Scribd Logo
Upload

Welcome to Scribd!

  • 2K views

    Brain 9

    Uploaded by

    Nurse Betty
    This document summarizes a patient's information including their age, gender, diagnosis, allergies, activity level, IV access and fluids, pain medications, vital signs, labs, notes, and medical history. It provides instructions for oxygen, nebulizer treatments, diet, weight, bathroom needs, consultations, stool tests, precautions, and blood sugar monitoring. The patient has a DNR order.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Brain 9

    Uploaded by

    Nurse Betty
    2K views1 page
    This document summarizes a patient's information including their age, gender, diagnosis, allergies, activity level, IV access and fluids, pain medications, vital signs, labs, notes, and medical history. It provides instructions for oxygen, nebulizer treatments, diet, weight, bathroom needs, consultations, stool tests, precautions, and blood sugar monitoring. The patient has a DNR order.

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document summarizes a patient's information including their age, gender, diagnosis, allergies, activity level, IV access and fluids, pain medications, vital signs, labs, notes, and medical history. It provides instructions for oxygen, nebulizer treatments, diet, weight, bathroom needs, consultations, stool tests, precautions, and blood sugar monitoring. The patient has a DNR order.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    2K views1 page

    Brain 9

    Uploaded by

    Nurse Betty
    This document summarizes a patient's information including their age, gender, diagnosis, allergies, activity level, IV access and fluids, pain medications, vital signs, labs, notes, and medical history. It provides instructions for oxygen, nebulizer treatments, diet, weight, bathroom needs, consultations, stool tests, precautions, and blood sugar monitoring. The patient has a DNR order.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 1

    RM# _______ PT: ____________________ age: ____ M / F Dr.

    __________________
    DX: ________________________________________diet: ________________ d/weight
    Allergies: ______________________________________________________________
    O2 : _____ nebs

    activity: ad lib / bed rest / in chair / PT / walker / assist x

    IV fluids: __________________________ access: ______________ PCA (dem / morph)

    DNR

    pain meds (last dose?): _____________________________________________

    voids: BRP / foley / BSC / urinal / diaper


    UA / C&S (need / done)

    SNF / rehab consult (need / done)

    stool x ___ for guiac / c-diff / WBC

    precautions: contact / fall / seizure / aspiration (HOB ___ ) / neuro


    FSBS: ac&hs / q ___ hrs / SS: regular insulin / Novolog
    2100: ____________ 0730: ____________ 1130: ____________ 1630: _____________
    labs: CBC / __MP / CE / BNP / Mag / Phos / K / Lytes / H&H / PT/INR / PTT / ________
    CXR / EKG / Echo / MRI / US / CT _____________________ permit? Y / N list? Y / N
    VS 0600 T ______ P ______ R ______ BP ____________ O2 ______
    _____ T ______ P ______ R ______ BP ____________ O2 ______
    Notes:_________________________________________________________________
    ______________________________________________________________________
    ______________________________________________________________________
    ______________________________________________________________________
    Hx : __________________________________________________________________
    Labs:
    Na: _________
    K: __________
    BUN: ________
    Creat: _______
    WBC: _______
    H/H: ________
    Plat: ________

    You might also like