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MRN: - Weight: - KG Age: - : Risk/Restraint

This document contains clinical information for a patient including their weight, age, allergies, admission diagnosis, past medical history, vital signs, lab results, neurologic status, respiratory status, gastrointestinal information, skin issues, social history, intravenous medications, and tasks to complete for the patient's care.

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rustiejade
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2K views2 pages

MRN: - Weight: - KG Age: - : Risk/Restraint

This document contains clinical information for a patient including their weight, age, allergies, admission diagnosis, past medical history, vital signs, lab results, neurologic status, respiratory status, gastrointestinal information, skin issues, social history, intravenous medications, and tasks to complete for the patient's care.

Uploaded by

rustiejade
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Room #: ________ MRN: __________________

Date:
______________

Weight: _______kg

Age: _____

Patient Name: _______________________________ Code Status: ___________


Allergies:
_____________________
Isolation: ___________________ Date of Admission:
_______________________________________________
Admit Dx:
___________________________________________________________________________________
PMHx:
_____________________________________________________________________________________
___________________________________________________________________________________
__
Labs:

Neuro:

WBC:
_____ 4.5-11
A&Ox___
Eyes: ___________
Cough/Gag: _______
Restraints: ____________
Hgb: _____ 12-16 13-18
Pain Issues: ____________________ Meds Last Given: __________________
Sedation: ____________________________________
Neuro Checks Q ___hrs
Hct: _____ 36-46 37-49
Plts: _____
Na+: _____
Rhythm: ______
HR: ______ MAP: _____ Systolic: _______/Diastolic: _______
K+:
_____
Pulses: UE ___/___, LE ___/___
Edema: UE ___/___, LE ___/___
T-Max: ______ Cl-:
_____
Access: #1 ________ #2 ________ #3 ________ #4 ________ #5 ________ CVP: _____
Mg: _____
Phos _____
Resp:
Ca+: _____
Natural/#__ ETT/Shiley/Bivona
___@ Teeth/Lip
O2: RA/NC/Mask/TC/Vent/BiPAP/CPAP
i Ca+: _____
Vent Settings: ________ FiO2: _____% Rate: _____ PEEP: _____ TV: _____
BUN: _____
Breath Sounds: _______/________ Secretions: _______________ Suction Q ___
Creat:
Resp Rate: _____ SpO2: _____%
PT:
_____
Chest Tube: R/L Water Seal/Suction Drainage: ____________ OP Last Shift: _____
PTT: _____
GI:
INR: _____
CV:

100-450
135-145
3.5-5.2
95-107
1.6-2.4
2.4-4.1
8.8-10.3
2.24-2.46
7-20
_____ 0.5-1.4
10-12
30-45
1-2

NPO R/L NGT


OGT
PEG G-J
Keofeed
LIWS PO Diet: __________________
ABG:
TF Type: __________ ml/hr: _____ H2O Boluses: ____mls Q ___hrs Prosource: _____pkts
pH:
_____ 7.35-7.45
TPN: _____ml/hr
Lipids: _____ml/hr
pCO
:
_____ 35-45
2
Rectal Bag/Rectal Tube/Flexiseal
pO2: _____ 70-100
Fingersticks Q ___hrs/ACHS

HCO3:

GU:
Foley/Texas Cath/Bedpan/Urinal/Bedside Commode/Diaper
Plan:
Color: __________
+/- _______mL Last Shift
Dialysis: _______________________

Skin:
#1: ________________________________________
#2: ________________________________________
#3: ________________________________________
#4: ________________________________________
Wound Care Consulted? Yes/No

Social/Family:

Drips:
________________

________________

________________

________________

_____ 19-25

To Do:
o Careplan
o

Morse Falls
Risk/Restraint

Education

Restraint Order UTD

______________________

______________________

0800

0900

1000

1100

1200

1300

1400

1500

1600

1700

1800

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