Room #: ________MRN: __________________Weight: _______lb/kgAge: _____Date: ______________Patient Name: _______________________________ Code Status: Full Code DNR Meds DNI Allergies: __________Isolation: ___________________ Date of Admission: _______________________________________________

Admit Dx: ___________________________________________________________________________________PMHx: HTN COPD CAD CHF DM CVA MI

Neuro:

A&Ox___ Eyes: ___________ Cough/Gag: _______Restraints: ____________Pain Issues: ____________________ Meds Last Given: __________________Sedation: ____________________________________Neuro Checks Q ___hrsCV:

Rhythm: ______ HR: ______ MAP: _____ Systolic: _______/Diastolic: _______Pulses: UE ___/___, LE ___/___ Edema: UE ___/___, LE ___/___T-Max: ______Access: #1 ________ #2 ________ #3 ________ #4 ________ #5 ________ CVP: _____Resp:

Natural/#__ ETT/Shiley/Bivona ___@ Teeth/Lip O2: RA/NC/Mask/TC/Vent/BiPAP/CPAPVent Settings: ________ FiO2: _____% Rate: _____ PEEP: _____ TV: _____

Breath Sounds: _______/________ Secretions: _______________ Suction Q ___Resp Rate: _____ SpO2: _____%Chest Tube: R/L Water Seal/Suction Drainage: ____________ OP Last Shift: _____GI:

NPOR/L NGT OGT PEG G-J Keofeed LIWSPO Diet: __________________TF Type: __________ ml/hr: _____ H2O Boluses: ____mls Q ___hrsProsource: _____pkts

TPN: _____ml/hr Lipids: _____ml/hrRectal Bag/Rectal Tube/Flexiseal

Fingersticks Q ___hrs/ACHS

GU:

Foley/Texas Cath/Bedpan/Urinal/Bedside Commode/DiaperColor: __________+/- _______mL Last ShiftDialysis: _______________________Skin:

#1: ________________________________________#2: ________________________________________

.#3: ________________________________________

#4: ________________________________________

Wound Care Consulted? Yes/No

Social/Family:

0800

0900

1000110012001300140015001600170018001900

Labs:

WBC: _____4.5-11

Hgb: _____12-16 13-18

Hct: _____36-46 37-49

Plts: _____100-450

Na+: _____135-145

K+: _____3.5-5.2

Cl-: _____95-107

Mg:_____1.6-2.4

Phos_____2.4-4.1

Ca+: _____8.8-10.3

i Ca+:_____2.24-2.46

BUN: _____7-20

Creat: _____0.5-1.4

PT:_____10-12

PTT:_____30-45

INR:_____1-2

ABG:

pH:_____7.35-7.45

pCO2:_____35-45

pO2:_____70-100

HCO3: _____19-25

Plan:

To Do:

Narrative: 08-10-12-14-16-18

Shift re: 08 12 16

Accu

PICC:

I&O

CP:

VAP:

PT EDUCATION:

CAUTI BUNDLE:

BEDSIDE ALARMS:

SKIN BUNDLE

GCS: 8 12 - 16

Drips:

________________

________________

________________

________________

________________

________________