscultation: Hypoactive bowel sounds all four quadrants
c. Palpation: Soft, no palpable masses
7. How often do you urinate: Unknown
8. Any problems with continence: None prior to stroke

9. Urine color/character of urine: Yellow, clear

10. Any catheter (check one):

External external

11. Bladder distention: None

12. Usual urinary pattern:
a. Nocturia: Yes
b. Dysuria: No, to the best of the wife's knowledge

c. Hematuria: No, to the best of the wife's knowledge

d. Poor or interrupted stream: No, to the best of the wife's knowledge

e. Straining: No, to the best of the wife's knowledge

f. Stress incontinence: No, to the best of the wife's knowledge

g. Hesitancy: No, to the best of the wife's knowledge
h. Frequency: No, to the best of the wife's knowledge

i. Urgency: No, to the best of the wife's knowledge

j. Pain (identify area, such as groin, abdomen, flank/kidney, perineal): Unable to determine
13. Alterations from normal urinary patterns: Unknown
14. Use of protective devices: Condom catheter

15. Previous treatment for urinary tract infections:

None
ACTIVITY / REST
1. Do you have any problems sleeping or resting?

Had problems sleeping before stroke

2. Patterns of sleep:

Restless night before stroke

3. Sleep routines:
Read before bed

4. Patient's perception of quality of sleep:

Unable to determine
5. Patterns of rest and relaxation:
Would meditate during the day
6. Patient's perception of their energy:
Unable to determine
7. Sleep aids (pillows, medication):
None
8. Exercise and recreational activities:
Walked
9. Limitations in activities of daily living:
Comatose
10. Ability to perform activities of daily living (ADL):
Some
ADL Independent
Assistance
some
Eating independent
assistance
some
Dressing independent
assistance
some
Ambulating independent
assistance
some
Toileting independent
assistance

some
Bathing independent
assistance

some
Grooming independent
assistance
some
Writing independent
assistance
some
Cooking independent
assistance
some
Cleaning independent
assistance
some
Shopping independent
assistance
 some
Doing laundry independent
assistance
some
Using telephone independent
assistance
some
Taking medication independent
assistance
some
Managing money independent
assistance
11. Limitations in mobility:
No movement left side, abnormal extension right side
12. List assistive devices:
Side rails
13. Muscular weakness or fatigue:
All extremities
14. Swelling, redness, or warmth around joints or over muscles:
No

15. Gait:

Unable to walk

16. Range of motion in limbs:

Passive range of motion present

17. Sensation:
Unable to determine
18. Home maintenance management:
None
19. Size and arrangement of home:
Single-level
20. Occupation(s):

Store owner

21. Housekeeping responsibilities:

None
22. Cardiovascular status:
a. Apical rate/rhythm: 72
b. PMI: 5th intercostal space left midclavicular line

c. Heart Sounds: S1 S2

d. Pacemaker: None
e. Blood Type: O
f. Rh Factor: Pos
g. Orthostatic BP as indicated:

Lying: 140/70
Sitting: Unable to sit
Standing: Unable to stand
h. Dizziness/lightheadedness (describe if present): Unable to determine
i. Jugular vein distention (describe if present): None
j. Pulses (3+ = bounding, 2+ = palpable, 1+ = faintly palpable):
Carotid: Deferred
Radial: 2+
Posterior tibial: 2+
Dorsalis pedis: 2+
k. Skin temperature and color: Cool and pale
l. Edema: None
m. Capillary refill:
  Fingers: <3 seconds
  Toes: <3 seconds

n. Intermittent claudication (check one):  no

o. Ascites (check one): no

22. Respiratory:
a. Rate: 20
b. Rhythm: Regular
c. Depth: Shallow
d. Quality (check one):  labored Labored  unlabored Unlabored
e. Breath sounds (describe): Clear, scattered inspiratory wheezes, diminished in both bases
f. Dyspnea (if yes, describe precipitating factors): No
g. Cough (check one):  productive Productive  unproductive Unproductive  none None
h. Sputum (describe): None
i. Splinting: None
j. Oxygen therapy: 2 liters per nasal cannula
PERCEPTION AND
COGNITION
1. Orientation: Comatose
2. Barriers to learning: Comatose
3. Best method for instruction: Family
4. Primary language: English
a. Read (check one): Yes
b. Write (check one): Yes
c. Understand (check one): Yes
5. Other language: Japanese
a. Read (check one): Yes
b. Write (check one): Yes
c. Understand (check one): Yes
6. Memory:
a. Short-term: Unable to determine

b. Long-term: Unable to determine
7. Decision making:
Comatose, wife is appointed as agent.
8. Speech and voice patterns:
None
9. Alternate form of communication:
None
10. Neurologic changes:
Comatose
11. Vision (describe impairments):
Eyes deviate to the right.
12. Visual aids:

None
13. Hearing:

Unable to determine

14. Auditory aids:

None
15. Taste, touch, smell:
Unable to determine
SELF-PERCEPTION

1. Patient's description of self:

Comatose, unable to determine
2. Effects of illness or surgery on self-concept:
Comatose, unable to determine
3. Recent stressful life events or life-changing events:
Comatose, unable to determine
4. Verbalizes feelings of fear or anxiety:
Comatose, unable to determine
5. Source of anxiety or fear:
Comatose, unable to determine
6. Physical manifestations of stress/anxiety:
Comatose, unable to determine
7. Perception of abilities:
Comatose, unable to determine
8. Body posture:
Comatose, unable to determine
9. Eye contact:
Comatose, unable to determine
ROLE RELATIONSHIPS

1. Marital status:
Married
2. Family processes:
Mr. Goro Oishi has been married to Mrs. Hiroko Oishi for 40 years. They have a
very close and happy relationship. Mrs. Oishi is a housewife. They have two sons.
The eldest son (Nimashi Oishi) is 37, married, has two daughters, and teaches at
a university in another state. The youngest son (Kiyoshi Oishi) is in his early 30s,
is married, has one son, and works with his father in a small family-owned and
operated electronic business.
3. Care-giving role:
Family financial support
4. Breastfeeding:
N/A
5. Role performance:
Head of household
6. Social interactions:
Mr. Oishi is the owner and CEO of a small electronics company that until a year
ago was doing well. This past year, the company has been failing. Mr. Oishi has
been under a great deal of stress. He has been abusing alcohol for the past 6
months in an attempt to deal with the stress and has been hiding it from his wife
and sons. His wife has suspected that he was abusing alcohol but never
confronted her husband. Mr. Oishi has been discussing retiring.

SEXUALITY

1. Sexual identity:
Wife was not comfortable answering for her husband.
2. Sexual function:
Wife was not comfortable answering for her husband.
3. Sexual patterns:
Wife was not comfortable answering for her husband.
4. Sexual response (satisfactory or unsatisfactory):
Wife was not comfortable answering for her husband.
5. Do you feel this illness will affect your femininity/masculinity:
Wife was not comfortable answering for her husband.
6. Last menstrual period:
N/A
7. Birth control:
N/A
8. Any sexually transmitted diseases now or in the past:
No
9. Age and health of significant other:
60 and in good health
10. Gravida:
N/A
11. Para:
N/A
12. Abortions:
N/A

13. Deceased children:

14. Living children:

NAME Sex Age

Nimashi Oishi M 37
Kiyoshi Oishi M 32
COPING AND STRESS
TOLERANCE

1. Have there been any changes in your life that may be causing stress:
Failing business
2. Coping:

a. Fear: Comatose, unable to determine

b. Anxiety: Comatose, unable to determine

c. Sorrow: Comatose, unable to determine

d. Loss: Comatose, unable to determine
e. Denial: Comatose, unable to determine
f. Adjustment: Comatose, unable to determine
3. Adaptive capacity:
Comatose, unable to determine
4. How will this hospitalization affect you, your family, or goals:
Hospice care
LIFE PRINCIPLES
1. Describe your preferred values and modes of conduct:
Lives the Zen way
2. Spiritual well-being:
Comatose, unable to determine
3. Decisional conflict:
Family has a decisonal conflict over the aggressiveness of treatment.
4. Do you have any spiritual or cultural practices that you feel are
important to your life:
Zen Buddhism
5. The hospital chaplain offers spiritual care. Do you want the chaplain to
visit you:
No
6. Would you like contact with other spiritual advisors:
Yes
SAFETY/PROTECTION

1. Infection risk:
Yes
2. Fall risk:
Yes
3. Physical injury, bodily harm, or hurt:
a. Injuries: None
b. Trauma: None
c. Skin integrity: Risk for skin breakdown
d. Tissue integrity: Risk for tissue breakdown
e. Dentition: Risk for gum infection

f. Suffocation: Risk for suffocation

g. Aspiration: Risk for aspiration
h. Airway clearance: Unable to clear own airway
i. Neurovascular function: Capillary refill fingers and toes <3 seconds
j. Evaluate cranial nerves: Deferred
4. Violence:
None
5. Environmental hazards:
No risk identified
6. Temperature regulation:
Risk for altered temperature regulation
7. Impact of disabilities on safety:
Totally dependent

COMFORT
Are you currently
experiencing pain, or do you
have chronic pain:
Comatose, unable to determine
2. Pain/discomfort:

a. Pain onset: Comatose,
unable to determine
b. Rating (scale of 0 to 10; 0
= no pain): Comatose, unable
to determine
c. Duration: Comatose, unable
to determine
d. Location(s): Comatose,
unable to determine
e. Quality: Comatose, unable to
determine
f. Radiation: Comatose, unable
to determine
g. Aggravating or associated
factors: Comatose, unable to
determine
h. Alleviating
factors: Comatose, unable to
determine
3. Nausea:
Comatose, unable to determine
4. Social isolation:
Comatose, unable to determine

GROWTH AND
DEVELOPMENT
1. Risk for growth:
Hospice care
2. Development:
Grief and bereavement for family

Signature: Kathy Wilson, RN
ths ago and was trying to hide

ge 16.
th advice or medication
to your medical condition:

alth:
eal): Unable to determine
Dependent
dependent
dependent
dependent
dependent

dependent

dependent

dependent
dependent
dependent
dependent
dependent

dependent
dependent
dependent
 mine

minished in both bases

ve  none None
MRN: 1868042 Room: 505
Patient: Goro Oishi
Sex: Male Age: 66
Physician: Gerald Moher, M.D.
Physician's Progress Notes

Day/Time Notes

Mr. Oishi's condition continues to deteriorate.

No motor response. Pupils are fixed and dilated
Wed 1500 bilaterally. Cheyne-Stokes respirations noted
with O2 sat in the low 80s on oxygen therapy.
BP 90/60, P 100, no urine output since 1000.

Day/Time Notes

Called out of family conference due to change in

condition. Left pupil is now fixed and dilated,
positive Babinski. BP 190/98, O2 sat 88% on
oxygen at 4L per nasal cannula. 200 mL urine
Wed 1120 output since 0700. Discussed with family the
possibility of a reoccurrence of cerebral bleeding
and treatment options. The wife refuses further
diagnostic tests and treatment. Will continue
present plan.

Physician's Progress Notes

Day/Time Notes
Discussed discontinuing IV therapy and IV
medications and substituting with enteral
Tue 2000 nutrition. The family is conflicted about whether
or not to initiate enteral feedings. Will continue
present plan.
Physician's Progress Notes
Day/Time Notes

Mr. Oishi is admitted for anticipated hospice

care following a large intracerebral hemorrhage.
Mr. Oishi has an advance directive on file
Mon 0700
appointing his wife as agent. Mrs. Oishi refuses
any invasive procedures at this time. See
History and Physical. No change in condition.
 Signature

Gerald Moher, M.D.

Signature

Gerald Moher, M.D.

Notes

Signature

Marlene Dirkson, M.D.

Notes
Signature

Marlene Dirkson, M.D.

MRN: 1868042
Patient: Goro Oishi
Sex: Male
Physician: Gerald Moher, M.D.
Pastoral Care Spiritual Assessment

Date: Wednesday

Gender: Male
Age Group: Geriatric

Care Settings: Long-term care, hospice

Nature of Chaplain's Visit: Death/dying

Primary Service to: Spouse/significant other, family

Response: Urgent
Speed of Response: Within 24 hours
Referral by: RN
Source of Hope/Hope Factors:
Spirituality/Faith Factors:
    Faith group: Buddhist

    Religious/Faith Practice:  

    Perception of God:  

    Relationship with God:  

    Effects of illness on spirituality:  
Key Psychosocial Factors: Terminal illness/awareness of mortality

Pastoral Interventions: Ethical deliberation, counseling/dialogue, affirmation/comfort/ministry of

presence, decision support/advance directives/organ donation

Outcomes: Not helpful--family is Zen Buddhist

Referral to: Zen Buddhist

spiritual advisor
Time In: 1100
Chaplain's Name: Alan Joyce
Chaplain's Signature: Alan Joyce
 Room: 505

Age: 66
Moher, M.D.
Pastoral Care Spiritual Assessment

Room No.: 505

g-term care, hospice

's Visit: Death/dying

: Spouse/significant other, family

e: Within 24 hours

ope Factors: Family
Factors:
dhist

actice:  

:  

God:  
n spirituality:  
Factors: Terminal illness/awareness of mortality

ions: Ethical deliberation, counseling/dialogue, affirmation/comfort/ministry of

upport/advance directives/organ donation

pful--family is Zen Buddhist

Accomplished?: no
Time Out: 1200
Alan Joyce
re: Alan Joyce
MRN: 1868042 Room: 505
Patient: Goro Oishi
Sex: Male Age: 66
Physician: Gerald Moher, M.D.
Day/Time Notes

Respirations labored at a rate of 24. O2 saturation

of 84% on 4 L/min oxygen. Turned onto back with
Wed 1200 head of bed elevated 30 degrees. Family has
decided to withhold any further diagnostic tests or
treatment.

Nurse's Notes
Day/Time Notes

Left pupil is fixed and dilated. BP 190/98, O2

Wed 1115 saturation of 88%. Oxygen therapy increased to
4L/min. Physician notified.

Nurse's Notes
Day/Time Notes

Assumed care of patient. See EPR for assessment

and care. Condom catheter in place to gravity
drainage with fair urine output. Range of motion
Wed 0730 done to all extremities by patient's wife. Physician
in to meet with oldest son. Family continues to
struggle with the palliative care plan. A family
conference is scheduled for 1100 today.

Nurse's Notes
Day/Time Notes
 Oldest son arrived from out of town after
physician left. Will arrange a meeting between
Wed 0600 oldest son and physician to discuss prognosis and
plan of care. Mr. Oishi's condition remains
unchanged.

Nurse's Notes
Day/Time Notes
Assumed care of the patient. See EPR for
assessment and care. Physician discussed with the
family inserting a feeding tube and initiating
enteral nutrition and discontinuing the IV therapy
Tue 1910 and IV medication. Mrs. Oishi requested more
time to think about the change in therapy.
Condom catheter in place to gravity drainage with
adequate urine output. Range of motion done TID
to all extremities.
Nurse's Notes
Day/Time Notes
Tue 1800 No change in condition.
Nurse's Notes
Day/Time Notes

Assumed care of patient. See EPR for assessment

and care. Family at bedside. Condom catheter in
Tue 0800
place to gravity drainage with adequate urine
output. Range of motion done to all extremities.

Nurse's Notes
Day/Time Notes

Assumed care of patient. See the electronic

patient record for assessment and care. Minimum
Mon 0800
data set (MDS) initiated. MDS coordinator notified.
Condom catheter in place to gravity drainage.
Height : 5' 4"

Weight: 105 lb

Signature

Rubeye Nasir, RN

Signature

Rubeye Nasir, RN

Signature

Rubeye Nasir, RN

Signature
Rebecca Atkins, RN

Signature

Rebecca Atkins, RN

Signature
Rubeye Nasir, RN

Signature

Rubeye Nasir, RN

Signature

Rubeye Nasir, RN
MRN: 1868042 Room: 505 Height : 5' 4"

Patient: Goro Oishi

Sex: Male Age: 66 Weight: 105 lb

Physician: Gerald Moher, M.D.
Complete blood count Monday
White blood count (WBC) 4.6
Red blood cells (RBC) 4.01
Hemoglobin (Hgb) 14.2g/dL
Hematocrit (Hct) 45%
Platelets 300, 000 mm³
Coagulation Panel Monday
Activated Partial Thromboplastin (aPTT) 35 seconds
Prothrombin time (PT) 11.6 seconds
International normalized ratio (INR) 1
Basic metabolic Panel (BMP) Monday
Sodium 139 mEq/L
Potassium 4.5 mEq/L
Chloride 105 mEq/L
Carbon dioxide 28 mg/dL
Glucose 104 mg/dL
Cholesterol 211
Trigylceride 180
HDL 39
LDL 117
Alcohol 100 g
nday

nday
MRN: 1868042
Patient: Goro Oishi
Sex: Male
Physician: Gerald Moher, M.D.
ADVANCE DIRECTIVE for PHYSICAL HEALTH CARE
In the following document, "I" and the "declarant" refers to: Goro Oishi
I hereby make known my desire that should I lose the capacity to make health care decisions, the
following instructions regarding consent to or refusal of medical treatment, and if I choose, the
designation of my health care agent. I intend that all completed secions of this advance directive be
followed.
Part I. Health Care Proxy:
A. Appointment of a Health Care Agent:
I hereby appoint the folowing individual as my health care agent to make any and all health care
decisions for me, except to the extent that I state otherwise, This health care proxy shall take effect
when and if I become unable to make my own health care decisions.
Hiroko Oishi
777 West 1st Street, Generation, CA 95555
555-623-0245
B. Alternative Health Care Agent (optional):
If the person appointed is unable or unwilling to serve as my health care agent, I hereby appoint the
following individual to act as my alternative health care agent.
Nimashi Oishi
899 Campus Ave, Grantsville, AZ 85563
555-434-3809
Part II. Statement Desires and Instructions Regarding Health Care Decisions and
Treatments:
A. General Intent:

1) If at any time I should have an incurable condition caused by injury, disease, or illness certified to
be a terminal condition by two physicians, and where the application of life-sustaining procedures
would server only to artificially prolong the moment of my death, and where my attending physician
determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct
that such procedures be withheld or withdrawn, and that I be permitted to die naturally.

2) In the absence of my ability to give directions regarding the use of such life-sustaining procedures
it is my intention that this directive be honored by my agent, my family and my physicians as the fina
expression of my legal right to refuse medical or surgical treatment and to accept the consequences
from such refusal.
3) I hereby grant to my agent full authority to make decisions for me regarding my health and perso
care. In exercising this authority, my agent shall follow my desires as stated in this document. My
agent's authority to interpret my desires is intended to be as broad as possible, except for any
limitations that I specifically state below. Accordingly, my agent is authorized:
i. To consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical
procedures, diagnostic procedures, medication, and use of artificial respiration, nutritional support an
hydration, and cardipulmonary resuscitation: and
ii. To authorize my admission to or discharge (even against medical advice) from the hospital, nursin
home, residential care, assisted living or similar facility or service.
B. Life-Sustaining Treatment:
With respect any life-sustaining treatment, which for purposes of this document mean any medical
procedure or intervention that would serve only to prolong the dying process, I direct the following:
1) Grant of Discretion to Agent to Begin or Terminate Treatment

i. To consent to life-sustaining treatment provided that all reasonable times therafter, such treatment
subject to continuing review in light of the fact that I do not want life-sustaining treatment begun nor
continued if my agen, after consulting with my family and/or physician, believes the burdens of
treatment outweight the epxected benefits. All relevant consideration shall go into making such
judgements including without limitations, relief of suffering, quality of life, possible extension of life,
expected nature of life extended, and the expenses involved in expected care.

ii. Even though life-sustaining treatment has been started by agent is authorized, based upon the
considerations listed in this proclamation, to have such life-sustaining treatment terminated at any tim
folowing consultation with my attending physician or physicians and my family.
2) Coma or Persistent Vegetative State
If I have an incurable condition, including but not limited to a coma or persistent vegetative state,
which my attending physicians reasonably conclude to be irreversible, I want all Life-sustaining
treatment stopped immediately and my agent is authorized to carry out these wishes.
3) Food and Fluid

I wish to make clear that I intend to include artificial administration of food and fluids amont the "life
sustaining procedures" that may be whitheld or withdrawn under the conditions stated above.

Part III. Declaration of Understanding:

I understand the full intent of this directive, and am emotionally and mentally competent to make thi
I understand that I may revoke this directive at any time.
Name (print):

Name:
Part IV. Statement and Signature of Witnesses:

Part IV. Statement and Signature of Witnesses:

The person known to us to be the preson whose signature appears at the end of the above directive,
the above directive, consisting of 3 (pages) including the page on which we have signed as witnesses
signed the directive in our presences and, at his/her request in his/her presence and in the presence
as
Thewitnesses.
declarant has been personally known to us and we believe him/her to be of sound mind. We are
or marriage, nor would be entitled to any part of the declarant's estate on the declarant's death, nor
declarant or an employee of the attending physician or a health care facility in which the declarant is
cliam against any part of the estate of the declarant on the declarant's death.

Richard Anderson, Attorney at Law

Richard Anderson, Attorney at Law
Joanne George, Legal Assistant
Joanne George, Legal Assistant

Liane Smith, Legal Assistant

Liane Smith, Legal Assistant
Room: 505 Height : 5' 4"

Age: 66 Weight: 105 lb

ake this directive.

Goro Oishi

Goro Oishi

ective, declared to us, the undersigned, that

nesses, was his/her directive, he/she then
sence of each other, we now sign our names
We are not related to the declarant by blood
h, nor are we the attending physicians of the
rant is a patient, or any person who has a

222 N. 4th Street

residing at Generation, CA
95555
 222 N. 4th Street
residing at Generation, CA
95555

222 N. 4th Street

residing at Generation, CA
95555
MRN: 1868042 Room: 505 Height : 5' 4"
Patient: Goro Oishi
Sex: Male Age: 66 Weight: 105 lb
Physician: Gerald Moher, M.D.
Intracerebral
Medical Diagnosis: hemorrhage--hospice
care
DATE INITIATED PROBLEMS OUTCOMES

Patient will have

Bladder/Bowel
adequate bowel and
Elimination
bladder function.

understanding of
Bone Marrow tests, pretransplant
Transplant conditioning,
procedures, illness
Patient/Family will
Cardiac maintain stable
cardiac status.

Patient/Family will
achieve
understanding of
their disease
process and effects
Chemotherapy of chemotherapy.
Patient will achieve
optimal effects of
chemotherapy
without severe side
effects.

Patient will have

Comfort/Pain reduced or minimal
pain.
or progress along in
Development the developmental
possessing the
continuum during
necessary
Discharge
knowledge and skill
to meet their
Patient will maintain
Fluid/Volume/Electrolyt
fluid and electrolyte
e Imbalance
balance.
Patient will
participate in ADLs
with minimal
Hematology discomfort.
 Hematology Patient/Family will
achieve
understanding of
their disease
process.
Patient will be free
of signs and
Infection
symptoms of
infection.
Patient will achieve
optimal
Neuro
neurobehavior
functioning.
Patient will
demonstrate optimal
nutritional intake.
Nutrition Patient will
demonstrate
improved oral
motor, swallowing,
feeding ability.
Patient/Family will
be fostered to
Monday Psychosocial
optimize bonding
and attachment.

Patient will
Monday Respiratory demonstrate optimal
respiratory function.

DATE INITIATED PROBLEMS OUTCOMES

Patient will be
provided with safe
Monday Safety environment of
care, avoiding any
accidental injury.

Patient will be free

of signs and
Monday Skin Integrity symptoms of
impaired skin
integrity.
Patient/Family will
be provided an
environment which
Monday Spiritual/Cultural
supports their
spiritual and cultural
needs.
 Patient will maintain
Monday Thermoregulation temperature within
normal range.

ADMISSION INFORMATION ALLERGIES/REACTI

Admitting Diagnosis: Drugs: None
Intracerebral hemorrhage Foods: None
History: Blood Products: None
Hypertension, hyperlipidemia ISOLATION/PRECAU
SURGERY Date
Date Type   
  
  
FLUID/NUTRITIO
MONITORING Diet:
Code Status:   DNR NPO
VS: q4h NVS: GCS q4h IV Therapy:
E = Describes how info/skill will
A = Return demonstration Peripheral
be applied at home
FLUID/NUTRITION
Date Site Solution
Mon R FA D5 NS with 20 mEq KCl

ELIMINATION
I/O: Every 8 hours
Ostomy:  
Foley: Condom catheter Size:  
Intermittent Cath:   Size:  
NGT/OGT (Date):  
Suction:  
G-Tube:  
ACTIVITY
 Bedrest
Mode of Transportation:
Stretcher
FiO2: Keep sat >93%
Mode: Nasal cannula
PEEP/Pressure:  
TV:  
CPT:

Tx:
CPAP/BiPAP:

Trach Branch:

Date Changed:
Chest Tube #1:   cm

Chest Tube #2:   cm

LABS

Time Scheduled

QAM

Q6H
Q12H

Time Bedside Testing

SCH ORD
 79 Sex Female
105 lb Allergies
 ALLERGIES/REACTIONS

ts: None
ISOLATION/PRECAUTIONS
Type

FLUID/NUTRITION

mL/hr
 100 
   

O2 Device: Wall Gerald Moher,

Attending:
O2 M.D.
Rate: 4L flow

IS:   FAMILY CONTACTS

  Freq: Name Phone
Hiroko Oishi
  Freq: 555-623-0245
(wife)
 Nimashi Oishi
555-434-3809
(son)
Kiyoshi Oishi
Size: 555-623-1206
(son)
INTERVENTIONS
H20Seal: Date
Range of motion
H20Seal: Mon
exercises TID
Notify physician of
neurological
changes,
Mon respiratory
distress, and
systolic BP >150
or <110
Keep head of bed
Mon elevated 30
degrees
Family conference
Wed to discuss plan of
care

SCH ORD

DIAGNOSTIC PROCEDURES
SCH ORD
DONE
MRN: 1868042 Room: 505 Height : 5' 4" 79
Patient: Goro Oishi 105 lb
Sex: Male Age: 66 Weight: 105 lb
Physician: Gerald Moher, M.D.
Vital signs Monday AM Monday PM
Time 800
Temp 98.8 F
Pulse 72
RR 20
BP (cuff) 140/70
O2 Sat 94% 2LPM N/C
GCS 4
Pain scale (numeric)
Intake
PO
Gastrostomy
IV 100
Blood
Other
Intake Total Total:
Output
Time
Urine
BM
Nasogastric
Drain
Other
Output Total Total:
Initial RN RN

Electronic Signature Shift Name

RN AM Rubeye Nasir
RA PM Rebecca Atkins
Sex Female
Allergies

Tuesday AM Tuesday AM Tuesday PM Wednesday AM

700
101.0 F
88
22
160/86

100

Total:

1900
adequate amount? 200

135 Total:
Wednesday AM Wednesday PM
1115 1200

190/98
88% 4LMP N/C 84% 4LMP N/C

1000
no urine

RN RN
MRN: 1868042 Room: 505 Height : 5' 4" 79
Patient: Goro Oishi 105 lb
Sex: Male Age: 66 Weight: 105 lb
Physician: Gerald Moher, M.D.

Order date Stop date PRN

Order date Stop date IV Therapy

Electronic signature Date

Sex Female
Allergies

0700-1900 1900-0700

0700-1900 1900-0700

Name