MEDICAL-SURGICAL NURSING BRAIN

Rm:
Name:
Allergies:
Med DX:

Age:

Team:_________________RT:___________________
Resident:_________________
New Orders/Rounds:

Wt:

Nx Dx:
Hx:

Symptom O

VS:
0800 BP:
Pul:
RR:
1200 BP:
Pul:
RR:
1600 BP:
Pul:
RR:
Cardiac: MAP> ________

T:
T:
T:

O 2:
O 2:
O 2:

P:
P:
P:
Priority of Care

Main IV ________________________ml/hr
CVL#1_____________IVF_________________ @ _____ml/hr
PIV#1_____________IVF_________________ @ _____ml/hr
PIV#2_____________IVF_________________ @ _____ml/hr
Rhythm: NSR / ST / SB --- Apical Pulse: _______BPM
Cap Refill: < 3 sec / >3 sec
S1 / S2 / S3 / Murmur / Click
Ht sounds: +1 +2 +3 +4

JVD R / L / bilat

Saftey
OLDCART

07

Bruit: ________________________

Pulm: R/A / NC / Mask ______L/min started at ___________

C / Fcrckles / Ccrackles / H / D / bilat / R / L

08
09

Cough: Non productive

Sputum:
GI: Diet: _____________
_______Tube ____Fr ______cm@nare
Active / Hypo / Hyper-- Non distended -- Soft / Firm
GU: __________Foley 12H U/O=__________cc/kg/hr
Not continent urine color/character:

10
11
12
13

Output:
Neuro: GCS _____ Pupil R____/____ L____/____ E R B S F
Alert and Oriented X: 1 2 3 4
Movement: symmetrical / non-symmetrical
Weakness: L / R U / L / Bilat

14
15
16

Skin:

17
18

Labs:
19

Diagnostic:
x-ray
CT

MEDICAL-SURGICAL NURSING BRAIN

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