Transcription of CRITICAL CARE FLOW SHEET - World's Largest …
1 START DATE:STOP DATE:WT Today:HT:WT Yesterday:PAST 24 BALANCE 24 OutputTIMETimeBS AlbuminBUN WBCCr HgbNa HctK PTCl INRCO2 PTTCa PlateletsPhos CPKM agnesium CK - MBCholesterol CPK IndexTotal Bili TroponinAlk. Phos Lactic AcidSGOT NH4 SGPT Pre-AlbuminTotal Protein DigoxinYES ISOLATIONNEGATIVE FLOWYESN/ANO TYPE:MAINTAINED:NOHEPAFILTERNOYES; If "YES", SPECIFY:FULL CODEDNROTHER:8850122 Rev. 05/05 PAGE 1 of 6 RESULTSLABWORKRESULTSC ritical care Flow Sheet_NURSING_CRITICAL care ISOLATION PATHWAY CODE STATUSPART OF THE MEDICAL RECORDCRITICAL care FLOW SHEET SIGNATURE / TITLE / INITIALSPA CatheterLAB DATAPATIENT IDENTIFICATIONSIGNATURE / TITLE / INITIALSTIMEINITIALSTIMESTAT MEDSSTAT MEDSINITIALSLABWORKO therArterial LineCentral LineCentral LineSheathIntakeKGLBSI nsertionDateInsertionSiteRemoval DateTYPE:00 BP Method PULSES (Code):O = AbsentD = Doppler1+ = Intermittent2+ = Weak3+ = Strong Hematoma Sandbag#1 DATE CORDIS TUBING DRESSING DRESSINGSITE PROX.
2 TUBING PRESSURE TUBING PRESSURE TUBING#2 DATE MEDIAL TUBING FLUSH BAG FLUSH BAGSITE DISTAL TUBING CO SET TUBING TUBING#3 DATE DRESSINGSITE8850122 Rev. 05/05 PAGE 2 of 6 CRITICAL care Flow Sheet_NURSING_CRITICAL care Pulse Ox Accu-CheckPULSESR adial R / L Dorsalis CENTRALALINESWAN GANZ SVRR / L CRITICAL care Vital Sign Flow SheetHOUR:00 - :59 Respirations120100 Pedal R / L 80604020 PAD PCWP200180160140240220 PAS40180160200601402007 - 07U MAP CVP220 MINUTE24080 INVASIVE LINE CARECHECK WHEN CHANGEDU PCHECK WHEN CHANGEDUOTHERCHECK WHEN CHANGEDP CO/CI TEMP120100P CHECK WHEN CHANGEDPART OF THE MEDICAL RECORD> <BPPERIPHERALPULSEBP MethodA = A-LineC = CuffD = DopplerPPNTPN INTRALIPIDS BLOOD MEDS CO INJECTATE TUBE FEEDING NG MEDS PO FLUIDS / URINE NG STOOL DRAINS8850122 Rev.
3 05/05 PAGE 3 of 6< 1/2< 1/2 ALL> 1/2 < 1/210111207 INTRAVENOUS0708090813148 HourTotal15161718192021228 HourTotal2324 Total0102030413148 Hour24 HourTotalTOTALINTAKE05068 Hour0910111224 HourTotalTotalTotalTotal020304058 Hour16178 Hour2324012118 DRUG DOSAGE (mcg/kg/min., mcg/min., etc.) DRIP WEIGHT:_____(KG) CRITICAL care Flow Sheet_NURSING_CRITICAL CARETOTALOUTPUT0619202215 BreakfastPART OF THE MEDICAL RECORD Lunch DinnerDIET INTAKEDIET INTAKEDIET INTAKEALL> 1/2 ALL> 1/2mcgormgmlmcgormgmlmcgormgmlmcgormgmlm cgormgmlmcgormgmlIV SITECHECKSQ 2 HrsPOSITIONR / L / B / CR = Right Side B = BackL = Left Side C = ChairFREE H O2 FLUID REMOVALHEMODIALYSISPRODUCTSB = BriskS = Sluggish- = No ReactionC = Eye ClosedPlease use numbers scale Spontaneously=4 To sound=3 To pain =2 None=1 Oriented=5 Confused=4 inappropriatewords=3 Incomprehensiblesounds=2 None=1 Obey commands=6 Localize pain=5 Withdraws=4 Flexion to pain=3 Exten.
4 To pain=2 None=1 ConsciousnessExtremitiesA = alertstrong orlethargicnormal/ drowsyW = weakR = restlessslightC = confusedmovementCT = comatoseabsent orstuporousparalyzed/ obtundedN/AIf initial order, document time restraints applied:1 Indication for use of restraints:Interference with medical treatmentRisk of Falls 2 Alternative intervention(s) attempted prior to restraint applicationsNursing interventions - , securing tubing, dressingEnvironment changeDiversional activity - , music, puzzles, stimuliSpend more time with patientsReality orientationFamily / significant other involvementBed alarm3 Alternative measures / significant other educated on restraintYesNoalternatives + reason(s) for restraint / significant other verbalized understandingYesNoNot understood by patient.
5 Significant other unavailable5 Type & location of restraint(s) in use:Hydration /NutritionToilet Standard for Acute care Setting in Confusional State Standard in use:YesNoChecked CirculationCheckedLOC / Mental/ EmotionalStaffInitials Back care Bed Surface Bath M = Maxifloat S = Softcare O = Other / Specialty Bed ( Specify ) Oral Hygiene Foley Catheter Ted / SCD / Plexiplus Lines Zeroed Activity ( BR, BRP, Chair, Ambulatory )8850122 Rev. 05/05 PAGE 4 of 6 MFALL PREVENTION STANDARD Seizure ActivityNSPART ONE: RESTRAINT INTERVENTION =A = PART TWO: OBSERVATION SHEET Call Light in Reach Fall Standard in Use Yellow ID band on Patient Yellow Card on Door Bed Low & Locked Bed Alarm On Side Rails UpNEUROLOGICAL ASSESSMENTC ritical care Flow Sheet_NURSING_CRITICAL CAREPUPILSR ightLeft verbal Best HandDETIMEINITIALS responseLEFTCOMA SCALEGLASCOW COMA SCALE TOTAL response Best openROMI ndicate Time(s)
6 Patient OUT OF RESTRAINTSN060008001200100020001400 TIME04000200ED1600180022002400 UPROUTINES & SAFETY S H I F TROUTINES & SAFETY S H I F TUP Consciousness LegL SpeechRIGHT LegPART OF THE MEDICAL RECORD motor Eyes Hand = SMILITARY TIMEEXTREMITY = = SizeReactionSizeReactionEyes closedby swelling= C Endotrachealtube ortracheostomy=TRecord bestlimb responseDirections: Documentevery 2 hours (MST / CCT may complete)X2X4 HEART SOUNDS+=PRESENT=DECREASED GALLOP MURMUR/FRICTION RUB+ / - = PRESENT / ABSENT SKINW = WARMCL = COOLCD = COLDH = HOTDI = DIAPHORETICCLA= CLAMMYM = MOISTDR = DRY COLORF = FLUSHEDN = NORMAL / PINKP = PALEC = CYANOTICJ = JAUNDICEDD = DUSKYM = MOTTLED JVD+ / - = PRESENT / ABSENT EDEMAN = NONEG = GENERALIZEDP = PITTINGNP = NON-PITTINGT = TRACE1+ = 2 MM PITTING2+ = 4 MM PITTING3+ = 6 MM PITTING4+ = 8 MM PITTING RESPIRATIONSR = REGULARI = IRREGULARS = SHALLOWL = LABOREDH = HYPERVENTILATION( RATE & DEPTH)0* = OTHER (Asterisk & Describe)
7 BREATH SOUNDSCL = CLEARRA= RALES / CRACKLESRH = RHONCHIWZ = WHEEZEE = EXPIRATORYI = INSPIRATORY= DECREASEDO=ABSENTBR = BRONCHIAL ABDOMENFL = FLATD = DISTENDEDL = LARGET = TENDERS = SOFTF = FIRMR = RIGID BOWEL SOUNDS+= PRESENTCOMMENTS:= HYPOACTIVE= HYPERACTIVEO=ABSENT8850122 Rev. 05/05 PAGE 5 of 6 PART OF THE MEDICAL RECORD TIMEHEARTSOUNDS GallopINITIALS RHYTHMS1 RESPIRATORYR U L SUCTION / RESPIRATIONS SITE DRAINAGE /L L LR M LR L L SUCTION SECR. COLOR SATPC / IETIMEE quipmentOxygen %FiO2 / LPMT idalVent ModeVolumeSpontan-eous TVCritical care Flow Sheet_NURSING_CRITICAL CARER / LS2 CHESTTUBES H2O SEAL / JVD EDEMA / LOCATIONGIGU URINE: (color, char.)
8 Method of output ABDOMEN BOWEL SOUNDS STOOL: description NG: descriptionMAKERPACEL U LCARDIOVASCULARBREATH MODE TYPE RATE / MASOUNDS CAPILLARY REFILL SKIN COLOR Murmur Fx RubRESPIRATORYTRACH / ET TUBEHOB 30CM MarkSizePositionpaO2 Vent Rate / PSS3S4 CODESPeak / MeanPress InsppaCO2 ABGSHCO3 SSS142S3(Describe)Bubbling +/-(CmH2O) R = RightM = MiddleL = Left COMFORT GOAL:RATING SCALE:S =NORMAL SLEEP, EASY TO AROUSE, ORIENTED WHEN AWAKENED, APPROPRIATE COGNITIVE BEHAVIOR1 =WIDE AWAKE - ALERT (OR AT BASELINE), ORIENTED, INITIATES CONVERSATION2 =DROWSY, EASY TO AROUSE, BUT ORIENTED AND DEMONSTRATES APPROPRIATECOGNITIVE BEHAVIOR WHEN AWAKE3 =DROWSY, SOMEWHAT DIFFICULT TO AROUSE, BUT ORIENTED WHEN AWAKE4 =DIFFICULT TO AROUSE, CONFUSED, NOT ORIENTED5 =UNAROUSABLE1 =2 =3 =A.
9 Position ChangedB. Relaxation TechniqueC. SplintingD. ImageryE. MusicF. EducationG. Other: _____ 1. TOTALLY LIMITED 1. TOTALLY MOIST 1. BEDREST1. TOTALLY IMMOBILE1. VERY POOR 1. PROBLEM 2. VERY LIMITED 2. VERY MOIST 2. CHAIRFAST2. VERY LIMITED2. PROBABLY INADEQUATE 2. POTENTIAL PROBLEM 3. SLIGHTLY LIMITED 3. OCCASIONALLY MOIST 3. WALKS OCCASIONALLY3. SLIGHTLY LIMITED3. ADEQUATE 3. NO APPARENT PROBLEM 4. NO IMPAIRMENT 4. RARELY MOIST 4. WALKS FREQUENTLY4. NO LIMITATIONS 4. EXCELLENT IF TOTAL SCORE < 17, PATIENT IS AT HIGH RISK FOR PRESSURE ULCERSERUMTOTAL SCORE: IMPLEMENT PRESSURE ULCER PREVENTION PROTOCOL IMMEDIATELYALBUMINCOMPLETED BY:STAGE:I = Reddened area (intact skin)II = Blister, skin breakIII =Skin break exposing subcutaneous tissueIV = Skin break exposing muscle and / or bonePERI-WOUND TISSUE:WNL = Within Normal LimitsR = ReddenedD = DarkenedM = MaceratedAPPEARANCE:P = Pink / CleanS = SloughE = EscharODOR:O = NoneM = MildF = FoulDRAINAGE:O = NoneS = SerousSG = Sero-sanguinousP = PurulentNAADDITIONAL DRESSING CHANGES DOCUMENT IN PROGRESS NOTES If more than 5 wounds, use OVERLAYSHIFT.
10 UPUPUPUPUPLOCATION: WOUND #:WOUND #:WOUND #:WOUND #:WOUND #:TYPE (Legend): TYPE:TYPE:TYPE:TYPE:TYPE:Stage: Appearance: Drainage: Odor: Peri-Wound Tissue: Size [L x W x D]# cm: Undermining [Y / N]: Nurse's Initials: Irrigation: Treatment: Time / Initials: 8850122 Rev. 02/05 PAGE 6 of 6 PAIN MANAGEMENTPRESSURE SORE RISK ASSESSMENT: TO BE COMPLETED EVERY 24 HRSPART OF THE MEDICAL RECORD(Legend) VERBAL:No HurtDISCUSS PAIN MANAGEMENT PLAN WITH PHYSICIANWOUND care :TYPESENSORY PERCEPTIONACTIVITYV enousTraumaticStasisSCORE:PressureUlcerT IMEINITIALSEVALUATIONPAIN LOCATIONRATINGRATINGINTERVENTIONINITIALS TIME/PAIN # CRITICAL care Flow Sheet_NURSING_CRITICAL CAREH urts Little BitHurts Little MoreFLACC PAIN SCALE:FRICTION & SHEARMOISTUREMOBILITYNUTRITIONPHARMACOLO GICAL (See MED KARDEX) NON-COGNITIVE:PAIN SCALES: WONG-BAKER: 0-10 VISUAL:3 (Faces)O4610 PAINSEDATION7 Hurts Whole Lot8952 INTERVENTION.
