University of Santo Tomas

College of Nursing
Bedside Worksheet

Oxygenation Intravenous Fluids CBG/Fractional Monitoring

NC FM @ ___ LPM No. Name/Additives Reg Level
ET TT to MV T-Piece TM IV/HL
FiO2: ___ TV: ___ BUR: ___ PS: ___ PEEP: ___ Mode: ___ CVP
NEB: ___________________Q ___ CPT IS IJ
BS: Equal Unequal Crackles Wheezing Diminished FC
Others: Labs Diagnostics Surgery
Cardiovascular
SBP: ___ DBP: ___ MAP: ___ CVP: ___
HR: ___ Regular Irregular Pulse: ___ HS: ________________________
Skin: Warm Cool Dry Clammy Pink Diaphoretic Pale
Pink Diaphoretic. Pale Flushed Mottled Cyanotic
Jaundiced
Capillary Refill: ___ secs Edema: ___mm
Others:
Neurologic
GCS: ___ E: ___ V: ___ M: ___ Medications Time/Shift Treatments
Pupils: ___mm Brisk Sluggish Equal Anisocoric 6-2 2-10 10-6
Activity: OOB Dangle MSU A/PROM TTS CBR BRP
SA PA CA Others:
Nutrition
Diet:______________________________________________________________
PO NPO __________ NGT-OF PEG-OF Jejunostomy
Elimination
IFC Straight Cath Q ___ Bedpan Commode Cystoclysis
Nephrostomy HD PD Colostomy Ileostomy NGT-GD
CTT JP Penrose Hemovac
Others:
Precautions
Seizure Fall Safety Suicide Arm DVT
Isolation Reverse Isolation Std. Droplet Contact
Airborne PTB Hepatitis Allergies: __________________
Others:
Name: Age: Ward: Room No.
Diagnosis: AMDS:
 University of Santo Tomas
College of Nursing
Bedside Worksheet

Date/Time Focus DAR