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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