Meadow Creek Health & Rehabilitation · Room 214-B

Doris M. Burke

Left hip fracture, post-op day 12 · Type 2 diabetes · CHF

Medicare benefit days

18 of 21 used

Today at a glance

Everything that was done for Miss Dot today, in the order it happened.

Turns / repositions

7 logged

On track

Meal intake average

76%

On track

Fluids

1,020 mL

On track

Falls today

None

On track

Turn & repositioning log

New: stage 1 heel area being watched
  1. 06:00

    Repositioned — right side

    Pillow wedge placed. Skin over sacrum pink, blanchable, no breakdown.

    Charted by A. Reyes · CNA #4412

  2. 08:05

    Up to recliner

    Transferred with 2-person assist and gait belt. Tolerated 45 minutes.

    Charted by A. Reyes · CNA #4412

  3. 10:00

    Repositioned — left side

    Heels floated on pillow. Barrier cream applied.

    Charted by A. Reyes · CNA #4412

  4. 12:15

    Repositioned — back with wedge

    Head of bed 30°. Incontinence care completed.

    Charted by T. Nguyen · CNA #5108

  5. 14:10

    Repositioned — right side

    Resident requested TV on. Call light in reach.

    Charted by T. Nguyen · CNA #5108

  6. 16:00

    Repositioned — left side

    Small reddened area right heel noted, reported to charge RN.

    Charted by T. Nguyen · CNA #5108

  7. 18:20

    Repositioned — back

    Skin check by RN: stage 1 pressure area right heel, offloading boot applied.

    Charted by K. Alvarez, RN · RN #2201

Meals, hydration & diet

Ordered diet: Carb-modified, mechanical soft, thin liquids

Breakfast · 7:40

Ate 75%

Scrambled eggs, oatmeal, peaches, 8oz milk, decaf coffee

Fluids 360 mL · Fed self with setup assist. Enjoyed the peaches.

Logged by A. Reyes, CNA

Lunch · 12:05

Ate 50%

Baked chicken (minced), mashed potatoes, green beans, pudding

Fluids 240 mL · Refused green beans. Encouraged fluids.

Logged by T. Nguyen, CNA

Snack · 14:45

Ate 100%

Greek yogurt, graham crackers

Fluids 120 mL · Dietitian-added protein snack.

Logged by T. Nguyen, CNA

Dinner · 17:30

Ate 80%

Salisbury steak (minced), rice, carrots, sugar-free jello

Fluids 300 mL · Sat up in chair for full meal.

Logged by T. Nguyen, CNA

Vitals & comfort

Blood pressure

128/74

08:00

Heart rate

78 bpm

08:00

Temperature

98.4 °F

08:00

O₂ saturation

96% RA

08:00

Blood glucose

156 mg/dL

11:30

Weight

148.2 lb (-0.6 lb)

06:30

Pain

3 / 10 hip

14:00

Bowel / bladder

1 BM, continent x3

All day