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  • N9 - Clinical Worksheet, 5 Pts

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    cutevives
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    The document appears to be a template for recording patient medical information and vital signs over multiple time periods. It includes fields for documenting measurements like blood pressure, temperature, oxygen levels, and pain level at various times throughout the day. Other sections provide space for recording information like patient history, admitting diagnosis, allergies, lab results, intravenous sites, fluid intake and output, and daily nursing notes. The template suggests it is intended to be used to systematically track important medical details for patients during their hospital stay.

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    N9 - Clinical Worksheet, 5 Pts (1)

    Original Title

    N9 - Clinical Worksheet, 5 Pts (1)

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    The document appears to be a template for recording patient medical information and vital signs over multiple time periods. It includes fields for documenting measurements like blood pressure, temperature, oxygen levels, and pain level at various times throughout the day. Other sections provide space for recording information like patient history, admitting diagnosis, allergies, lab results, intravenous sites, fluid intake and output, and daily nursing notes. The template suggests it is intended to be used to systematically track important medical details for patients during their hospital stay.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xls, pdf, or txt
    156 views9 pages

    N9 - Clinical Worksheet, 5 Pts

    Uploaded by

    cutevives
    The document appears to be a template for recording patient medical information and vital signs over multiple time periods. It includes fields for documenting measurements like blood pressure, temperature, oxygen levels, and pain level at various times throughout the day. Other sections provide space for recording information like patient history, admitting diagnosis, allergies, lab results, intravenous sites, fluid intake and output, and daily nursing notes. The template suggests it is intended to be used to systematically track important medical details for patients during their hospital stay.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xls, pdf, or txt
    of 9

    1. Report 2.

    Drs Orders, Labs, Dx Pt/Room: Admit Dx/Date: Hx: 800 1200 1600 N B/P P O2 RR T PAIN Pt/Room: Admit Dx/Date: Hx: 800 1200 1600 N B/P P O2 RR T PAIN Pt/Room: Admit Dx/Date: Hx: 800 1200 1600 N B/P P O2 RR T PAIN Pt/Room: Admit Dx/Date: Hx: 800 1200 1600 N B/P P O2 RR T PAIN Pt/Room: Admit Dx/Date: Hx: 800 1200 1600 N B/P P O2 RR T PAIN CV RGI Last BM: GU f/c Last pain med: IV SITE 1 IV SITE 2 F/S DRESS CV RGI Last BM: GU f/c Last pain med: IV SITE 1 IV SITE 2 F/S DRESS CV RGI Last BM: GU f/c Last pain med: IV SITE 1 IV SITE 2 F/S DRESS CV RGI Last BM: GU f/c Last pain med: IV SITE 1 IV SITE 2 F/S DRESS CV RGI Last BM: GU f/c Last pain med: IV SITE 1 IV SITE 2 F/S DRESS -

    3. Check meds/cart

    4. Intro/VS

    5. Assess Allergies:

    Today:

    WBC (4-11k)

    Hgb (11.7-16) Hct (36-46%)

    Plat (150-450) ND: 1) 2) 3) 4) Labs:

    Na (135-145) l (95-105) BUN (8-26) C K (3.5-5) TCO2 (23-29) r (0.7-1.2) C voiding Ga. Ga. Fluid: Fluid: Amb: PCA: Solo Assist Bed

    Glu (70-120)

    Procedures: Rate: Rate: Diet: Allergies: Date: Date: Pneumo: Need Flu: Need Today: Don't Don't Refused Refused

    WBC (4-11k)

    Hgb (11.7-16) Hct (36-46%)

    Plat (150-450) ND: 1) 2) 3) 4) Labs:

    Na (135-145) l (95-105) BUN (8-26) C K (3.5-5) TCO2 (23-29) r (0.7-1.2) C voiding Ga. Ga. Fluid: Fluid: Amb: PCA: Solo Assist Bed

    Glu (70-120)

    Procedures: Rate: Rate: Diet: Allergies: Date: Date: Pneumo: Need Flu: Need Today: Don't Don't Refused Refused

    WBC (4-11k)

    Hgb (11.7-16) Hct (36-46%)

    Plat (150-450) ND: 1) 2) 3) 4) Labs:

    Na (135-145) l (95-105) BUN (8-26) C K (3.5-5) TCO2 (23-29) r (0.7-1.2) C voiding Ga. Ga. Fluid: Fluid: Amb: PCA: Solo Assist Bed

    Glu (70-120)

    Procedures: Rate: Rate: Diet: Allergies: Date: Date: Pneumo: Need Flu: Need Today: Don't Don't Refused Refused

    WBC (4-11k)

    Hgb (11.7-16) Hct (36-46%)

    Plat (150-450) ND: 1) 2) 3) 4) Labs:

    Na (135-145) l (95-105) BUN (8-26) C K (3.5-5) TCO2 (23-29) r (0.7-1.2) C voiding Ga. Ga. Fluid: Fluid: Amb: PCA: Solo Assist Bed

    Glu (70-120)

    Procedures: Rate: Rate: Diet: Allergies: Date: Date: Pneumo: Need Flu: Need Today: Don't Don't Refused Refused

    WBC (4-11k)

    Hgb (11.7-16) Hct (36-46%)

    Plat (150-450) ND: 1) 2) 3) 4) Labs:

    Na (135-145) l (95-105) BUN (8-26) C K (3.5-5) TCO2 (23-29) r (0.7-1.2) C voiding Ga. Ga. Fluid: Fluid: Amb: PCA: Solo Assist Bed

    Glu (70-120)

    Procedures: Rate: Rate: Diet: Date: Date: Pneumo: Need Flu: Need Don't Don't Refused Refused

    800
    BP R T O2

    900
    HR PAIN

    1000

    1100
    BP R

    1200
    T O2

    1300
    HR PAIN

    1400

    1500
    BP R

    1600
    T O2

    1700
    HR PAIN

    1800

    BG BP R T O2 HR PAIN BP R T O2 HR PAIN

    BG BP R T O2 HR PAIN

    BG BP R T O2 HR PAIN BP R T O2 HR PAIN

    BG BP R T O2 HR PAIN

    BG BP R T O2 HR PAIN BP R T O2 HR PAIN

    BG BP R T O2 HR PAIN

    BG BP R T O2 HR PAIN BP R T O2 HR PAIN

    BG BP R T O2 HR PAIN

    BG

    BG

    800

    900

    1000

    1100

    800
    BP T P R O2 Pain BP T P R O2 Pain BP T P R O2 Pain

    900

    1000

    1100

    Pt: PHYS: Hx: Admit Dx: Allergies:

    Nursing Dx: Plan of Care:

    Hgb 11.7-16

    AM
    T P R B/P O2 PAIN

    PM

    NCVL RGI GU IV SITE 1 IV SITE 2 f/c voiding Ga. Ga. fluid: fluid:
    Na K

    WBC Hct

    Plat 150-450

    Cl CO

    BUN Cr Glu

    Cl 102-110 CO 21-31

    Rate: Rate:

    BUN 8-26 Cr 0.7-1.2

    DRESS -

    Pt: PHYS: Hx: Admit Dx: Allergies:

    Nursing Dx: Plan of Care:

    Hgb 11.7-16

    AM
    T P R B/P O2 PAIN

    PM

    NCVL RGI GU IV SITE 1 IV SITE 2 f/c voiding Ga. Ga. fluid: fluid:
    Na K

    WBC Hct

    Plat 150-450

    Cl CO

    BUN Cr Glu

    Cl 102-110 CO 21-31

    Rate: Rate:

    BUN 8-26 Cr 0.7-1.2

    DRESS -

    700

    800

    900

    1000

    1100

    1200

    1300

    1400

    1500

    1600

    Room Number

    Time

    Med/Class

    Mech of Action/Th. Action

    Side Effects

    Monitor/Assess

    IV

    Med/Class

    Mech of Action/Th. Action

    Side Effects

    Monitor/Assess

    Vasotech

    Benedryl

    CNS depressant

    Drowsiness/ Paradoxil excitation

    Assess for confusion / FALL RISK

    Morphine Sulphate

    Dilautid

    Name of Drug Dosage/frequency/route last dose

    Mode of Action Indications for usage

    Specific results outcomes seen in pt.

    Nursing precautions specific to patient

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