September Brown
|Room: Name: |
|Age: Sex: |
|Code Status: Initial Hospital Admit Date: Transfer Date: Estimated Discharge Date: |
|Diagnosis: |
| |
|Hospital Goals: |
|Doctor: |
|Consults: |
|Allergies: |
|Isolation: Standard / Contact / Airborne / Neutropenic MRSA / VRE / C-Diff /___________ Wound / Stool / Urine / Sputum / Blood / _______ |
|Social: |
|Cognition: |Speech: |Vital Signs: |
| | |Notify Nurse / Doctor if: |
|Emotions: |Swallowing: |Blood Sugar: |
|Behavior: |Aspiration Precautions |Temp: |
| |Straws / No Straws |Pulse: |
|Eyesight: |Elevate HOB |Resp: |
|Hearing: |Eat in Dining Room only |SBP: |
|Other: seizure precautions, neuropathy | |DBP: |
|[pic] |Diet: |Cardiac: |
|Skin MPGs: | | |
| | | |
| |Supplements: | |
| | | |
| | | |
| |Food Consistency: Reg / Ground / Soft / Pureed | |
| |Liquid Consistency: Regular / Nectar / Honey | |
| |Restrict / Encourage Fluids: | |
| |7-15______ 15-23_______ 23-07_______ |Monitor / Telemetry: |
| |Food Allergies / Restrictions: | |
|Brace / Splint / Cast / Sling |Gastrointestinal: |Respiratory: |
|Immobilizer | | |
|CPM: |Gastroccult / Hemoccult |O2: |
|TEDs: Thigh High / Knee High |#1_____ #2_____ #3_____ | |
|SCDs / Compression Boots |Continent / Incontinent |Breathing Treatments: |
|Popliteal Wedge / Abductor Pillow |Bowel Program: | |
|Prafo Boots / Diabetic Shoes |Toilet / BSC / Diaper / Bedpan |CPT: |
|Aqua-K Pad / Corn Bag / Ice |Last BM: |Incentive Spirometer: |
| Activity: |Continent / Incontinent |Intake & Output: |
|Wt Bearing: |Bladder training: |Height: |
|Transfers: |Bladder Program: |Weight: |
|Mobility: |Bladder Scan: |Shower: |
|Repositioning: |Foley / Voids | |
| |Toilet / BSC / Diaper / Bedpan / Urinal | |
| |Dialysis: | |
|Restraints: |Lab: |IV: |
| | | |
|Fall Hx: |Nurse Draw / Lab Draw |Pill Swallowing: |
|Fall Risk: |FSBS: |Whole / Halved / Crushed |
|Low / Medium / High | |With Water / In Applesauce / In Pudding |
| |SSI: None / Low / Medium / High / VH / Other |All at Once / Few at a Time / One at a Time |
|Wound #1 |Wound #2 |Wound #3 |
| | | |
|Drsg Changes: |Drsg Changes: |Drsg Changes: |
|Nursing / Drsg Cart / Therapists |Nursing / Drsg Cart / Therapists |Nursing / Drsg Cart / Therapists |
|Saline / Betadine / Chlorhexadine |Saline / Betadine / Chlorhexadine |Saline / Betadine / Chlorhexadine |
|Silvadene / Bactroban / Neosporin |Silvadene / Bactroban / Neosporin |Silvadene / Bactroban / Neosporin |
|Island / Gauze / Kerlix / Wet to Dry / Tegaderm |Island / Gauze / Kerlix / Wet to Dry / Tegaderm |Island / Gauze / Kerlix / Wet to Dry / Tegaderm |
|Duoderm / Tape Allergy / Betadine Allergy |Duoderm / Tape Allergy / Betadine Allergy |Duoderm / Tape Allergy / Betadine Allergy |
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