YOUNGSTOWN STATE UNIVERSITY ins Coke el Dl. gelsie ay Department of Nursing Nurse’s flame a Nursing 4840L Clinical Data Base ee a ros Pts Initials PZ Date admittes_[0 (15 Height_22 Room #4 Cut DNR status—FulL _ Adm. Weight 22216, Age—G@L Isolation type——_AJ00& Sex Allergies AVDA __ Diagnosis (es): SAM ALE Knerygum Reason for Admission/Events Leading to Current Hospitalization: (include reason patient is still in Unit > 2 days if appropriate) Pr Reeser ko ED ww) Compiinr’s of A Y days. Oar Cebit tom CT cum —aneitinen —ai Site ——§ Wwe fond, Ps wor haven Ko suger GC aa ___ Pio previ Coil. Pertinent History of Ilnesses/Surgery: a) Ao Oi Oxygenation (circle): Vent Settings: Pain: N/C_____——__ Mode Score: FM/ Venturi NAB FiO2_—_ Rate——__ Seale Used: C.POT cpap = Fio2__——_ Fie a Location BIPAP Foo Wo Duration: ETT (sizeflip-tine) ——— PEEP__—__ Intervention: Trach (size/type) ———— PSV- Re-eval (30 min): Intake/OutputiWeight: Zin nate, 2324 Todays weignt 224. prordays weight 224 24 hr Output: SHTS Cumulative Fluid Balance (prior day): — BIGG Page 1 am).Head to Toe Assessments Neurological: 16. 1S ferton [Coabsterienation; Contos ordered Sedation: Adore Opens Eyes: fovea ecs:__\\__ Pupils: Suge Speech: Conkustes Tongue: fidlint Face Symmetry: Quel Bi-jat Cardiovascular: Rhythm: Sav Pulse Heart Sounds: 1,22 wo:_M2 Cap Ra Loe cvp: _——_pewr: == Cyanosis Location: Pacemaker wk paper (Prem) PeripherahYascular: Pe Ea Radial: RELL AZ Pedal: RL Lk post Tibia: RH LA Edema: Location: — Respiratory: Breath Sounds: Clo’ / Foust | Briaseal Sputum: Sta been Chest Tubes (Location/system/Sx setting: —————_ Cough: Y. Pre ive/Nonproductive) Degree: —————— Gl: , Diet MG Tue Feed ak ae TE (ypotatey, OSMOLHE Com, (Qparecer (circle) NG Sx Draina ‘Abdomen: S264 _]Yours/ for te Bowel Soundg: ACE stoofDn Incontinent: Y/N Ostomy (type) re EMS: Colorlchatac: GU: Urine: Colo NOMOY Clarity Gltal ‘Amount QOOCK. Catheter Typelsize: Me 47 Genital Iritation: ¥ AQ), Dialysis (ype): _————> ‘Skin: feng cen caine Foetus SB sec Incisions: re) Mucous membranes: {0 s Wounds: Cee nia Musculoskeletal: UE Movement 22 Srergh ees Sensation FULL. LE Movement stengih—t __ Sensation LULL /21 Irealcagnt & emshields, Page?ied on Kod Sheet Continuous IV Drips: 1V Drips must also be looked up & f Medication Concentration Rate = [tine ABG Analysis: fae E A ABG's: pH PCO2 | PO2 | HCO3 | Interpretation ' ‘Admission 7 Date: Ete] to, DATA Jw: LARS s Day prior Date: Te eee | DATA fis EARS: 5: | Day ofcare | ___ cs J 4 Date: — | we DATA Iw LARS Diagnostic Test: | Results: Chest X-Ray Jo}l@ -\0/17 CTA WO Const ieee lo fI5_- |9I2@ US “Torseruriay Dopp” t diagnostc tests |10/1T V6 Woe Qlacemens- (include date) Pathophysiology of Primary Diagnosis or Surgery (include book used & page #) As He _aeconmiagia & bod It Me pen ingen AML avid Jeyer & fu Pia ier Salads Rue. bys eS Psychosocial Considerations: Pt hos altees (oc Ud| varity eo _Comeren eate seruel Pages Revised 8/21 Ircalcagnt & cmshields‘Admission |Day prior [Day of care aa lo | 6 lo I 26 ‘Reason for Abnormal Value Net 132-14 (AV _|Spote wl nine (emir Ke HIS ond ese 9 7 49-107 am Chccakions Ie Cor He x VA, Glucose BMP. BUN ‘Creatinine ‘Calcium * a= \o.U ‘Albumin -5.0 Total protein | Cheat ‘ALP (Alk Phos) =124 ALT/SGPT Honk |AST/SGOT o-m Total Bilirubin = |Magnesium : [Phosphate | Cholesterol Triglycerides. { RBC. Hgb Het Platelets WBC v neutrophils 1.@-7.. Got lymphocytes =4% Ta monocytes eosinophils basophils PT GSH | aS aX INR HPTT/PTT cK [ck MB Troponin Brype nara popise (BNP) Lactate [Ammonia i GFR CMP (+ BM Up a cBC Cardiac | Coat * Calcium part of BMP in some facitios Revised 8/21 Irealeagnl & cmshields Page + i. Bid Doak bad ia.Medications (Include all scheduled meds & continuous IV meds, even if student is not administering on shift) Allergies [Generic Name Dose | Route/How | Reason Pt. Receiving 2 Common Side Effects. (Classification to administer 5 e reve Soture | tremor aed (2S) MER) ip onerginn | By Steo\S [Lovensn. | Home| SueQ Prevent Jur bleedin, Anticon iinct = nie [Atresoiing, | forts] Ty come SRE7Ibo) Rene menironry Aasitope Ke v75 Se pi Conkte\ WR | Rradyer ra, Pos IS) V6 Jone 8 Airytneses Packie | 7, [uae [Wes iMesoy Mased buning, AaticiotwC Gutsy | ong ton 6 Com r ietdal bebous ees beng Ao __, [Depression Wy ee or eve irkteion Ayneres LOC Lavunt | Jeoon ure Rae Eee ASG fom. Sugita, Aor Revised 8/21 Irealeagnl & emshields Page 6ECG Interpretation: ‘Post 6 second ECG strip here or on back (no identifiers). interpret using 5 sep method. thee HD eoah 2. RAR intent Reguiar: © )N 3. P wave present(Q/N PR intenat OZ consene Dx 5. P precedes each N 6. ORS tntervat —O-0% 7. OT Intervat: —Oalg B.ECG mteqeetston A/S Priority Nursing Diagnoses: (Select top 3 issues of highest concern for patient} Priority ND/Probiem: (Revised 8/21 trcakcagni & cmshieltsTime: s B g |o0o Complete Assessment Los | Vital Signs (document hourly) Temperature HR RR BP MAP Spo2 cvp Artline check (circ, line, bag) IV Check Meds Focused Assessments (specify) Hourly urine output B Mouth care Restraint check Check lab results Turn (document position) WW NEN | AAAS \ ECG strip NG placement NG residual Call light/rails \ Blood Sugars Initial when complete() eeuifecocceon