shift notes 7a-3p - res #3 - RN
(fictional resident, my shorthand)

J.M. 34M hx autism, IDD (moderate), seizure d/o, PICA, GERD
AM meds given per MAR ~0800 took all w/o issue, no refusals
behavior calm AM. ~1400 agitated after program schedule change - pacing, loud
vocalizations, no SIB. redirected w/ weighted blanket + quiet room, deescalated
by ~1430. no aggression toward staff/peers
PICA - 1100 attempted to mouth a small plastic piece from activity, staff removed,
redirected. no ingestion. reinforced 1:1 supervision per BSP
seizure precautions intact. NO seizure events this shift
ate 100% breakfast, 90% lunch. 1x loose BM 1230 (bowel protocol - watching, last
BM was 2 days ago per prior note)
vitals 1000: BP 128/78, HR 78, T 98.2, RR 18, SpO2 98% RA
PT visit 1000 - amb in hall w/ rolling walker x50ft, tolerated well
skin check - no new areas, existing stage 1 on coccyx unchanged, barrier cream applied
participated in afternoon group (music) - engaged, calm
family: sister called 1330, updated, no concerns
no injuries, no incidents, no restraints
plan/handoff: monitor agitation around transitions, RN to f/u bowel protocol if no
BM by tomorrow AM, continue seizure + PICA precautions, 1:1 during activities