The following are some of the common forms that will be used across a variety of scenarios as you review the nursing chart during the simulation lab.

Transcription

1 The following are some of the common forms that will be used across a variety of scenarios as you review the nursing chart during the simulation lab.

2 CARPLAN No Known Allergies Level of support: ADLs Health Challenges: Hypertension Atrial Fibrillation Medications: Hydrochlorothiazide 25mg orally daily ASA 81mg orally daily Digoxin 0.25 mg orally daily Warfarin (Coumadin) 2 mg orally daily See MAR for PRNs ADLS: Provide encouragement 1P set-up with minimal assistance with personal hygiene Mobility: Wheelchair to mobilize with RoHo cushion One-person assistance pivot with transfer belt Cane Dressed and in wheelchair for all meals Rehabilitation at 1030 Occupational therapy at 1400 Nutrition: Set up breakfast with minimal assistance during meals Breakfast in room all other meals in dining room Communication: nglish Fall Risk: Risk for falls Safety: wear hip protector, non-slip socks or slippers Call bell attached to the wall and pinned to the bed

3 HALTH CAR PROVIDR ORDRS No Known Allergies Allergies & Sensitivities Diagnosis: Not yet diagnosed Date Time Health Care Provider Orders and Signature Feb 14, Cardiac Diet as tolerated Vital Signs once a week Hydrochlorothiazide 25mg orally daily ASA 81mg orally daily Digoxin 0.25 mg orally daily Warfarin (Coumadin) 2 mg orally daily Activity as tolerated Refer to PT Refer to OT INR every Thursday and call MD with results Dr. Stevenson Sep 15, Acetaminophen mg po PRN Docusate Sodium 200mg po PRN Dr. Stevenson

4 History and Diagnostic Studies Month 02 Day 15 Year 2016 PMHx Hypertension, Atrial Fibrillation Diagnosis: Not yet diagnosed Social Hx Born in ngland Retired Nurse at the age of 55. Marital status Support system Leisure activities Smoking and Alcohol use Behaviour Physical xam Plan Married No children. The couple has lived in the same house since they got married. Has many friends in the neighbourhood njoys sewing and gardening Non-smoker, A glass of wine once in a while Flat affect, withdrawn Irregular heart rate atrial fibrillation Transition to home Dr. Stevenson

5 MDICATION ADMINISTRATION RCORD Diagnosis: Not yet diagnosed Allergies: NKDA MDICATION Dosage Route Frequency Scheduled Medications DAT: February 15, 2016 TODAY Time of Administration: Hydrochlorothiazide 25mg orally daily ASA 81mg orally daily Digoxin 0.25 mg orally daily Warfarin (Coumadin) 2 mg orally daily PRN Medications 0800 LT RN 0800 LT RN 0800 LT RN 1700 Time of Administration: Acetaminophen mg q 4h orally PRN Docusate Sodium 200mg orally PRN Dimenhydrinate (Gravol) 25-50mg q4h orally PRN mg LT RN

6 INTAK OUTPUT 12 HOUR RCORD (ALL MASURMNTS IN ML S) DAT: Feb 15, 2016 DAYSHIFT INTAK: INCLUDS MINIBAGS, FLUSHS, IC CHIPS, BLOOD PRODUCTS TIM START SOLUTION AND ADDITIVS RAT (ml/hr) AMOUNT START TIM STOP TOTAL IV IN ORAL FD INITIALS IV STARTS (TIM, SIZ, SIT, # ATTMPTS, INITIALS) 12 HOUR CUMMULATIV INTAK DAYSHIFT TOTALS OUTPUT: URIN, STOOL, RSIDUALS, CHST TUBS, PIGTAILS, WOUND DRAINS TIM START URIN CATHTR VOIDD INCT GASTRIC RSIDUAL MSIS NG STOOL DRAINS INITIALS STANDARD VOLUMS OSTOMY LT RN SOUP BOWLS 180 ml DAYSHIFT TOTALS 12 HOUR CUMMULATIV OUTPUT INSULATD MUG CRAMR STYROFOAM CUP ICCRAM, JLLO POPSICL TTRAPACK JUIC/MILK PORTIOND JUIC/MILK POP CANS PRBC PLASMA PLATLTS 180 ml 15 ml 180 ml 120 ml 75 ml 235 ml 120 ml 335 ml 350 ml 200 ml 50 ml/ unit

7 NURSS NOTS/PROGRSS NOTS Month 02 Day 15 Year 2016 Time vent Details Diagnosis: Not yet diagnosed 0100 Nausea States she's nauseated. Vomited 100ml clear fluid at Antiemetic given as per orders. LTRN 0130 Nausea Reports no further nausea. No further vomiting. LTRN

8 VITAL SIGNS RCORD YAR: 2016 Client Name: Age: DOB: PHN: MONTH: Feb DAY: 15 TIM: 1200 T M P ORAL R RCTAL A T U R AXILLA X B L O O D P R S S U R & P U L S SYSTOLIC Lying v Standing x Sitting DIASTOLIC Lying ^ Standing x Sitting v ^ BP LOCATION - RA, LA LA PULS LOCATION - A, R R PULS RHYTHM - R, IR R RSPIRATION RAT 16 O 2 SATURATION 97 O 2 RA / L/min / % RA O 2 MODALITY O 2 SAT ACTIVITY sitting WIGHT Kg 65 INITIALS SG

9 Activities of Daily Living (ADL) Bedside Care Plan Name Preferred Name Allergies Room Number: Safety Alerts Fall Precautions Hip Protector: Type Size Bed Alarm Chair Alarm Non-slip Socks Fall Mat(s) Low Bed/Knee Height Risk of Choking Nothing by Mouth/Tube Feed Thickened Fluid Pureed Food Risk of Leaving Restraint/Safety Other Risk Special Precautions: Type: Wheelchair Seat Belt Side Rails: Upper R Upper L Lower R Lower L Frequency of Safety Checks: Repositioning Schedule: Special Precautions: Independent Partial Assist Full Assist Communication Verbal Non-Verbal; Language: Best approach: Hearing Aid: R L Dentures: Y N Glasses: Y N Transfers 1 person 2 person Repositioning Mobility Standing Transfer Transfer Belt Supervision Only Transfer Pole Slider Sheet Positioning Sling Tri-Turner Sling Mobility Aids: Reviewed: OT PT Continence Routine: Days Nights Bathing Bath Shower Wash Hair Y N Routine: Dressing & Grooming Skin Care Oral Care Dining Diet Type: Texture: Fluids: Special Utensils: Routine: Sleeping Wake Up Time: Nap Time: Bedtime:

10 Spiritual & Cultural Respiratory Special Interests & Activities Mon Tues Wed Thurs Fri Sat Sun