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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CBI Color of urine: Clear Yellow Amber Supra Pubic Cath Cooperative Uncooperative Good eye Contact Playful / Conversant Withdrawn Depressed Quiet Anxious Combative Family / SO @ BS Parent @ Bedside Airborne Droplet Contact Neutropenic 0700 - 1500 1 2 3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 One = Risk for Falls Continue / Initiate risk for falls Crawls / walks Confusion Sensory Deficits Impaired Mobility Sedative/Narcotics Diuretics/Laxative Substance Abuse Anesthesia
OTHER
2 1 . . . . . . . . . .
Pain Intensity 5
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
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
O-NO,
0900
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
Vital Signs :
AM
PM
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:
Init
Signature
Init
Signature
Discipline
Time
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
MS
MS04
MeS04
SQ SC S
D/C
CC
PATIENT IDENTIFICATION
Student Name:____________________________________