YOUNGSTOWN STATE UNIVERSITY pate of care [0/13 UC i : ie Department of Nursing Nurse’s Name- Nursing 48401 Clinical Data Base tie ee Law P's Initials Date admitioa OH /2% Height 5S ese Room DNR status—_[-ULL Oo Soe @oncieer Isolation type Vor sox Eecaie Allergies H1d(oG dont Diagnosis (es) ow ion ay Reason for Admission/Events Leading to Current Hospitalization: (Include reason patient is still in Unit > 2 days if appropriate) ea lowe puovien (rsh. Pt Selk ag Pop ater barium enema Cab oe wu cr Pin Qv@ on \oli2 @ [3b Pertinent History of Illnesses/Surgery: YUE Tok ABD Colertomy wend LLcostery * Pemow! OK Diovan mass Quel 9 Rua ostory! % Oxygenation (circle): Vent sung: Pain: jeeseesecamen Mode—C_ Score: —Q__ A FMI Venturi NRB_Fi02, Rate IH Scale Used: CLOT _ —_| prenag CPAP == FiO2__ F020 Location: —____ wl BiPAP Fio2—_____ w—Hio___ Duiey cece av ETT (sizetlipine) peep Intervention; eat Trach (size/type) ——— psv-—O__ Re-eval (30 min): w Sane nates ae Today's Weight: 2¢4+. prior Day's Weight: C24 24 br Output, N42 Cumulative Fluid Balance (prior dayy: + 14, OBS» % Revised 6/20 realeagn fe cashilds = SAS Se EeHead to Toe Assessments Nourloieatins yas oyetaion Qev604 [Pate Tint ordered Sedation, VECSED epi (pase Opens Eyes: ReBs> Comass> ccs: 15 —__ Feels: Sem speech: 15 Tongue: Madling, NO deviotiafice Symmetry: Ee ; FD commend W/ Maemyr ae) Cardiovagcular: Rhythm: Acie CUR Pulse: Reguieffiregular )) Heart Sounds AS cama vp: 220. Cap Rett (aecDps es = POWr: Pacemaker: ee Cyanosis Location: Asan Esema +3 UTA sw] AT Ure ry PeripheralVascular: Pulses (Pap: Doppler). Radial: RUYALMIA Pedal: RL LA. Post Tibial: RO- LO. Edema: Location: LEE IZLE Degree: FZA3 pvt Respiratory: ae Breath Sounds: CACC | dimminvkees [Ons sputum: Seteut_| Yetoundh Chest Tubes (Location/systemi'x sting; —aag —_ oust @LN Eicon + ae p——_—— Bowel 06S Bier Stick _ APO ten_Lore” TF (ypelrate): AyOde CigociPecirt (cree) (R, oes §x Drainage: YU*/o/esh apdomen: Leader / Slim lise” Bowel Sounds: Stool: Y/D Incontinent: ¥ A) Ostomy type: CV@ |) ems: —=—— Coloricharac: AO Presens Tex |, Poytoe toanel obs cu: Urine: Color tMloel” Clarity Codey — Amount 2 Catheter Typelsize: L@ 6 Gerital Irritation: 7 Dialysis (ypelsitey:. _———— Skin: Fame: oat Color: Pale. Fugen Zee, Mucous membranes: Oe Incisions: AQ MLL Wounds: ABD MET" Dost-6F Lue. OR Musculoskeletal: Presi UE Movement Le Teg’ IA stongth tl GAP Fle oof EX 2" ton Peetenct Le wevemart, Cen ES an SA_Fledion JE Sensation Preset ——— Revised 8/21 Ircalcagnl & cmshields Page 2Continuous IV Drips: IV Drips must also be looked up & included on Med Sheet [Medication = Rate me a recy | in| Hong hh __|© dvotae| CHE & . Twill aees | 33 mck we > |Auiodetsee | fo pase Ata [rat we 3 |LEvo Qila_no weit, eet min | rans = ILG [aon te Ugsine [a ®& wes | Tu eset in os ‘S ES mes [Il G forcain | TV | == | VagowressiW Dus Ke VM 0.03 ufon'n | & wis | DU 2 Weg alee “ SOP 7 ie Cd TriOr5, Page 3Normal ‘Admission |Day prior [Day of care Lab Test ‘Values eal o }lo Jol u lol B Reason for Abnormal Value ie 3 \ fevious elevations (HF ie S90 [Sl [eh evi 5 z ct ®-101 % Joe TWA) buch OS ASO gico 22-9 {1 1% [Glucose TH: lod a BUN Creatinine OT-O YU cotd bee Cenat_Comp of Calcium * i= OL Qt fn [Albumin 5° 5h D> | eu | © [Total protein |@laLp (aPros)| Sowio4 | 13 e a | pea | [Total Bilirubin : |—|Magnesium | [e-C-Y 771 > Unsure of Sligt Elev Phosphate Ci (3008S Meet +g [Cholesterol Cotes ig ov 227 [Triglycerides i 7 RBC Hob W5~ {5-5 | Joo | 4-6 fas ca i Het u=46 | 328 | Zot Wt x | [Platelets B[wac ©lneutrophils —_[[-9- 7-5 - Ttionin 7 fbmpheeyies [20-40 YA {2.0 Cy OOF Dbskeetin, monocytes om ‘eosinophils “faa etsy WRC basophils Pr 3-124 [TS TS 2H [Pon Heparin foe [INR fy A ol HeTTPTT N ic tke : 3 CK MB oa 2 z E [Troponin = ek ieee 8 lege manic OStL (yore, sce (ENP) omese (Wr Codes Wd Lactate _ o5-t.t | 34 }@ 2.6 | 3.6 Ts in Goatinns Ath, ., |Ammonia “eat dior ip MORNE GaiaSs's (ie on a T Ore oleSNuction, Resin PA49 Cor ivy U = * Calcium oart of BMP in some facilties Revised 6/21 Ircalcagni & cmshields age +ECG Interpretation: Post 6 second EGG strip here or on back (no identifiers). Interpret using 6 step method. fee Onan 2. RR Interval Reguiar: YC) 3. Pwave present: Y@)(heonsiskat) PR Interval -O:22_ constant: A) 5.P precedes each ORS: YA) 6. QRS Interva —Q-0 9 _ 7aTinerat—O.2G 8. ECG interpretation Arad RUC __ Priority Nursing Diagnoses: (Select top 3 issues of highest concern for patient) Priority #|___pverobiem Bik o& decessts cating cats (Ik Cetin b66ren General Goal; Maina’, Tloo_4 MAPS 7O Measurable Outcome: 1X Interventions: Pt. Responses: 1, Aiiodosone Admins ation 1, Sein ACIS 2 Sea Levoohe ds 2 hetaare, eae ee dus Nit eurrt3 Be Si cf fhgtenie ine 4. BP Myer OnE? Evaluation of Outcome: ‘ ND/Problem: ne Cie & inkection (Ht agen & > at Prony) Burge waErsion, zs General Goat: : Clana. inerston Measurable Outcome: post R wee Evaluation of Outcome 2 is, in Priority # eee ih F WN i General Goal: ication lend Measurable Outcome: ‘aii Gao us da Ve Evaluation of Outcome: Bepeey 0 fo ttlane lab valet rests ONS AKG Needs en Pages WN Meni ned Che Revised 6/21 Irealcagni &cmshieldsMedications (\nclude all scheduled meds & continuous IV meds, even if student is not administering on shit) on oe Dose Fibperectied Reason Pt. Receiving 2 Common Side Effects —_———— administer Glassifeation z \ Inf [Vo Preven Chor | \pgedin, peur oie Heese NTO Je Ast Inermucrn iy e\ [ARDS [emre Faliwre 330 Polassivm Chev Heer ial Neue Joe oe bie, 4a areer, pepe f| Diaodin \26m% |TV Kok te AGI ny ae especialy (Cobia ayeoril "5 CONSID beirs 5 {aes W/ AmioxefoR, S 930 Inevtuke. I Raster, (Mt acer k ere eee (| sas aie | v ee taeo Ve 2, i Levo ple’ Wnerease BR and ese _ fn rt eS [MidaZoin } Sedokion to WeCP) Apena, ourstserion Renzodia2enie "fel er eS dn A [Fenrun | esrey TV O}e inwerton | Brasyeersian, Re | otis (He Pain map 1p quesesstion(L3e) Portopezote, Home, Tv tuyh | Proven vices Yorn bacyfopts i PRL Pan | ee ee [enue er men Pigecrmin, HS | TY TR ok inkectton fattening eserrer Ankisiontc » Ct Regoarion | kt) oma Candida Ctworreriaive, ICAP Raertion) LR._Qleckoor t) Revised 6/21 Irealeagni & cmshields Page 6N4840 Daily Clinical Schedule: Interventions/Treatments Time: | O8'5 “| p40 | 000] {100 Complete Assessment Vital Signs (document hourly) Te Temperature HR I2o RR 2 BP jou /s3 MAP 790 sp02 o cvP Atline check (cic, ine, bag) | 2 fot IV Check Meds Focused Assessments (specify) Hourly urine output V | i: al fame A Restraint check we Check ib resuts Yo Tumm (document position) ECG strip Zi NG placement NG residual Call ightrails Blood Sugars Vv Initial when complete Revised 8/21 Irealeagni & cmshields Page?ronson 9 IRR(APNEA}2 IMP (APNEA)2_PR RRGND HID [59029