Room #: ________ MRN: __________________ Weight: _______kg Age: _____ Date: ______________

Patient Name: _______________________________ Code Status: ___________ Allergies: _____________________

Isolation: ___________________ Date of Admission: _______________________________________________

Admit Dx: ___________________________________________________________________________________

PMHx: _____________________________________________________________________________________
_____________________________________________________________________________________

Labs:
Neuro:
A&Ox___ Eyes: ___________ Cough/Gag: _______ Restraints: ____________ WBC: _____ 4.5-11
Pain Issues: ____________________ Meds Last Given: __________________ Hgb: _____ 12-16 13-18
Sedation: ____________________________________ Neuro Checks Q ___hrs Hct: _____ 36-46 37-49
Plts: _____ 100-450
CV: Na+: _____ 135-145
Rhythm: ______ HR: ______ MAP: _____ Systolic: _______/Diastolic: _______ K+: _____ 3.5-5.2
Pulses: UE ___/___, LE ___/___ Edema: UE ___/___, LE ___/___ T-Max: ______ Cl-: _____ 95-107
Access: #1 ________ #2 ________ #3 ________ #4 ________ #5 ________ CVP: _____
Mg: _____ 1.6-2.4
Phos _____ 2.4-4.1
Resp:
Ca+: _____ 8.8-10.3
Natural/#__ ETT/Shiley/Bivona ___@ Teeth/Lip O2: RA/NC/Mask/TC/Vent/BiPAP/CPAP
Vent Settings: ________ FiO2: _____% Rate: _____ PEEP: _____ TV: _____ i Ca+: _____ 2.24-2.46
Breath Sounds: _______/________ Secretions: _______________ Suction Q ___ BUN: _____ 7-20
Resp Rate: _____ SpO2: _____% Creat: _____ 0.5-1.4
Chest Tube: R/L Water Seal/Suction Drainage: ____________ OP Last Shift: _____ PT: _____ 10-12
PTT: _____ 30-45
GI: INR: _____ 1-2
NPO R/L NGT OGT PEG G-J Keofeed LIWS PO Diet: __________________
TF Type: __________ ml/hr: _____ H 2O Boluses: ____mls Q ___hrs Prosource: _____pkts ABG:
TPN: _____ml/hr Lipids: _____ml/hr pH: _____ 7.35-7.45
Rectal Bag/Rectal Tube/Flexiseal pCO2: _____ 35-45
Fingersticks Q ___hrs/ACHS pO2: _____ 70-100
HCO3: _____ 19-25
GU:
Foley/Texas Cath/Bedpan/Urinal/Bedside Commode/Diaper Plan: To Do:
Color: __________ +/- _______mL Last Shift o Careplan
Dialysis: _______________________
o Morse Falls Risk/Restraint
o Education
Skin:
#1: ________________________________________ Drips: o Restraint Order UTD
#2: ________________________________________ ________________ o ______________________
#3: ________________________________________ ________________ o ______________________
#4: ________________________________________ ________________ o ______________________
Wound Care Consulted? Yes/No ________________ o ______________________
________________ o ______________________
5Ps/Family: ________________ o ______________________

0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800
 7S Needs and Guidelines

1. 6:45 AM report groups in break room

2. 7am work up your pt, you get 30 minutes--- divide skills
3. 8am get vitals, be ready pass meds (perform any focused assessment for meds)
4. Full assessments with neuro assessment as well as rest of day as outlined below
5. Code was given and have on hand

Assessments to be done every 4 hours:

1. Neuro assessment,
2. complete assessment,
3. Vitals

Every 1 hour a bedside 5Ps:

1. Call lights
2. Bed down
3. Pain
4. Toileting needs
5. Other needs

Make sure bed alarms are always on, bed lowered.

1. Reports all abnormal vitals finding to primary RN and instructor
2. No IV pushes
3. Remember top chart I&Os ----SO IMPORTANT