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    Example of Completed Form: Admit Dx/Chief Complaint/Hx Current ILLNESS: - Bowel Obstruction Respiratory

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    Joseph
    GT is a 60-year-old male admitted for bowel obstruction with a history of HTN, cardiomyopathy, renal calculi, schizophrenia, bipolar disorder, inguinal hernia, CHF, and osteoarthritis. On examination, he has a heart rate of 60, BP of 122/64, diminished breath sounds, and abdominal distension with hyperactive bowel sounds. His top priorities for care include preventing falls, ensuring comfort, and monitoring his ECG and labs closely given his cardiac conditions.

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    Example of Completed Form: Admit Dx/Chief Complaint/Hx Current ILLNESS: - Bowel Obstruction Respiratory

    Uploaded by

    Joseph
    539 views3 pages
    GT is a 60-year-old male admitted for bowel obstruction with a history of HTN, cardiomyopathy, renal calculi, schizophrenia, bipolar disorder, inguinal hernia, CHF, and osteoarthritis. On examination, he has a heart rate of 60, BP of 122/64, diminished breath sounds, and abdominal distension with hyperactive bowel sounds. His top priorities for care include preventing falls, ensuring comfort, and monitoring his ECG and labs closely given his cardiac conditions.

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    Example of pt assessment in ICU

    Original Title

    ICU assessment

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    GT is a 60-year-old male admitted for bowel obstruction with a history of HTN, cardiomyopathy, renal calculi, schizophrenia, bipolar disorder, inguinal hernia, CHF, and osteoarthritis. On examination, he has a heart rate of 60, BP of 122/64, diminished breath sounds, and abdominal distension with hyperactive bowel sounds. His top priorities for care include preventing falls, ensuring comfort, and monitoring his ECG and labs closely given his cardiac conditions.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    539 views3 pages

    Example of Completed Form: Admit Dx/Chief Complaint/Hx Current ILLNESS: - Bowel Obstruction Respiratory

    Uploaded by

    Joseph
    GT is a 60-year-old male admitted for bowel obstruction with a history of HTN, cardiomyopathy, renal calculi, schizophrenia, bipolar disorder, inguinal hernia, CHF, and osteoarthritis. On examination, he has a heart rate of 60, BP of 122/64, diminished breath sounds, and abdominal distension with hyperactive bowel sounds. His top priorities for care include preventing falls, ensuring comfort, and monitoring his ECG and labs closely given his cardiac conditions.

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    SITUATION & BACKGROUND

    PATIENT INITIALS: GT_ AGE: 60_ ADMIT


    DATE:_02/15___

    ADMIT DX/CHIEF COMPLAINT/HX CURRENT


    ILLNESS: _Bowel Obstruction
    _____________________________________________
    _HTN, cardiomyopathy, Renal calculi,
    Schizophrenia, Bipolar disorder,
    Inguinal hernia, CHF (15% EF),
    Osteoarthritis._____________________________
    __
    PAST MEDICAL/SURGICAL HISTORY: __
    Hepatitis C, Recovering alcoholic and
    substance user.
    _____________________________________________
    Neck Surgery 1987, ruptured disk 1996.

    REVIEW OF SYSTEMS (INITIAL


    SHIFT ASSESSMENT)
    VITAL SIGNS: HR_60_ B/P_122/64 _MAP N/A RR_18 _
    TEMP_97.6

    PAIN: rating_4/10_ locat._All over__


    descript_Dull/aching__

    NEURO:
    Orientation (LOC):___A&O X3________________ GCS:__15____
    PERRLA _X_Y _OR____N__ Pupils (size/reaction)__3.
    Appropriate______
    Upper/Lower Motor Strength(equal/un;
    weak/strong)__Strong_______
    Paralysis? Where? _None_______ Fine/gross motor?
    __Gross________
    Facial drooping?__No____tongue midline?__Yes___swallowing?
    _Yes____
    C-collar?__No_____ Halo?____No________ TLSO brace?
    __No_____
    Numbness?___No_________Headache?__No___Seizures?
    __No____

    CARDIAC:
    Heart sounds:__Slow and strong_____ murmurs/extra
    sounds?__No____
    EKG rate/rhythm:__60bpm-Ventricular________
    PR:_176__QRS:102____
    Pulses: radials___60______ dorsalis pedis__60____post.
    Tib.__60____
    Cap refill:__> 3 seconds___edema?_None_____turgor:__No
    tinting______
    DVT?__No____Art. Line?
    _N/A_Waveform/Correlates__N/A____________
    Pulm. cath?__N/A_____CO/CI_N/A__ PAP_N/A__SVO2 N/A
    PCWP__N/A__
    Balloon Pump?_N/A_______Potent Drips?_N/A______________
    Pacemaker?___Yes____ Settings?_Battery died 6 months
    ago_
    Cardiac enzymes?__N/A________echo? EF?_N/A___cath?
    _N/A______

    Example of completed form


    Coags?__N/A_________Lipid panel?____N/A________________
    Bleeding?__N/A___________H/H?__117/136___Blood Prod.?
    _N/A___

    RESPIRATORY:
    Lung sounds:_Diminished and clear____________Oxygen?
    __No_______
    Effort/chest symmetery:__Equal bilaterally________O2
    sat_95%_____
    Cough?__No___Prod/non-prod?___N/A____ sputum?
    __None________
    Chest Tubes? Location/site descript./suction? Drainage?
    _________________
    ________________N/A___________________________________
    Artificial Airway? Type:__N/A____location:_N/A___
    size/depth:__N/A___
    Ventilator? Mode_N/A rate(d/t)_N/A_ vt_N/A_ fio2_N/A_
    p_N/A_ ps_N/A_
    ABGs? pH_N/A___pco2_N/A____hco3_N/A___po2__N/A___
    be__N/A__
    Chest xray?
    Findings__N/A______________________________________

    GASTROINTESTINAL:
    Abdomen __Distended______Bowel sounds: Hyperactive. All
    4 quadrants
    Tubes/drains? Location/ site descript./ output/
    suction/gravity/clamped?
    ___N/A_____________________________________________________
    last BM?__2/17_____characteristics?_____Soft__________C-Diff?
    __No___
    Diet type:__Clear liquid________ %consumed:__100____ N/V?
    __No____
    If tube feedings: type___N/A____
    rate(current&goal)__N/A_________
    residuals? _N/A____free H20?__N/A_______ Bolus?
    _N/A_________
    Blood sugars?___96_________treatment:___N/A______________

    REVIEW OF SYSTEMS (continue)

    GENITOURINARY:
    Voids? Foley?Size?__Void_______ urine
    characteristics(color/clarity/amt.?
    _____Yellow, clear________________________________________
    Irrigation?______N/A___________Dialysis?__N/A_______________
    Electrolytes:______N/A_____________________________________
    Treatment:____N/A__________________________________________

    MUSCULOSKELETAL:
    Fall risk?_Y_ precautions:__Side rails___
    ROM: All
    extremities Activity ordered:Ad lib_ observed: frequent
    ambulation ___how tolerated_Well___
    Restraints? Where?____N/A__________Why?_N/A_________
    Ambulatory Aid?
    ______None___________________________________
    Contractures?Casts?Traction?_No
    _______________________________

    INTEGUMENTARY:

    Braden scale:20_Skin descript. Color/temp/moisture_warm /


    moist_______
    Wounds/Incisions/Breakdown?
    ____None_____________________________________________________
    ____________________________________
    Wound Vac/Dressings or other
    Treatments:____None________________
    _______________________________________________________________
    _______________________________________________________________
    IVS? Site location & description/size/whats running
    continuously (if potent/sedative/analgesic gtt the report in
    dosage not ml/hr):
    IV fell out this morning. Pt refusing to have another
    one put in.
    _______________________________________________________________

    PSYCHOSOCIAL/SPIRITUAL:
    Mood/affect:_Cheerful___________ support system:__Chaplin
    __________
    Disposition after discharge: ___home_____
    Spiritual:__Yes______ Participates in care?
    __Yes______Understands disease process?__Yes____

    INFECTIOUS DISEASE:
    Fever?_No____ WBC?_3.8_________ Neutropenic?____No______
    Positive cultures? Where? What organism? Treatment?
    Isolation?
    _None____________________________________________________

    MEDS(REVIEW HOME MEDS FOR


    CONGRUENCY):
    _______________________________________________________________
    Nicotine patch, Protonix, Lasix, Colace, Lopressor, MS
    Contin, Lactulose, Xanax, Milk of Magnesia, Dilaudid,
    Restoril, Maalox.
    _______________________________________________________________
    _______________________________________________________________

    Prioritized Plan of Care:


    1.
    2.
    3.
    4.
    5.

    Prevent Falls
    Ensure pt is comfortable.
    Ensure pt is in minimal pain.
    Monitor ECG and pertinent labs. [Should be #1]
    Monitor I&Os and weight daily. [Should be #2

    Prioritized Top 3 Nursing Diagnosis:


    1. Decreased cardiac output r/t altered heart rate AEB
    bradycardia.__________________
    2. Excessive fluid volume r/t decreased cardiac output
    AEB diminished breath sounds.
    ________________________________________
    3. Ineffective tissue perfusion r/t decreased cardiac
    output. ___________________________________________________

    MD ORDERS QUESTIONS/CONCERNS FOR


    PHYSICIAN:

    Follow up Care after


    discharge?
    _

    Electrolyte replacement? Any


    concerns?
    SHIFT CARE PLANNING TIMELINE:
    0700 - shift report/review labs, mar, x-rays,
    orders
    0800 - Initial assessment/vs/reposition/scheduled
    meds/daily sedation wake-up/bundles
    reviewed/zero/level pressure lines/verify alarm
    limits
    0900 - scheduled meds
    1000 - vs/reposition/scheduled meds/oral care
    1100 - scheduled meds
    1200 - repeat assessment/vs/reposition/sched.
    meds
    1300 - scheduled meds
    1400 - vs/reposition/scheduled meds/oral care
    1500 - scheduled meds
    1600 - repeat assessment/vs/reposition/sched.
    meds
    1700 - scheduled meds
    1800 - vs/reposition/sched. meds/oral care/ shift
    I&Os/ daily weight

    OTHER ROUTINE CARE TO COMPLETE:


    Bathing/linen change______________________q
    24hrs
    C-collar care______________________________q
    shift
    Trach care _______________________________q
    shift
    Peri/foley/rectal tube
    care___________________q shift
    Reposition oral ETT_________________________q
    shift
    Pneumatic compression
    devices/stockings_______off at least 2hrs q
    shift
    AROM/PROM_____________________________q
    shift
    Normal Values
    WBCs
    RBCs
    Hgb
    Hct

    5-10
    4-5mil
    12-18
    35-45

    value
    s
    3.8
    3.97
    11.7
    35.9

    Platelet
    s
    Absolute
    Neutro

    BUN
    Na
    K
    Cl
    CO2
    Glucos
    e
    Creat
    Ca

    150400
    2.9-9.1

    229

    8-20
    135145
    3.5-5
    95-105

    27.9
    138

    2.1

    70-100

    4.0
    96
    29
    96

    0.6-1.3
    8.6-10
    6.3-8.3

    0.86
    9.2
    8.2

    Alb
    Mg
    Phos
    GFR
    PT
    PTT
    INR

    3.5-5
    1.5-2.5
    2,6-4.9
    >90.0
    11-16
    25-35
    0.76-3

    4.4
    N/A
    N/A
    N/A
    N/A
    N/A
    N/A

    pH

    7.35-

    N/A

    Total
    protein

    CO2
    PO2
    HCO3
    BE
    CKMB
    troponi
    n
    myoglo
    b
    Lipase
    culture
    s

    7.45
    35-45
    80-100
    22-26
    0
    0.5-3.6
    0-.050

    N/A
    N/A
    N/A
    N/A
    N/A
    N/A

    0-110

    N/A
    44

    *Gray Required in CM for all


    patients
    IV Catheter Color/Gage Guide for JPS ICU *subject to change
    18G
    Green
    20G
    Pink
    22G
    Blue
    24G
    Yellow

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