ASU PATIENT CARE RECORD

Hospital
ALLERGIES      
CODE STATUS:       MEDICAL POA:       DATE       SHIFT      
(relationship only) ASSIGNED NURSE       STUDENT NURSE:      

TIME 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700       Pacemaker     
1900 2000 2100 2200 2300 0000 0100 0200 0300 0400 0500 A-Line      
Rhythm                                                                   PA Line      
IABP      
Heart tones / CVP      
Color / Temperature / / / / / / / / / / /
CARDIOVASCULAR

Right Upper

Right Lower
PULSES

Left Upper

Left Lower

Mucous membranes

Capillary refill    secs    secs    secs    secs    secs    secs    secs    secs    secs    secs    secs    secs

Edema

Antiemboli device                                                                        

NURSING NOTES:      

TIME 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800
1900 2000 2100 2200 2300 0000 0100 0200 0300 0400 0500 0600 ETTi:
FiO2 %     %     %     %     %     %     %     %     %     %     %     %     % Nasal Oral
VENTILATOR

mode:       Size      

OXYGEN

Placement      
Pressure / PEEP                                                                        
VT / Rate                                                                        
Trach:
Pressure support                                                                        
Size     
Site / Suctioned Inner Cannula      
Color/Consistency
RESPIRATORY

CARE

Chest Tube      

Catheter size                                                                        
Location      
Trach Care Suction      
Chest tube CMH2O Waterseal
Chest expansion
Quality of respirations
RU
SOUNDS
LUNG

RL
LU
LL
Cough / sputum
Incentive spirometry                                                                        
NURSING NOTES:      

TIME 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 Restraints Document
1800
1900 2000 2100 2200 2300 0000 0100 0200 0300 0400 0500 0600
on 24 hr. Restraint
ISOLATION Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Assessment
Position Fall risk document
PROTECTION / COMFORT

Bath Wounds, dressings,

drains document on skin
Linen changed
risk/assessment
Eye care Contact
Oral care Respiratory Airborne
Peri care Respiratory
Call light within reach
Alarm limits                                                                        
Bed low, wheels locked
Risk for Fall
Side rails up UR LR UL LL
NURSING NOTES:      
 TIME 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800
Stool and
1900 2000 2100 2200 2300 0000 0100 0200 0300 0400 0500 0600
urine
Abdomen documented

GI
Girth / cm     cm     cm     cm     cm     cm     cm     cm     cm     cm     cm     cm     cm on I&O
ELIMINATION

Bowel sounds
Last BM:
Tube location                                                                        
TUBE      
Site / size                                                                        
Color / character
Stool
Urine
NURSING NOTES:      

TIME 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 0600
1900 2000 2100 2200 2300 0000 0100 0200 0300 0400 0500
Eye opening
GCS

Verbal
Motor
Pupil Size    mm    mm    mm    mm    mm    mm    mm    mm    mm    mm    mm    mm PUPIL SIZE
R

Reaction
Pupil Size    mm    mm    mm    mm    mm    mm    mm    mm    mm    mm    mm    mm Ventriculostomy
LT

Reaction      
NEURO

Arms
ICP TYPE
R

Legs      
Arms
LT

Legs
Orientation
Speech
Memory
Reflexes
Emotional Support
ICP                                                                        
NURSING NOTES:      

TIME 0700 1900 0800 2000 0900 2100 1000 2200 1100 2300 1200 0000 1300 0100 1400 0200 1500 0300 1600 0400 1700 0500 1800 0600

Activities of daily living

Muscle tone
ACTIVITY / REST

Range of motion
Interventions
Activity
Assistive devices                                                                        
Gait                                                                        
Traction                                                                        
NURSING NOTES:      

Fall Assessment (Morse Fall Scale) Time High Risk Fall Interventions ( score = 51 or greater)
Every shift, when patient transferred,
Change in physical or mental status, after fall                         Utilize all Universal Precautions Environmental Interventions
No = 0 Patient Identification J. Clear environment of potential hazards
History of falls Yes = 25                        
A. Yellow armband applied / maintained K. Utilize side rails appropriately (use 4 side
No = 0
Secondary Diagnosis Yes = 15                         B. Fall precautions sign posted / maintained rails with caution, increases chances of
None / bed rest / walk with nurse = 0 injury)
Mobility Aid                         Mental Status Interventions
Crutches / cane / walker = 18 L. Maintain night light for evening and night
Walks with furniture = 30 C. Reorient patient to surroundings as hours
No = 0 (score 0 if SL for access only) needed
IV or saline lock (SL) Yes = 20                         Mobility Interventions
None / immobile = 0
D. Remind patient to call for assistance
Gait / Transfer                         when ambulating / transferring / toileting M. Assist / supervise when ambulating /
Weak = 10 Impaired = 20
transferring / toileting
FALL RISK

h E. Encourage family attendance with patient

Oriented to own ability = 0 N. Consider requesting Physical Therapy
Mental Status Overestimates own ability = 15                         Elimination Interventions consult to evaluate mobility needs
Universal = 0 – 50 F. Provide supervision when toileting
Total Score High Risk = > 51                         O. Provide transfer and mobility aides as
G. Remind patient to call for assistance ordered
High Risk Precautions                         H. Offer toileting at regular intervals and Monitoring / Devices
Indicate letter of intervention implemented before bedtime P. Bed alarm in use and maintained
I. Provide bedside commode as needed
Universal Precautions / Interventions (Score = 0 – 50)  Place personal items / call light / assistive devices within reach
 Instruct patient / family regarding Fall Prevention precautions and interventions  Maintain appropriate side rail positions
 Orient / reorient patient to room and environment  Maintain bed in low position with wheels locked
 Assist with ambulation / transfers as indicated (support patient with gait changes, postural  Use non-skid footwear
instability and spasticity)  Provide physically safe environment (eliminate spills and clutter, tangled electrical cords,
 Assist with elimination needs as indicated and unnecessary equipment), provide adequate lighting
Signature       Time      
PHYSICIAN CONTACT ADDITIONAL SHIFT COMMENTS      
Physician Visit Call Placed Reason/Problem Call Rec’d
                             
                             
                             
INITIAL SIGNATURE/TITLE
                        TRANSFER: TO       FROM       PER       TIME      
                         CONDITION: GOOD FAIR SERIOUS CRITICAL
RECEIVING RN      
                       

ASU PAIN MANAGEMENT/

Hospital SKIN ASSESSMENT

DATE:      
Plan for Pain Management to Increase patient’s comfort and function *pain Scale: (self-report)
Patient’s goal for pain: (0-10)       0 – 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
ADL Observation Scale: (nurse may use for non-verbal patient
Ambulation Sleeping grimacing moaning restless constant
Calm/relaxed with with moaning
Physical Therapy
Not agitated movement movement without stimuli
Other      
Document the pain/symptom, intervention and follow up evaluation below.
Time Pain or Symptom Pain Rating Patient Sedation Medication Complementary Re-Evaluation Initials
Location Number/ Description/ Scale Given/Route Therapy
Observation Duration of Pain *** (list type)
Time Pain Rating
Self report ** ****
Number/
(SR/O)*
(SR/O)*
                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         
SKIN RISK: Check all that apply and total score (to be done daily)

GENERAL PHYSICAL CONDITION MENTATION INCONTINENCE (Bowel and Bladder)

0 Good (minor) 0 Alert 0 No Incontinence
1 Fair (major but stable) 1 Lethargic 2 Occasional Incontinence (less than 2 times / 24 hrs)
2 Poor (chronic/serious, 2 Semi-comatose 4 Usually Incontinent (more than 2 times / 24 hrs)
not stable) 3 Comatose 6 No Control
ACTIVITY MOBILITY NUTRITION
0 Ambulatory 0 Willing and able to move self 0 Appetite good
2 Needs Assistance 2 Needs assist to turn 1 Occasionally refuses meals (eats 50%)
4 Chairfast 2 Cast on extremity or pain wi/joint movement 2 Enteral tube feedings
6 Bedfast 4 Patient does not tolerate turning Hyperalimentation
4 Physical condition does not permit turning 3 Seldom eats a meal / NPO
5 Total immobility, quad, para
Total score:       The patient scoring 11 or more needs: Special Bed Referral and/or Nutritional Referral Reassessment
SKIN IMPAIRMENT: Document in this section when a skin impairment is noted on assessment

                 

                 

                             

1
Diagram Skin Impairment (ie: surgical Color (ie: pink, red, Odor/Drainage (ie: Interventions/Comments (ie: dressing clean, dry, and intact, use
Number incision, drains, pressure yellow) none, foul, purulent, of incontinence products, frequent repositioning, heels elevated on
ulcer, hematoma, burn, rash, serous, bloody) pillows, dressing changes, wound care, specialty bed, wound care
excoriation) consult)
                             
                             
                             
                             
                             
                             
                             
                             
 Specific Recommendations
Topicals: semi/occlusive dressing perineal wash moisture barrier antifungal barrier antifungal cream/powder
Frequent repositioning Elevate heels off mattress heel guards elbow guards frequent toileting schedule
specialty sleep surface:       Other:      

INITIAL SIGNATURE/TITLE INITIAL SIGNATURE/TITLE

                       
ASU PATIENT CARE
Hospital RECORD

DATE:      
HEALTH DEVIATION NEEDS
TEACHING
      TEACHING TO INCLUDE:
DISEASE PROCESS  Who was taught
 What was taught
       Response to teaching
MEDICATIONS

      PT/FAMILY TEACHING RESPONSE

ACTIVITIES CODES
1 = Received Literature
      2 = Communicates Understanding
NUTRITION/FLUIDS 3 = Requires Reinforcement
4 = Previous Experience
PRE-OP/       5 = Return Demonstration
PROCEDURES 6 = Objective Achieved
7 =Referral Initiated
     
8 = Refused
MISCELLANEOUS 9 = Preprinted Teaching Protocol
10 = Preprinted Teaching Protocol
DISCHARGE PLANNING CATEGORIES (Document daily) REFERRAL / ACTION      
1. Clear mentation Perform ADL’s and ambulation independently or with minimal
assistance Normal activity with effort Adequate support sytem
PLAN OF CARE: Initiated
2. Alert In/out of confusion Moderate/Maximal assist with ADL’s and mobility
Potential HHC evaluation, ECF placement, or transfer to other facility
Reviewed
Revised
3. Markedly debilitated Complex social situation Recent discharge Requires
ongoing therapies/extensive teaching
4. Re-evaluate later.
IV THERAPY
APPEARANCE SITE COMMENTS
CATH D/C’d
Site DATE/TIME SITE TYPE/ TUBING
# INSERTED LOCATION SIZE IV SOLUTION DOSE/DEVICE CHANGE 7-3 3-11 11-7
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     

INITIAL SIGNATURE/TITLE
IV CODES APPEARANCE
Site Location Catheter 1=Asymptomatic            
L = Left AC = Antecubital UAF = Upper S.G. = Swan Ganza 2=Red
R = Right UA = Upper arm Anterior H.D. = Hemodialysis 3=Swollen            
S = Scalp UPF = Upper Forearm Hick = Hickman 4=Ecchymotic
Ft = Foot Posterior LAF = Lower G = Groshong 5=Warm            
F = Femoral Forearm Anterior Port = Port-A-Cath 6=Cool
H = Hand LPF = Lower Forearm or other 7=Draining            
W = Wrist Posterior IJ = Internal implanted 8=Leaking
Forearm Jugular port            
SC = Subclavian I = Introducer Luman
PP = Pace Port d=distal
           
m=middle
p=proximal
           
Vital Signs
DATE:       0700 1900 0800 2000 0900 2100 1000 2200 1100 2300 1200 0000 1300 0100 1400 0200 1500 0300 1600 0400 1700 0500 1800 0600
TIME
Temperature°                                                                        
Celsius Fahrenheit
Temperature route
Heart rate                                                
Respiratory rate                                                
Blood pressure – cuff     /         /         /         /         /         /         /         /         /         /         /         /    
Blood pressure - arterial     /         /         /         /         /         /         /         /         /         /         /         /    
Cardiac Output / Cardiac      /min      /min      /min      /min      /min      /min      /min      /min      /min      /min      /min      /min
Index
CVP / PAP / ICP                                                                        
O2 sat     %     %     %     %     %     %     %     %     %     %     %     %
Accucheck                                                

Intake / Output

INTAKE
NPO 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 SHIFT 24 HR
1900 2000 2100 2200 2300 0000 0100 0200 0300 0400 0500 0600 TOTAL TOTAL
      Days since last intake
DIET TYPE:                                                                        
% ingested                                                                                    
PO fluid intake (mL)                                                                        
FEEDING SOLUTIONS 1.       2.       3.       4.      
Route
Placement verified
Tube Equipment changed
feeding
Residual                                                                        
(mL)
Discarded                                                                        
Intake amount                                                                                    
SOLUTION TYPE
1.                                                                                          
2.                                                                                          
IV Fluids 3.                                                                                          
TPN 4.                                                                                          
Drips
5.                                                                                          
Medication
6.                                                                                          
volume
Flushes 7.                                                                                          
(mL) 8.                                                                                          
9.                                                                                          
10.                                                                                          
Blood 1.                                                                                          
Products 2.                                                                                          
(mL) 3.                                                                                          
Intake TOTAL            
OUTPUT
Urine Amount                                                                                    
Color / Characteristics
Stool Amount            
Color / Characteristics
Emesis Amount                                                                                    
Color / Characteristics
Gastric Amount                                                                                    
Color / Characteristics
Drainage 1:                                                                                          
Drainage 2:                                                                                          
Drainage 3:                                                                                          
Dialysis type:       Net                                                                                    
Irrigation type:       Net                                                                                    
Output TOTAL            
Initials                                                                        
NURSING NOTES: