npw1 ms2

complete this pdf, with information on a 72 year old steven johnson patient named julian (female) no pain meds prior ro wound dressing change

Room

Patient/Age/Sex

Attending & consults

Allergies Admit date Isolation & organism Code status

Primary diagnoses

CC/HPI

Past medical hx

Past surgical hx

Neuro/Psych GCS
Primary language Eyes _____
Level of consciousness Verbal _____
Orientation & follow commands Motor _____
Mood/behavior Total _____
Pupils
Muscle strength: LUE _____ / RUE _____ / LLE _____ / RLE _____

Labs BGM frequency _____ / 07 _____ 11 _____ 17 _____ 21 _____

GFR ________ HgbA1C ________
Troponin ________ Lactate ________
BNP ________ Procal ________
CK ________ CRP ________
D-dimer ________ ESR ________
Fibrinogen ________ Amylase ________
Ammonia ________ Lipase ________
UA _________________________________
Cultures ___________________________
____________________________________

Cardiac Echo EF _____ %
Heart rate trends
Tele rhythm trends
SBP/MAP trends & goal parameters
Temp trends & method/fevers & Tmax
Pulses: L rad _____ / R rad _____ / L ped _____ / R ped _____
Edema & grading

[ ] Pacemaker / [ ] AICD
Respiratory IS [ ] & trends/max _____ ml
Lung sounds & work of breathing/rhythm
O2 delivery _____ @ _____ LPM / _____%
O2 sat trends
Secretion amt & character/suction method
Chest tube(s) output & character

ABG date _____: pH _____ / pCO2 _____ / HCO3 _____ / pO2 _____
GI Lt NG / Rt NG taped @ _____ cm / PEG
Continent/incontinent Suction __________ / Output _____ ml
Last BM & character Current TF rate @ _____ ml/hr
Bowel sounds TF goal rate _____ ml/hr
Abdomen appearance & palpation TF max residual _____ ml
Diet/TF formula
Rectal tube/colostomy output & character

Fluid restriction _____ ml/day

Diagnostics/Imaging 12-lead ECG
XR
CT
MRI

Ultrasound
EEG

GU Foley insert date _____ Indication __________
Continent/incontinent Last bladder scan _____ ml @ _____
Voiding method Last I&O cath _____ ml @ _____
Shift/hourly urine output
Urine character

HD sched __________ & last HD amt removed _____ ml

Specialty: Advanced Med/Surg
Neuro/Psych – Richmond Agitation-Sedation Scale
RASS

Cardiac – Hemodynamics
PA cath @ _____ cm
CI _____ / SvO2 _____ / CVP _____ / PAP _____ / SVR _____

Respiratory – Artificial airway & mechanical ventilation
ETT size _____ taped @ _____ cm @ teeth / gum / lip
Trach brand __________ & size _____
Vent mode ____________
Rate _____ VT/PS _____
FiO2 _____% PEEP _____

GI – Enteral tube
OG taped @ _____ cm

Musculoskeletal/Safety & Mobility [ ] SCDs [ ] VTE ppx meds
Pain & scale utilized
Assistive devices
Level of assist
Calls for assist/safety concerns
Restraint type & location
Sitter/tele-sitter

Rehab consults: [ ] PT [ ] OT [ ] SLP
Skin & Drains/Tubes
Pressure injuries/wounds
Wound tx/dressings output & character
Drains/tubes output & character

Wound care consult [ ]

OTOs/PRNs given & time last given To-do/Follow-up/Notes

IV Lines
1
2
3
4
5
6
7
8

Continuous IV Drips
1
2
3
4
5
6
7
8

Hct
Hgb

PltWBC

Na Cl BUN

Glu

K CO2(HCO3) Cr

Bili

AST ALT

PT

aPTT

INR
Phos

Ca Mag

Alk
Phos

Alb

Shift Notes Vitals 08/20 12/00 16/04
07/19 08/20 09/21 10/22

Temp &
source

HR &
rhythm

11/23 12/00 13/01 14/02

BP & MAP

Resp
rate

15/03 16/04 17/05 18/06
SpO2 &
delivery
method

Pain &
pain
scale
used

Medication Administration Record – provide 5 most critical/priority medications
Generic & trade name Pharm class Dose Route Freq Indication(s) r/t patient Common SEs/ADEs (at least 3) Nursing considerations (at least 3)

Plan of Care (Clinical Judgment Plan)
Priority problem #1 [hypothesis]:

Pertinent assessment data [cues]:

S.M.A.R.T. goal/outcome #1 [solution]:

Interventions with frequency & rationale [actions]:
Assess/monitor:

Manage:

Educate:

Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):

Priority problem #2 [hypothesis]:

Pertinent assessment data [cues]:

S.M.A.R.T. goal/outcome #2 [solution]:

Interventions with frequency & rationale [actions]:
Assess/monitor:

Manage:

Educate:

Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):

Priority problem #3 [hypothesis]:

Pertinent assessment data [cues]:

S.M.A.R.T. goal/outcome #3 [solution]:

Interventions with frequency & rationale [actions]:
Assess/monitor:

Manage:

Educate:

Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):