Shift: _________

Charge Nurse: _________________

Staff Nurse: ___________________
ROO
M
#

NAME OF
PATIENT

PHYSICIA
N/S

COMPLAIN
T/S

Date: ___________________________
Total Census: ____________________
Student Nurse:___________________

SUMMARY OF NURSING CARE PLAN

IV FLUIDS
IV #/ IV FLUID/ RATE/ TIME DUE/ HEPLOCK

IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock

VITAL SIGNS
q15/ qh/ q2h/
q4h

INPUT/OUTPUT
qh/ q2h/ q4h/
qS

DIET

LABORATORY

__

Diabetic Diet-

U/A-

__

Soft DietClear Liquid DietNPO-

S/ECBCCBS-

__
__
__

DATNo Dark Colored FoodsSalt Fat Diet-

Executive PanelRenal Panel2D EchoUltrasound-

__

Potassium Diet-

__

Protein Diet-

Culture and Sensitivity-

__

Fiber-

__

BreastfeedingFormula FeedingBrecht FeedingBlenderized Feeding-

Skin TestSputumLumbar TapParacenthesisThoracentesisArthrocentesis-

__

Small Frequent Feedings-

Cardiopulmonary-

__

Limit p.o Feedings-

X-ray-

Limit p.o Fluids-

CT ScanMRI-

__

__

FOR OR/ MOR

__
__
__
__
__
__
__
__
__
__

LEGENDS
L

- left

- right

- with
- without
MHBR- moderate-high back rest
CFCA-consistencym, frequency,
characteristics, amount
WOD- weigh once daily
MDLIT- may dangle legs if
tolerated
DBE- deep breathing exercise
DAT- diet as tolerated
- none

IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock
IV#__,_____@___ due:___
heplock

__
__
__
__
__
__
__

SPECIAL ENDORSEMENTS

TREATMENT

MHBRSuction PrecautionSeizure PrecautionTSBBedside CommodeCFCAS/CFCAV-

Perineal CarePerilight ExposureMech VentCardiac Monitoring-

__

Dressing SetAbdominal Status-

Steam InhalationDBENebulization-

__

WODO2 Inhalation-

Chest TappingTracheostomy Care-

__

24 Urine Collection-

Blood Transfusion-

__

MDLITActive ROMPassive ROM-

Hot/ Cold Application-

__
__
__
__
__
__
__
__
__

Warm Compress-