Pt.
:____________ Age:____ Diagnosis: |
N/A ASSESSMENT AGE: LOC: Alert Lethargic Drowsy Unresponsive Spontaneous Oriented Disoriented Confused Speech: Clear Slurred Intubated Rambling Inappropriate Infant/Aphasic Pupils: Size L/R Response L/R Sensation: Normal Abnormal Ant/Pos Fontanel FOC Soft & Flat Sunken Full/Bulging Facial Dropping Pattern: Regular Irregular Labored Unlabored Sound: Clear Diminished Wheezes Rhonchi Cough: Absent Non-Productive Productive Secretions/Sputum Resp.Rate: Indicate Abnormal: Indicate Ventilator SpO2 / Pulse ox Oxygen @ lpm IS @ Bedside Bipap/Cpap Heart Sounds S1, S2 Abnormal Heart Rhythm Apex: Regular Irregular Peripheral Pulses Brachial/ Radial L/R Pedal L/R Vascular Access: L/R or Other Edema: Location 0700 - 1500 1 2 3 SYSTEM M U S C U L O S K E L E T A L ASSESSMENT ROM - Full Limited None Gait: Steady Unsteady Paralysis Weakness Contractures Traction - # SCD Muscle Strength* RUE LUE RLE LLE ABD: Soft Firm Distended ____cm Tender Other: Bowel Sounds Present Absent Hypo/Hyper Last BM Emesis / Nausea Tubes Placement verified Suction Type Skin: Intact Other:ie, scars Temp: Warm Hot Turgor: Good Fair Poor Moisture: Warm / Dry Cool / Dry Clammy / Moist Diaphoretic Color: good Pale Flushed Ashen Cyanotic Jaundiced Mucous Membranes Pink, Pale, Moist, Dry Critical Values Lab: RSV, ROTA X-Rays ABGs VCUG Culture 0700 - 1500 1 2 3 SYSTEM SYSTEM
Other:
ASSESSMENT Suicide Seizure Aspiration Suction at BS One on One Head of Bed Voiding Foley to BSD Inserted ______ Incontinent CBI Color of urine: Clear Yellow Amber Supra Pubic Cath Cooperative Uncooperative Good eye Contact Playful / Conversant Withdrawn Depressed Quiet Anxious Combative Family / SO @ BS Parent @ Bedside Airborne Droplet Contact Neutropenic 0700 - 1500 1 2 3
Pre Cautions
N E U R O
G U
G I
P S Y C H O L O G I C
R E S P I R A T O R Y C A R D I O V A S C U L A R
ISOLATE OTHER
S K I N
RISK FOR FALL
RISK FOR FALL One = Risk for Falls Continue / Initiate risk for falls Crawls / walks Confusion Sensory Deficits Impaired Mobility Sedative/Narcotics Diuretics/Laxative Substance Abuse Anesthesia
OTHER
Time / Signature and Initial
Date: _____________ Daily Weight: ________
TIME 10 08 . . . . . . . . . . 09 . . . . . . . . . . 1 0 . . . . . . . . . . 11 . . . . . . . . . . 12 . . . . . . . . . . 13 . . . . . . . . . . 1 4 . . . . . . . . . .
Height: __________ Patient
15 . . . . . . . . . . 16 . . . . . . . . . . 17 . . . . . . . . . . 18 . . . . . . . . . . 19 . . . . . . . . . . 20 . . . . . . . . . .
Progress Documentation Form
2 2 . . . . . . . . . . 23 . . . . . . . . . . 24 . . . . . . . . . . 01 . . . . . . . . . . 02 . . . . . . . . . . 0 3 . . . . . . . . . . 0 4 . . . . . . . . . . 0 5 . . . . . . . . . . 06 . . . . . . . . . .
2 1 . . . . . . . . . .
Pain Intensity 5
0 Relief Acceptable (Y/N)
TUBE FEEDING RECORD INTAKE Oral GT IVPB IV Fluids Hyperal 07001500 1500 0700 24 Hr Total OUTPUT Urine Emesis Gastric Suction Drainage Tube Stool 07001500 1500 Time 0700 24 Hour Strength/ Total Type Rate CODE TYPE Code:
Diet
Pump
N-NPO : R-Refused P-Poor F-Fair G-Good E-Excellent
Tube Bag & Tubing Checked Change C-Clear liquid placement O-Other R-Regular
Residual
Breakfast
Lunch
APPETITE
Breakfast
Lunch
%
Rate Pump Tube/Filter Site Care Needle Site
TOTAL
IV Time IV# IV Solu
TOTAL
AMT
I.V. SITE CHECKS* CODE:
Time Site # Redness Drainage Edema Tenderness Heat IV Dressing Dry & Intact Restarted IV Checked Q2 Hours Initials 0700
O-NO,
0900
ABSENT - YES PRESENT
1100 1500
Hygiene / Safety
Am Care - BB/SH Pm Care - BB/SH Partial Bath Oral Care/ # teeth Back Care Sitz Bath Patient Resting Or Sleeping Foley Care / Diaper area Turn Q 2 hours Bed locked Y or N Call light within reach
07001500
15000700
Patient Progress Documentation
Student Name :____________________________PATIENT IDENTIFICATION
Vital Signs :
AM
PM
Patient Progress Documentation
Date: _____________Patient Id: _____ Age :______ DX :_______________________ Other :____________________________________ Time 0900 Problem (System) RESP Nsg. Dx; Outcome; Interventions Time Problem RESP Evaluation
Nsg. Dx.: Ineffective air clearance r/t obstructive airway aeb excessive mucus, ineffective coughing, crackles & RR. Outcome: Client will maintain a clear airway aeb thinner secretions, productive cough, clear breath sounds bilaterally. Interventions:
Shift 0700 0700 1900 1900
KEYS:
Init
Signature
Init
Signature
Discipline
Time
07001500 07001500 15002300 23000700
REST/SLEEP: G = Good I = Intervals P = Poor Hygiene: BB = Bedbath BC = Back Care SH = Shower Activity: A = Assist S = Self FACE-COGNITIVE PAIN SCALE 0No particular expression or smile 1Occasional, grimace or frown, withdrawn, disinterested 2frequent to constant frown, clenched jaw, constant grimacing BREATHING PATTERN -0-Normal 1 Increased resp rate 2 Increased resp rate, difficult to oxygenate, fighting ventilator ACTIVITY 0 Lying quietly, Normal position and moves easily 1 Squirming, shifting back/forth, tense 2 Extremely restless or extremely tense unwilling to move HEART RATE / BLOOD PRESSURE 0 Normal 1 Occasional heart rate or blood pressure elevations 2 Constant increased heart rate, blood pressure CONSOLABILITY 0 - Content Relaxed 1 Calmed by occasional touching, or talking to Distractible 2 Difficult to console or comfort
Discipline Legend
CDE Cert. Diabetic Educator
= Routine care given / Normal findings l = Not Applicable * = See Patient Progress Notes WNL = Within Normal Limits R = Right L = Lift *5/5 Full Muscle Strength 4/5 Movement Against MOD. Resistance 3/5 Rise Against Gravity 2/5 Muscle Contraction Without Gravity 1/5 Muscle Twitch 0/5 No Movement
CH = Chaplain CLS = Child Life Specialist CM = Case Manager Diet = Dietary HCP = Health Care Provider (MD, Specialist (ID, GI, Pulmonologist, NP, PA, DDS, etc) PT = Physical Therapy Rad = Radiology RT = Respiratory Therapy SW = Social Worker
IU
OD
OOD
Trailing 0 Back of loading )
MS
MS04
MeS04
SQ SC S
D/C
CC
Patient Progress Documentation
PATIENT IDENTIFICATION
Notes : _______________________________________________ ______________________________________________________
Student Name:____________________________________
