Silliman University Medical Center Dumaguete City Patien’sNane:_N-T-M. ctor: alas. D-fgo Be No: CASE 0-1 Ferm ia. 201943 PHYSICAL ASSESSMENT SHEET. cate location sitetype when needed. ka italicized item is checked. STRUCTIONS: Document your assessment findings with a check (V) mark every si ied items may be identified asa PROBLEM for nurse's notcs.Inate Fall Prevention Protocol fany 6 DATE. a DATE carrenta_ |fofe|nfpfe ln pope |spprelNpoyelspoe|sfofe| __ CRITERA. i Oneal ing Normal ive Ts Fregue 7 Coie: Normal Cad Bod Tinier denon Flank pun ete lode Err Oood otis ones i jays Aces oom relspoyelspolefpore|sp>le| s/o} Sooo ee Newel Ca ‘GENTTO-URINARY Tea ral Lint Toit pains swe Nee DAT Full Soft OF ae NO, Goad "Poor ie Ralls auto Bieedi Fal a Fall Rat tar Sandard Tttore. et “Conte Reverse Talation seizure Suicide ‘Aspiration orand Wits Farsiout Nowa Sw aiica E NURSE'S INITIALS# Silman University Medical Center i Dumaguete City Patient'sName: N-T- Motor: Dr Ballas , De: fod Bed No: cost no} = ferenezuine? INTRAVENOUS SITE. ASSESSMENT SHEET __ Sanne manor samonar BRETTON | scaux | wanacenert | ini | SCALE | MANAGEMENT | Assen scate a cr a ee ° i ; a Termes Foods d ciate | (cemereees onset oar netrwas eseeesea ee [etsy mee | nueteonee | 1 | “eaelananee coattotaan 1 | “Sinus” | Soe 1 peo Siren pacatebe pene, hiner = annenh—_|! Seg via —eaiysaeet | Seueea posse eave Teper (0 Semmzs- Henne swenyo 2 | Tl seperate seoatace coat oh 2 | “erate am. _ || eee eee =e catts_|| sates = — mer aes 3 pen steht seco Sun score em srourt ‘pacer || Saeeee ipa ete oe a) | comes wepeue | Sizes, | . | cena Tatetarsn” | 3 Sale meae ‘noel ‘Advecndatage of |] Noa cat et ——— — sorrerteamed || Serre ene entero oer meas || see San. 4 [RESITE CANNULA ‘Treat inmeciataty~ moa easton “Tsuen on feaking TREATMENT™ ain at infusion site ‘Stop nfusion Sin aectore Sases Dntaming he Bete Lem anna 9 section Pcs “Stun blanching ‘eta for ree cxsen soos get vst ay Setarched ae pioegee ie | ‘ocr ———_ “Advanced sage of ienigate atlected area | sparc 4 | Retr acer penrcsnetes cadet | 4 | wencorenin | np argon se | Seen ween conve | Reiner wouraame | 5 werare || Arenal ccttion SnD econ Ste | Seaee wenmame,. || Ate cae |, mage a a" | FESS we eet MeiLa || Sorc ne INSTRUCTIONS: Indicate a check mark (8) in te box when applicable. Write the sor IATRU TION wend docament inthe Naraes’ Notes, **Asterisked management guide ball be ‘documented completely inthe Nurse's Notes. Date, 0-2} - 2000 cots EEE EEE Fi |aation Toca: intron scale [Preis scale | [extravasation e316 [Dressing intact. sr = | ven eiraon P38 eres Sele | [Recannulaion [pecktow Tocatr:[intitration scale [Phisb scale [Exravesston scale intact Gaape tush Recannulaion 7B [Becxtow Tecatn: [infiration scale Piet scale [Exravasation scale [Dressing intact Gauge: (NURSE'S INITIALS Te Assess and reassess as Flows 7 r reassess as follows: Hourly for pediatric patient, intensive care patients (NICU, MICU, SICU, and PICU), atleast 2 hourly for adult patients. | = | t |= was ic = Silliman University Medical Center 4 Pump EW Gloria Bollos (LGB), Dr. Doctor:_Maria Isabelle BedNo:__CASENO.1 Form No, 2019-06 prvemongan Arco INTRAVENOUS FLUID RECORD SHEET = Deon | ue tect Date | crime | Bottle | pisiy Additive Total | Flow eT ol g al RN Stenature over Startea | Strted | Oyo" | Fluid Type (oseVolumey | Volume | Rate | ¢ | g (F(Z HES * 4) | geese =e" ami) s { seanene “ IDSNSS|7720H| 7 Hypettonie iL SBatts/m|n LZ A} thyperhnic it __{aqttelnta A Ed E 3 i tL [isatsinin —otooy TTF a] eabait { 4 peotmo Q3D0H | & ih iL ah i pooH 25 in i La lospl [7 “ DENS £006 | o4ua| mal lee | goon | | 7SILLIMAN UNIVERSITY MEDICAL CENTER FLUID INTAKE AND OUTPUT RECORD SHEET name _N-T.M Bed No. (ast Nol Date: 10-48-04) 3pm to 14pm. ‘11pm to 7am. Kind [Vol [Kind Vol} FLUID INTAKE Yakut, Oral Fluid DSENGas | P [I ‘ Eqht(min_| BY ce é i |_fogts|min | Idee Intravenous Fluid TOTAL j | FLUID LOSS Urine et 280 Perspiration Visiblz Perspiration $2 tt Vomitus: ‘Stool 100 co Suction Misc. TOTAL Signature of Nurse Over Printed Name ‘Summary in 24 Hours Total Fluid Intake: _ ee Total Fiuid Loss: Signature of Nursé Over PriniedName { 8/113SILLIMAN UNIVERSITY MEDICAL CENTER FLUID INTAKE AND OUTPUT RECORD SHEET NIM Bed No.CASE NO.1 Date: _|0- 41-020 [—Tanwospm | —spmio tiem —] cc Name: FLUID INTAKE — = DSNSS_| 720 ml Intravenous Fluid TOTAL Sale ces mal FLUID LOSS Urine 387 mi Perspiration Visible Perspiration 87 ml : ‘Signature of Nurse Over’ Printed Name ‘Summary in 24 Hours Total Fluid Intake: Total Fluid Loss: Signature of Nurse Over Printed Name BAN3SILLIMAN UNIVERSITY MEDICAL CENTER VITAL SIGNS/MONITORING SHEET ee Bed No. care 0.) Date | Time a PR | RR | BP on Sa0, | Abdominal | RN Signature = ab~ | Aub 2Cyel AD com | sbi ; eal 06H _| BU ACL ppm | 3.0 cp | ala FEE IS A a yt BikSILLIMAN UNIVERSITY MEDICAL CENTER VITAL SIGNS CHART nome: NT Bed No. Cae M2-)__ Date (0-ap [0-24 borat __ Hospital Day P.O. Hospital Day : = : Hour of Day a. a s 280) 42°C 270 260 41°C 250 240| 40°C 230 | 220 |E 39°c 210 a ; [| 200 & 38°c B 190 B 10} 37°C — 170 B 160} .368c : |3 (3)-— : i a 140} 35°C % 130 ; : T a 120 60 I Ez 110 55 : {00350 90 45 80 § 40 i @ 35 i 60/5 30 : 50} 25 : 40 ao + 30] 15 20 10 10 STOOLS ‘ URINE |SILLIMAN UNIVERSITY MEDICAL CENTET . MEDICATION AND TREATMENT Recon] | . Name: __N. TM Jed No._Cast 0. ECIMEN SIGNATURES OF NURSES ONDI “SPE Painted Name [Specimen Signature] Printed Name | Specimen Signature] |" PrintedName | Specimen Signature Lamwen A casas | Qedhe Dae Date iad tae MEDICINE/TREATMENT | (0-4-2070 Furosemide (| ri : [ Tpptae ov