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Nursing Report Sheet

This document contains a patient's medical information including codes, isolation status, physician notes, vital signs, past medical history, admission diagnosis, pulmonary status, gastrointestinal/genitourinary status, diagnostics, labs, and care plan.

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sarah
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434 views2 pages

Nursing Report Sheet

This document contains a patient's medical information including codes, isolation status, physician notes, vital signs, past medical history, admission diagnosis, pulmonary status, gastrointestinal/genitourinary status, diagnostics, labs, and care plan.

Uploaded by

sarah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Full Code DNR Meds DNI

Isolation:__________________

Physicians: Neuro: WNL Sedated Confused ACHS Q4 Q6


TOF ___/4 PERRLA Skin: WNL 1900
VTE: SCDS / HEP SQ /
Allergies:
2000 Adult PS EKG
Cardiac: WNL Murmur Edema P:

PMH: HTN COPD CAD Goals: 2100


CHF DM CO:
CI:
sV02: 2200

Rhythm:
CC/DX: Admitted__________ 2300
CO:
CI:
sV02: 0000 Adult PS CHG

LDA: 0100
Pulmonary: WNL NC______ L/min
ETT # @ cm@
Trache # 0200
BiPap ___/___ ___%
Plan:
Mode: Rate: 0300
FiO2: PS:
TV: PEEP:
0400 Adult PS PM Chores
Lung Sounds: Pink Sheet CTS

GI/GU: WNL Diet ______________


Foley_________ml/hr 0500 AM LABS
PEG NGT/OGT _____cm @
Diagnostics/Labs: Feeds____________@________ml/hr Gtts:
0600
Type: Replace:
-pre:
-post: 0700 CP Edu Charges
Bflow: UF:
Dialysate:
Full Code DNR Meds DNI
Isolation:__________________

Physicians: Neuro: WNL Sedated Confused ACHS Q4 Q6


TOF ___/4 PERRLA Skin: WNL 1900
VTE: SCDS / HEP SQ /
Allergies:
2000 Adult PS EKG
Cardiac: WNL Murmur Edema P:

PMH: HTN COPD CAD Goals: 2100


CHF DM CO:
CI:
sV02: 2200

Rhythm:
CC/DX: Admitted__________ 2300
CO:
CI:
sV02: 0000 Adult PS CHG

LDA: 0100
Pulmonary: WNL NC______ L/min
ETT # @ cm@
Trache # 0200
BiPap ___/___ ___%
Plan:
Mode: Rate: 0300
FiO2: PS:
TV: PEEP:
0400 Adult PS PM Chores
Lung Sounds: Pink Sheet CTS

GI/GU: WNL Diet ______________


Foley_________ml/hr 0500 AM LABS
PEG NGT/OGT _____cm @
Diagnostics/Labs: Feeds____________@________ml/hr Gtts:
0600
Type: Replace:
-pre:
-post: 0700 CP Edu Charges
Bflow: UF:
Dialysate:

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