Professional Documents
Culture Documents
Rm:
Initials:
Allergies:
Med DX:
Age:
MD:
AM Report:
Wt.:
RN:
Nx Dx:
Hx:
VS:
0800 T:
HR:
RR:
BP:
1200 T:
HR:
RR:
BP:
1600 T:
HR:
RR:
BP:
Cardiac:
Rhythm: NSR/ ST/ SB --- Apical Pulse:
Cap Refill: < 3 sec / > 3 sec
S1/ S2/ S3/ Murmur/ Click
O2:
O2:
O2:
P:
P:
P:
GI/Fluids/Nutrition:
Diet:
__________ Tube ______ Fr ______ cm@nare____
Active/ Hypo/ Hyper Non distended Soft/ Firm
IVs
CVL#1___________IVF_______________@_______ml/hr
PIV#1___________IVF_______________@________ml/hr
PIV#2___________IVF_______________@________ml/hr
24 hr fluid calc:
Maintenance ____________________ ml/hr
1 times maintenance _______________ ml/hr
Pulm:
RT tx: C/ Fcrackles/ Ccrackles/ H/ D bilat R L
Time
O2 L
O2 Sat
Rx
VS
Infant
Temp 96-99.9F
90-170/min
HR
30-50/min
RR
85-86/37-40
BP
Labs/Diagnostics:
E. Child
M. Child
Adolescent
95.9-99F
70-150/min
20-30/min
85-93/37-52
95.9-99F
65-130/min
14-25/min
93-102/53-61
96.4-99.6F
65-110/min
12-20/min
103-118/61-67
Priority of Care:
Pathophysiology:
Medications
Time Name
07
Skin:
09
08
Dressings:
Tubes/Drains:
Activity/ Restraints/Isolation:
Activity:
Safety Precautions:
Isolation:
10
11
12
13
Amt/Rt
Route
Class/Action