Y,,. UNGSTOWN STATE UNIVERSITY student el ake Department of Nursing Dato of care /9//9 Nursing 4840L Clinical Data Base Lynn Nurse's Name. Date admittea 4/4/29 DNR status_//l rode Isolation type “”°** — syerew) Allergion MEA _ Pt's Initials 4 RoomaZcu /6 Age 7 Sex__ Height! 05 ~ Adm. Weight 71.6 b4 Diagnosis (es) Ae Resp, Foilere Reason for Admi n/Events Leading to Current Hospitalization; (Include reason pat nt is still in Unit > 2 days if appropriate) Lap cholecy Ste Att 321, Stee fo Vibrwi for rehab Nd fed 0 [res buf wire! Yr dcwle vege. LS, on IS we) PA. intobated , erye pv tend: 2ehP" bilet seell plewal effin, Fever 102, VTL. foul fericaroh nt Foiled Clap 448 splliatnbeled biagso nea, Pertinent History of llInesses/Surgery: nired peavig Mision dicbeleS, schizg Sy Steric d, byob Cap’ thslecyStabony fa. Day of Care (range: Vent Settings: \ ot - t wig] 1 oufas eI (eizeripsine) 9/2 Trach (sizeltype) op Safa = 10 i Vent: ModeA/« map____-/24__ Rate_If__ HR PO FiO He rRIg= 23 wot ‘$P02 (range) 1-0 peep_£0 Psy Oxygenation (circle): Nic = FM Venturi = NRB_ FiO2———__ CPAP BIPAP, = FiQ2___ Page 1 Revised 6/16 rcaleagn &cmshields| Neurological; 3. ed. toc —edeked Orientation: JY person ¥ Opens Eyes foswund/ahr® goa fe —— Ordered Sedation = Nh 7 Pupils: 3a (fondo Speech: YA. 7 Tongue 0, mallina nie thf. = ce Symmetry. “Yeoh Cardiovascular; Rhythm: SU Jvp; Wowk = — Pulse: eadertrequir Cap Refill 3 gah Pacemaker, _//?* Heart Sounds: 51, 57 sec) CVP. Cyanosis Location; “2* Fane — Peripheral Vascular: Pulses: (Palp or Doppler) Radial. R2” Edema: YesiNo Location: Respiratory: blah, oll thes Sputum: Stell, chear/ptale Breath Sounds: Jivin’t. Chest Tubes (Location/system/Sx setting, WHA?” Tver) Cough: ae 1 Post Tibia: RE". Degree: Lo scehni ced Nonproductoiy Gk 1 Die PD _ TPN TF typeraey — NGOGPEGIFT (circle) QG Sx Drainage: eee ‘Abdomen: !-dtt,ruseo) dsloded Bowel Sounds: efit XY Stook YAN) incontinent Ostomy (type); ———— Ve Color/charac: cu: i de O. Gnnie: Color svelloe,*@ciariy Llendy mou 3264 Catheter Typelsize: 4 Genital Irritation: vw ) Dialysis (type’site). —— i 6 the Sem: rere coor fells : Turgor: & bh C ebebarctn anid A. Mucous membranes: f'+4.loy _Incisions: 1 abl ail aloes sh heck ski shre 1 Wounds: 1" +4 rebres),bolentasignhutols ust) Musculoskeletal: 2iHlenessos obdomen ( ities: . fell weverent fei" stengin ee Sensatio Lower Extremities: y A ee Sensatior Movement fll 2s _ Strength — Page? ‘Revised 6/16 Ircalcagni & cmshieldsContinuous 'V Drips: IV Drips must also be looked up & included on Med Sheet Medication Concentration [Rate Site Line | “45% Nall | pO mt Some @ PLC Fen heny] 74 | 2500, Gf 25 pA REESE & cc | [Bear Intake/OutputWeight: 24 re intake SO%M 4 n- Quipur!O29+ cumulative Fd Balance (pcr ay) BZD — $70 Bh. take: Lee oe BIO Dally We aday) AUBVS rer day, 2-41 KS Pain/Pain Management: Location: GAMA APE Duration: ___ Scale 1-10 Intervention: ————_____Evaluation (win 30 min) ABG Analysis: ABG's: pH PCOz = PO2z =| HCO3_ Interpretation [Baia 7.4o OH ye | | th Conpaaded cop. cadets | bata 13¢ eH gs (tS) nposckd cexp. ccd ‘Day of tare Date [fone fete | Diagno: 7 | “Chest XRay 4) wadevele pejumrdel efRSOn | finctude datey | ET RHC Jevm chive charved By tbe in srmacly ‘Other pertinent T - a diagnostic tests (include date) —__————: « \ \ \—a—maaw0_————— Page 3