Dx

Lab blood draw Transfusion OT/PT/RT Fall/aspiration/hip prctn Pain ( ) CSM ( ) SCD IS Diet ( ) Flatus/BM Incont/ FC Future procedure D/C plan + Flu/PNA, test reading Asst max/mod Discharge date______

MD notes __________ POD#

I V L o c a t i o n / T y p e / R a t e / V e r if y ? I V / R a t e : P a i n ( L a s t T i m e ) / F U p / S c

I Problem/POC/L ast RN notes 0800 VS 1200 VS

New Orders

o r e

A T C Day PMH

All
F/DNR

Day PMH

All
F/DNR

Dx

MD notes __________ POD#

Lab OT/PT/RT blood draw Transfusion Fall/aspiration/hip prctn Pain ( ) CSM ( ) SCD IS Diet ( ) Flatus/BM Incont/ FC Future procedure D/C plan + Flu/PNA, test reading Asst max/mod

I V L o c a t i o n / T y p e / R a t e / V e r if y ?

iv /Rate: Pain Time/FUp /Score

Problem/POC/L ast RN notes 0800 VS 1200 VS

ATC

New Orders

MED

Day PMH

All
F/DNR

Dx

MD notes __________ POD#

Lab OT/PT/RT blood draw Transfusion Fall/aspiration/hip prctn Pain ( ) CSM ( ) SCD IS Diet ( ) Flatus/BM Incont/ FC Future procedure D/C plan + Flu/PNA, test reading Asst max/mod

I V L o c a t i o n / T y p e / R a t e / V e r if y ?

iv /Rate: Pain Time/FUp /Score ATC

Problem/POC/L ast RN notes 0800 VS 1200 VS

New Orders

MED

Day PMH

All
F/DNR

08 PCA check ? Verif y+do c Check pump clear calcul ate tot volum

e. Doc in flow sheet 09 10 11 12 13 14 15

16 17 18 19 VS/NE URO Afebri le, AO, lgg NV Csm intact . No neuro defici t CARD IO Denie s CP RESP CDB

IS LSCT A even unlab ored? dimin ished GI/GU Flat, BM since, tolera te diet FC, color lasix SKIN Site of incisi on stapl e, red, swell, drain, JP MOBI LITY PT, pain? Refus e to ambu late. Actifi ty most of the shift. Amb to hall/n urse st with mod/ max asst. impor tance of ambu lation reinfo rced

PAIN Mana ged with Non phar mace utical appro ach

__ mg/_ _ min

__ mg/__ min

_ _ m g / _ _ m i n

__mg/__ min

IV patent Follow up

This week goal Flexicare Haldon and impulsivity PNA >65 Ace wrap Methadone Bacloven How dod you know how much PCA is given- just curious Talk to charge nurse

Progress Note: Date: Time

DATA REVIEW

NURSING: MD: LAB results

VS: Neuro: A&Ox__, alert, pleasant, cooperative, confused, apprehensive, withdrawn, agitated, lethargic, PERLA NV checks: CSM intact, no neuro deficits, numbness Cardio: Heart rhythm regular, denies CP, Pulses present (Radial Femoral pedal, post tib) Edema, diaphoretic Respiratory: LSCTA diminish (loc: productive/non productive. ), breathing is even and unlabored, crackles, rhonci, wheezes, dyspnea. Cough

GI/GU: BS hypo present non, flatus, BM, LBM ____ abd: flat, soft, distended, tender. Denies N/V. tender Voiding via urinal/BR. DTV Reports appetite poor, fair. Tolerate reg/CL diet. Skin: Warm, CDI, dressing intact (, reddened, integrity impaired, bruise, ecchymotic areas Mobility/Precautions: OOB ad lib ambulating in room and took 2 long walks with his mom around the hospital OOB ad lib ambulating in room and took 2 long walks with his mom around the hospital Treatment Team: Tt Pamf Med 4, Pgr 23434 Pain: managed with Meds ATC/PRN POLast shift given/lvl Time/Pain lvl Follow up T/P POPOIVIVPCA-

Non pharma Time/Pain lvl Follow up T/P Non pharma Time/Pain lvl Follow up T/P Non pharma Time/Pain lvl Follow up T/P Non pharma

contact

reason

documented

Problem based on acuity English

Plan See what is required-WST website.

Follow up

Comments

VS: Neuro: A&Ox__, alert, pleasant, cooperative, NV checks: CSM intact, no neuro deficits Cardio: WNL, denies CP Respiratory: LSCTA, breathing is even and unlabored GI/GU: +/-BS, +/- flatus, LBM ____ abd: flat, soft, distended, tender. Denies nausea today. Voiding via urinal/BR tender to palpation over pubic symphysis. Reports some improvement with appetite. +BS, +flatus, LBM 2/20, abd flat, soft, tender to palpation over pubic symphysis. Reports some improvement with appetite. Denies nausea today. Voiding via urinal/BR Skin: Warm, dry and intact Mobility/Precautions: OOB ad lib ambulating in room and took 2 long walks with his mom around the hospital OOB ad lib ambulating in room and took 2 long walks with his mom around the hospital Treatment Team: Tt Pamf Med 4, Pgr 23434 Pain: Lower abdominal/groin pain managed with

1 Norco and Ms Contin 15mg Q12hrs, has not needed to use Dilaudid PCA today. Other: Mom with pt all day today, Dad to spend the night. Very supportive and helpful Mom with pt all day today, Dad to spend the night. Very supportive and helpful Lower abdominal/groin pain managed with 1 Norco and Ms Contin 15mg Q12hrs, has not needed to use Dilaudid PCA today. Other: Mom with pt all day today, Dad to spend the night. Very supportive and helpful Mom with pt all day today, Dad to spend the night. Very supportive and helpful IV/Drains: NS@ 25cc/hr for PCA. New IV placed today in R AC NS@ 25cc/hr for PCA. New IV placed today in R AC IV tubing last changed: Patient's condition has changed/not changed since last shift: Follow up items: Per MD note, waiting for final result of BC before placing PICC line for pt to go home with IV ABX Per MD note, waiting for final result of BC before placing PICC line for pt to go home with IV ABX Patient's condition has changed/not changed since last shift: Follow up items: Per MD note, waiting for final result of BC before placing PICC line for pt to go home with IV ABX Per MD note, waiting for final result of BC before placing PICC line for pt to go home with IV ABX Non-urgent issues for the MD to address in the next shift: Date: 2/21/2012 Shift: 7A-11P S/P I&D and Revision R THA POD #7 Primary issue(s) this shift: Blood transfusions, increased mobility, discharge planning Blood transfusions, increased mobility, discharge planning VS: BP 111/62 | Pulse 74 | Temp(Src) 37.4 C (99.3 F) (Oral) | Resp 18 | Ht 1.829 m (6') | Wt 136.079 kg (300 lb) | BMI 40.69 kg/m2 | SpO2 94% Neuro: A&Ox3, pleasant Neuro: A&Ox3, pleasant NV checks: +ppp, +d/p flexion, denies n/t BLE. Feet warm and pink, brisk cap refill +ppp, +d/p flexion, denies n/t BLE. Feet warm and pink, brisk cap refill Cardio: WNL, denies chest pain, denies dizziness when OOB WNL, denies chest pain, denies dizziness when OOB Respiratory: LSCTA, breathing is even and unlabored. O2 sat >94% RA

LSCTA, breathing is even and unlabored. O2 sat >94% RA GI/GU: +BS, +flatus through colostomy, tolerating regular diet with good appetite, denies nausea. Very small amt of liquid brown stool noted from colostomy- pt has been declining stool softeners and laxatives 2/2 increased ostomy output 2 days ago. Pt has agreed to resume taking stool softener but continues to decline laxative. Abd round but soft and non-tender. Voiding via urinal QS clear yellow urine +BS, +flatus through colostomy, tolerating regular diet with good appetite, denies nausea. Very small amt of liquid brown stool noted from colostomy- pt has been declining stool softeners and laxatives 2/2 increased ostomy output 2 days ago. Pt has agreed to resume taking stool softener but continues to decline laxative. Abd round but soft and non-tender. Voiding via urinal QS clear yellow urine Skin: R hip drsg with dry gauze, C/D/I. Small amt erythema noted around incision site. Pt with multiple dried scabs to BUE from scratching/dry skin- moisturizer applied, benadryl given for itch R hip drsg with dry gauze, C/D/I. Small amt erythema noted around incision site. Pt with multiple dried scabs to BUE from scratching/dry skin- moisturizer applied, benadryl given for itch Mobility/Precautions: OOB with PT using the Sabina, hip abduction brace on when OOB. Weak LEs, unable to bear weight. Pt states he is w/c bound at home. SCDs to BLE, Lovenox for VTE prophylaxis OOB with PT using the Sabina, hip abduction brace on when OOB. Weak LEs, unable to bear weight. Pt states he is w/c bound at home. SCDs to BLE, Lovenox for VTE prophylaxis Pain: Reports constant dull pain to R hip- medicated with Oxycontin 10mg Q12hrs and Roxicodone 10-20mg Q4hrs PRN Reports constant dull pain to R hip- medicated with Oxycontin 10mg Q12hrs and Roxicodone 10-20mg Q4hrs PRN Other: Hct 21.1, dizzy when OOB with PT yesterday so 2 units of PRBCs ordered and transfused without incident. Hct 21.1, dizzy when OOB with PT yesterday so 2 units of PRBCs ordered and transfused without incident.BP 111/62 | Pulse 74 | Temp(Src) 37.4 C (99.3 F) (Oral) | Resp 18 | Ht 1.829 m (6') | Wt 136.079 kg (300 lb) | BMI 40.69 kg/m2 | SpO2 94% Neuro: A&Ox3, pleasant A&Ox3, pleasant NV checks: +ppp, +d/p flexion, denies n/t BLE. Feet warm and pink, brisk cap refill +ppp, +d/p flexion, denies n/t BLE. Feet warm and pink, brisk cap refill Cardio: WNL, denies chest pain, denies dizziness when OOB WNL, denies chest pain, denies dizziness when OOB Respiratory: LSCTA, breathing is even and unlabored. O2 sat >94% RA LSCTA, breathing is even and unlabored. O2 sat >94% RA

GI/GU: +BS, +flatus through colostomy, tolerating regular diet with good appetite, denies nausea. Very small amt of liquid brown stool noted from colostomy- pt has been declining stool softeners and laxatives 2/2 increased ostomy output 2 days ago. Pt has agreed to resume taking stool softener but continues to decline laxative. Abd round but soft and non-tender. Voiding via urinal QS clear yellow urine +BS, +flatus through colostomy, tolerating regular diet with good appetite, denies nausea. Very small amt of liquid brown stool noted from colostomy- pt has been declining stool softeners and laxatives 2/2 increased ostomy output 2 days ago. Pt has agreed to resume taking stool softener but continues to decline laxative. Abd round but soft and non-tender. Voiding via urinal QS clear yellow urine Skin: R hip drsg with dry gauze, C/D/I. Small amt erythema noted around incision site. Pt with multiple dried scabs to BUE from scratching/dry skin- moisturizer applied, benadryl given for itch R hip drsg with dry gauze, C/D/I. Small amt erythema noted around incision site. Pt with multiple dried scabs to BUE from scratching/dry skin- moisturizer applied, benadryl given for itch Mobility/Precautions: OOB with PT using the Sabina, hip abduction brace on when OOB. Weak LEs, unable to bear weight. Pt states he is w/c bound at home. SCDs to BLE, Lovenox for VTE prophylaxis OOB with PT using the Sabina, hip abduction brace on when OOB. Weak LEs, unable to bear weight. Pt states he is w/c bound at home. SCDs to BLE, Lovenox for VTE prophylaxis Pain: Reports constant dull pain to R hip- medicated with Oxycontin 10mg Q12hrs and Roxicodone 10-20mg Q4hrs PRN Reports constant dull pain to R hip- medicated with Oxycontin 10mg Q12hrs and Roxicodone 10-20mg Q4hrs PRN Other: Hct 21.1, dizzy when OOB with PT yesterday so 2 units of PRBCs ordered and transfused without incident. Hct 21.1, dizzy when OOB with PT yesterday so 2 units of PRBCs ordered and transfused without incident. IV/Drains: NS with 20mEq KCL@25cc/hr infusing through L upper arm PICC- stopped during blood transfusions. Intra articular PICC to R hip capped- used by MD for daily Dapto admin into joint space. Pt also receiving IV Dapto daily. Hemovac with small amt serosang drng NS with 20mEq KCL@25cc/hr infusing through L upper arm PICC- stopped during blood transfusions. Intra articular PICC to R hip capped- used by MD for daily Dapto admin into joint space. Pt also receiving IV Dapto daily. Hemovac with small amt serosang drng IV tubing last changed: Patient's condition has changed/not changed since last shift: Follow up items: Ostomy RN unable to see pt today but needs to see pt tomorrow AM. D/c to Manor Care in AM Ostomy RN unable to see pt today but needs to see pt tomorrow AM. D/c to Manor Care in AM Patient's condition has changed/not changed since last shift: Follow up items: Ostomy RN unable to see pt today but needs to see pt tomorrow AM. D/c to Manor Care in AM

Ostomy RN unable to see pt today but needs to see pt tomorrow AM. D/c to Manor Care in AM Non-urgent issues for the MD to address in the next shift: