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).
2 O = AbsentD = Doppler1+ = Intermittent2+ = Weak3+ = Strong Hematoma Sandbag#1 DATE CORDIS TUBING DRESSING DRESSINGSITE PROX. 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
4 Confused=4 inappropriatewords=3 Incomprehensiblesounds=2 None=1 Obey commands=6 Localize pain=5 Withdraws=4 Flexion to pain=3 Exten. 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)
5 For restraint / significant other verbalized understandingYesNoNot understood by patient; 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.
6 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) 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.
7 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
8 = HYPERVENTILATION( RATE & DEPTH)0* = OTHER (Asterisk & Describe) 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.
9 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.) 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.
10 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. Position ChangedB. Relaxation TechniqueC. SplintingD. ImageryE. MusicF. EducationG. Other: _____ 1. TOTALLY LIMITED 1.
