Braden: 18 or less = Risk

Falls: > 24; 45 or greater = low bed/Tele sit

Output: <240cc in 8 hrs OR <30 cc/hr
Postop Vitals:
 Local Anesthesia: Admission + 1 hr later
 Others: Initial, Q ½ hr x 2; Q 1 x 2; Q4 remainder of 24 hrs
RRT:

 Decrease in LOC
 New agitation/delirium
 Repeated/Prolonged seizures
 Acute Neuro changes
 SBP <90 despite tx
 HR > 130
 HR < 40
 Chest pain
 Respiratory distress
 Threatened airway
 RR > 28
 RR < 8
 O2 < 90
 Difficulty speaking
 Temp > 100.4 or < 96.8
 SIRS: 2 or more & new for patient
o O2 < 32
o Leukocytosis > 12,000 or > 10% bands
o Leukopenia WBC < 4000
o HR > 90
o RR < 28
Suction: 80-120 (oral/trach); 40-60 (Purewick);
Tele DC: (-) cardiac enzymes (for chest pain); No dysrhythmias after 48 hrs of suspected dysrhythmias; (-
) MRI on Stroke protocol; 24 hrs post pacemaker insertion with no arrythmias; 24 hours post-op with no
critical dysrhythmias; No IV meds needing tele; Pt comfort care; Discharge
Tube feeding: Put back if < 350cc; If >350 cc, replace up to 300 cc
Urinary Catheter: If voided in last 4-6 hours ok; If < or = 180 in 4-6 hours; Check urination within 2 hrs of
PVR <300-500; Straight cath if PVR > or = 300-500; Repeat PVR in 4-6 hrs to determine straight cath;
Report if still > or = 300-500; If voided > 180 in 4-6 hrs = Good!