USD Healthcare Center

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1 Sally Nelson DOB: 11/29/1941 HCP: Dr. Winters Age: 68 yrs. Height: 67 in. (170 cm) Weight: 145 lbs. (65.9 kg.) MR# PCS62800 Gender: F No Known Allergies Allergies & Sensitivities PCN, Sulfa Diagnosis: Pancreatic Mass Date Time PHYSICIAN ORDER AND SIGNATURE DAY OF SURGERY 1100 Admit to surgical unit for Dr. Winters Post-op exploratory laparotomy Vital signs every 4 hours Foley catheter to straight drainage Intake & output and daily weight IV: D5 0.45% NS with 20 meq KCL at 125 ml/hr Sequential compression pumps when in bed or TED hose NPO may have sips of water; no more than 30 ml per hour TCDB every 2 hours; incentive spirometer every 1 hour Progressive ambulation Call physician for: HR greater than 100 or less than 60; RR greater than 25 or less than 10; Temp greater than 38.5 C; Pain greater than 4/10 on current meds; Urine output less than 60 ml in 2 hours; SpO2 less than 90% Reinforce dressing PRN Medications: 1. Morphine sulfate per PCA. See PCA order sheet for dosing and assessment protocol. 2. Lorazepam (Ativan) 0.5 mg IV push every 6-8 hours PRN anxiety 3. Prochlorperazine (Compazine) 5 mg IV every 8 hours PRN severe nausea or POSTOP DAY 1 vomiting 0400 Discontinue morphine PCA Initiate hydromorphone hydrochloride (Dilaudid) PCA. See PCA order sheet for dosing and assessment protocol. Diphenhydramine hydrochloride (Benadryl) 10 mg IM PRN itching Discontinue morphine PCA Initiate hydromorphone hydrochloride (Dilaudid) PCA. See PCA order sheet for dosing and assessment protocol. Diphenhydramine hydrochloride (Benadryl) 10 mg IM PRN itching PHYSICIAN/PROVIDER SIGNATURE 1

2 Physician s Order Name: Physician: DOB: Age: Sex: MR Number: Date / Time Physician Orders Patient: DOB 00/00/00 HCP: MR #: Date / Time Physician Orders Patient: DOB 00/00/00 HCP: MR #: Date / Time Physician Orders Patient: DOB 00/00/00 HCP: MR #: 2

3 Admitting Dx: Pancreatic Mass Weight: 65.9 kg Allergies: Penicillin, Sulfa Sally Nelson DOB: 11/29/1941 Medical Record Number: PCS62800 HCP: Dr. Winters SCHEDULED & PRN MEDICATIONS N=NPO V=NAUSEA/VOMITING R=REFUSED H=HELD O=OFF-UNIT C=SEE CHART START STOP MEDICATION Morphine Sulfate PCA: basal rate 2 mg/hr; bolus dose 0.5 mg; 15 minute lockout; limit of 4 mg/hr Lorazepam (Ativan) 0.5 mg IV push every 6-8 hours PRN anxiety Perchlorperazine (Compazine) 5 mg IV push every 8 hours PRN nausea/vomiting Diphenhydramine hydrochloride (Benadryl) 10 mg IM PRN itching Hydromorphone hydrochloride (Dilaudid) PCA: basal rate 0.1 mg/hr; bolus dose 0.1 mg; 15 minute lockout; limit of 0.5 mg/hr Initials Legal Signature/Title Property of USD Healthcare Center 3

4 Nursing Assessment Flowsheet Date: Assessment 7AM 7PM Neurological/ Alert when awake Sensory Oriented X 3 Cardiovascular/ Peripheral Vascular Heart sounds regular Sinus tachycardia Capillary refill < 3 sec. Homan s sign negative Respiratory Lungs clear; diminished in bases Incentive spirometry used with encouragement Abdominal/ Gastrointestinal Surgical dressing dry and intact over midline incision. Small amount pink drainage on underlying gauze Bowel sounds absent Urinary Genitalia Foley to dependent drainage Clear, yellow urine Output > 40 ml per hour 4

5 Musculoskeletal Compression stockings on lower extremities Moves all extremities X 4 to command Integumentary Midline abdominal incision with staples IV intact in L wrist; no swelling or redness; denies discomfort Pain C/O sharp, burning pain in abdomen radiating to back. Rates between 2 & 8 Psychological/Social Patient Learning Needs Daughter, Jane, at bedside Distraught over diagnosis; some denial noted 5

6 CBC with Differential Sally Nelson DOB: 11/29/41 Medical Record Number: PCS62800 Dr. Winters Allergies: Sulfa, Penicillin, sensitive to IV morphine Date Test Normal Patient CBC Hct (M) 40-50% (F) 35-45% Hbg. (M) g/dl (F) g/dl RBC (M) m/mm3 (F) m/mm3 MCV µm3 MCH pg MCHC g/dl WBC (M)5,000-10,000/mm3 Neutrophils 50-70% 6

7 Eos <4% Basos <2% Lymphs 20-40% Monos 2-10% PLT ESR 150, ,000/mm3 (M) <15 mm/h (F) <20 mm/h 7

8 Patient Name: DOB: Medical Record Number: HCP: USD Healthcare Center Complete Metabolic Panel Date CMP Normal Patient Na meq/l K meq/l Cl meq/l Mg meq/l Glucose mg/dl BUN MG/DL Creatinine MG/DL Calcium 9-11 MG/DL Total Protein Albumin GM/DL GM/DL 8

9 INTAKE and OUTPUT Beverage cup 200 ml Glass, juice 120 ml Glass, water 200 ml Broth 120 ml Cream soup 240 ml Gelatin 120 Creamer 10 ml Ice cream/sherbet 90 ml Ice cubes 1 cup 120 ml Milk carton 240 ml Pop small can 240 ml Pop regular can 360 ml Popsicle (whole) 74 ml Syrup 30 ml Time Intake ( ) Time Intake ( ) Time Intake ( ) Total PO: Total IV: Total PO: Total IV: Total Total Total Total PO: Total IV: Time Output ( ) Time Output ( ) Time Output ( ) Total Urine: Stool: color, character, amount Drain(s): Total Urine: Stool: color, character, amount Drain(s): Total Urine: Stool: color, character, amount Drain(s): Total Total Total 9

10 Patient Information Card USD Healthcare Center Patient Name: Diagnosis: History: Type of operation: Height: Weight: Consultation: Age: Gender: Physician: Advanced directives: Diet: Fall precautions: Restraints: Isolation precautions: Allergies: Unit: Support person: Phone contact: Immunization status: Monitoring: I/O VS q _2_hours Telemetry SpO 2 q Neuro checks Neurovascular Blood Glucose Level q 1 hr b c d e Drains: Foley cath Nasogastric tube Wound drain Feeding tube Chest tube Dressing change Medication: _X_IV access _X_IV fluid ml/hr Regular insulin Oral medications prescribed IV medications prescribed IM/SQ medications prescribed Respiratory: Incentive Spirometry O 2 Nasal cannula Oxygen mask Nonrebreather mask Ventilator Nebulizer Activity of Daily Living: Independent Assisted Assistive devices Total care Diagnostic studies Lab X-ray Rhythm strip Telemetry 12 lead EKG CT scan/mri Social History: Teaching needed: Discharge Planning: 10

11 IV Flow Sheet Patient: Gender: HCP: DOB: Diagnosis: MR#: Date & Time Site IV Cath Solution Rate Site Lido 11

12 Nursing Care Flow Sheet Patient: Gender: HCP: DOB: Diagnosis: MR#: Date/Time Nurse s Notes 12

13 Nursing Assessment Flowsheet Assessment 7 AM 7 PM Neurological/ Sensory Cardiovascular/ Peripheral Vascular Respiratory Abdominal/ Gastrointestinal Urinary Genitalia Musculoskeletal Integumentary Pain Psychological/Social Patient Learning Needs 13

14 TELEPHONE NUMBERS HCP: Laboratory Radiology Pharmacy Respiratory Therapy Family: 14

15 Nurses Shift Summary Report (Example) Patient: Age: Sex: MR# Date: Physician: Nurse to Physician Communication: **S Primary Diagnosis: Past Medical History: **B Story of Diagnosis: Where patient came from: Fall Risk: Level of assistance Isolation: Shower/Comfort/Bath: Dentures/Hearing Aides: **A Pain Assessment WNL? Y/N Neurological Assessment WNL? EENT Assessment WNL? Cardiac Assessment WNL? Circulatory Assessment WNL? Respiratory Assessment WNL? Musculoskeletal Assessment WNL? Integumentary Assessment WNL? GI Assessment WNL? Genitourinary Assessment WNL? ** R Anticipated Discharge Date:?? Discharge Disposition:? Any Special Needs: 15

16 ** Nurse to Nurse Communication: (Any abnormal or critical labs, procedure follow-up, MD calls, etc.) Nurse Name: Initials: Nurse Typ 16