Patient Name: Millie Larsen

Room: 616
DOB: 01/23/1926
Age: 84

MRN: 000-555-000
Doctor Name: Dr. Eric Lund
Date Admitted:

PATIENT CHART
Chart for Millie Larsen

Physicians Orders
Allergies: NKA
Date/Tim
e:
Day 1, 0900

Bedrest, BRP with assist

Regular, low fat diet
I&0
captopril 25 mg po three times a day
metoprolol 100 mg every day
furosemide 40 mg po twice per day
Lipitor 50 mg once daily
pilocarpine eye drops 2 drops each eye 4 times a day
Fosamax 10 mg every day
Celebrex 200 mg po once a day
tramodol for arthritis pain prn
Ciprofloxacin 250 mg every 12 hours
Acetaminophen 325 mg po prn
IV fluids D5 .45 NaCl 20 mEq KCL at 60ml/hr
Dr.
Eric Lund

Nursing Notes
Date/Tim
e:
National League for Nursing, 2015

0900

Pt Alert and oriented. Denies pain. Pt up and ambulating on won with

minimal assist. Will continue to monitor.
T.
Williams RN

Medication Administration Record

Allergies: NKDA
Date
of
Orde
r:
Day 1

Medication:

Dosag
e:

Rout
e:

Frequenc
y:

Hours to be
Given:

Captopril

25 mg

po

0800, TW 1200
TW,1600 TW

Metoprolol
Furosemide

100 mg
40 mg

Lipitor
Pilocarpine eye

50 mg
2 drops
each
eye
10 mg

three
times a
day
every day
twice per
day
once daily
four times
a day

drops
Fosamax
Tramodol
Ciprofloxacin

250 mg

Acetaminophen
Celebrex

325 mg
200 mg

po

po
po

every day
for
arthritis
pain/prn
every 12
hours
prn
once a
day

Date
s
Give
n:
Day 1

0800 TW
0800 TW, 1600
TW
0800 TW
0800, TW 1200
TW ,1600 TW
2000 SH
0800 TW

Day 1
Day 1

0800 TW, 2000

SH

Day 1

0800 TW

Day 1

Day 1
Day 1
Day 1

Intravenous Therapy
Date of
Order:
Day 3

IV Solution

Rate Ordered:

IV fluids D5 .45 NaCl

20 mEq KCL

60ml/hr

Date/Time Hung:
Day 1, 1200 TW

0400 SH

National League for Nursing, 2015

Nurse Signatures
Initial
TW

Nurse Signature
Terrence Williams, RN

Initial
SH

Intramuscular legend:
A=RUOQ ventrogluteal
B=LUOQ ventrogluteal
C=R Deltoid
D=L Deltoid
E=R Thigh Lateral
F=L Thigh Lateral

Nurse Signature
Scott Hansen, RN, BSN

Subcutaneous site code:

1=RUQ abdomen
2=LUQ abdomen
3=RLQ abdomen
4=LLQ abdomen
5=RU arm
6=LU arm
7=R leg
8=L leg

Vital Signs Record

Date:
Time:
Temperatur
e:
BP:
Pulse:
O2
Saturation:
Weight:
Respiration
s:
GMR:
Nurse
Initials:

Day 3

Day 3

Day
3
1600
37.2

Day
3
2000
37.1

Day
3
0000
37.0

Day
3
0400
37.1

0800
37.2

1200
37.3

130/68

126/70
76
96

1288
0
78
96

132/6
8
72
94

128/7
6
74
94

126/7
4
68
94

80
94
12

14

14

14

10

12

TW

TW

TW

SH

SH

SH

National League for Nursing, 2015

Intake & Output Bedside Worksheet

0900-2100 INTAKE
ORAL
TUBE
IV
FEED
240
720
360
120
240

IVPB

OTHER

ORAL

IV

Other

Drains
Type:

Other

Total Output this shift: 2000

INTAKE
TUBE
FEED

Drains
Type:

500
750
750

Total Intake this shift: 1650

2100-0900

URINE

OUTPUT
Emesis
NG

OUTPUT
IVPB

OTHER

URINE

Emesis

NG

National League for Nursing, 2015

240
480

720

200
400
400
250

Total Intake this shift: 1440

Total Output this shift: 1250

Nursing Assessment Flowsheet

GENERAL APPEARANCE:
male
female
awake
cheerful
crying
fearful

RESPIRATORY:

sleeping
lethargic
calm

agitated
anxious
combative

see nursing notes

RESPIRATIONS:
RATE: 14
O2: RA
SPO2:94%
regular
even
irregular

labored
uses accessory muscles
cough

BREATH SOUNDS:
SKIN:
notes

see wound care sheet

BRADEN SCALE SCORE:

breakdown
COLOR:
acyanotic
pale
ruddy
jaundiced
cyanotic
TEMP:
warm/dry
hot

see nursing
risk skin

TURGOR:
<3 sec
> 3 sec

HAIR:
shiny
dry/flaking

LEFT:
clear
crackles
wheezes
decreased

RIG

absent
THORAX:
even expansion
uneven expansion
SMOKING:
cigarettes pk/day ____________
cigars
marijuana
cocaine

National League for Nursing, 2015

cool
cold/clammy
diaphoretic
NEUROLOGICAL:
ORIENTATION:
person
place
time
RESPONDS TO:
name
stimuli
SPEECH:
clear
garbled
slurred
FACE:
symmetrical
drooping
EYES:
PERRLA
unequal
drooping lid
HEARING:
WNL
HOH
HX:
seizures
CVA
brain injury

balding
lesions
lice
see nursing notes

GASTROINTESTINAL/NUTRITION:
nursing notes

disoriented
confused
impaired memory

APPEARANCE:
flat
round
obese

non-responsive

BOWEL SOUNDS:
active
hypoactive

aphasic
inappropriate
cannot follow
conversation
drooling
SIGHT:
no correction
glasses
contacts
blind
hearing aid

spinal injury
other

PALPATION:
non-tender

see

soft
gravid

hyperactive
absent
mass (location)
_______

tender
(location)______
LAST BM yesterday
incontinent
stoma- _______
constipation

diarrhea
mucous
blood

DIET: normal
impaired swallowing
choking
NG tube
color drainage:______________
feeding tube
tube feeding
type: ______________ rate:_________

National League for Nursing, 2015

MUSCULOSKELETAL:
GAIT:
steady

GENITOURINARY:

see nursing notes

voids
unsteady

ACTIVITY:
up ad lib
walker
cane
crutches
wheelchair
HAND GRIPS:
AMPUTATION:
left
LOCATION:____________
LEFT:
strong
weak
flaccid
contractures
ROM:
ARMS:
full
weak
flaccid
contractures
AMPUTATION:
right
left
SPINE:
kyphosis
scoliosis

see nursing notes

nonambulatory
ASSIST:
x1
x2
lift
bed bound

catheter

APPEARANCE OF URINE:
clear
light yellow
amber
brown

BLADDER:
soft
firm/distended

right
RIGHT:
strong
weak
flaccid
contractures
LEGS:
full
weak
flaccid
contractures
TED hose

cloudy
sediment
red/wine
clots

incontinent

FEMALES: LMP: in the 70s sometime

WNL
BIRTH CONTROL:
yes
no
SEXUALITY:
sexually active

dysmenorrheal

BSE monthly
menopause
taking estrogen
safe sex

MED HX:
urinary retention
BPH
Frequent UTI

BKA
AKA
other
osteoporosis

OTHER:
CAST LOCATION:___________
TRACTION:_____________

National League for Nursing, 2015

CARDIOVASCULAR:

see nursing notes

HEART SOUNDS:
normal S1abnormal S3S2
S4
PULSE:
APICAL:
regular
irregular
strong
faint

murmur

PEDALIS:
regular
irregular
strong
faint

nonpalpable

nonpalpable

generalized (anasarca)

SITE #1:____________

SITE #2: ____________

pitting
1+
2+
3+
4+
non-pitting

pitting
1+
2+
3+
4+
non-pitting

CAPILLARY REFILL:
FINGERS:
brisk
slow
HX:
Pacemaker
HTN
CAD

see nursing notes

see MAR
PRECIPITATING: walking, general movement
QUALITY:_ dull, aching
REGION: bilateral knees

RADIAL:
regular
irregular
strong
faint

EXTREMITY COLOR & TEMP:

warm
acyanotic
cool
cyanotic
cold
discolor
EDEMA:
none

PAIN ASSESSMENT:

SEVERITY (0-10/10): 3
NOW: 3

AT WORST: 6

AT BEST: 1

TIMING:_______________________________________
__

SAFETY:

see nursing notes

fall risk

PRECAUTIONS:
side rails x 2
bed down
call light
nightlight
DISCHARGE/TEACHING:
notes

see nursing

NEEDS:________________________________________
________________________________________________
________________________________________________
________________________________________________
_
TYPE OF LEARNER:
visual
auditory
kinesthetic

TOES:
brisk
slow
CHF
PVD
Other: _________

EDUCATIONAL LEVEL: High school

FAMILY PRESENT:
yes
no

National League for Nursing, 2015

FLUID BALANCE:
INTAKE:
PO

see nursing notes

NURSE SIGNATURE: Terrence Williams, RN

TIME COMPLETED: 0800

IV
REASSESSMENT:

SOLUTION: D5 .45 RATE: 60 ml/hr

TIME: 1200

SITE LOCATION: L FA
clean
patent
redness

swelling
cool
hot

MUCOUS MEMBRANES:
moist
sticky
pink
coated
TODAYS WT: 48
kg

no
change

pain
tubing change
dressing
change

see nurses
notes

Initials TW

see nurses
notes

Initials TW

see nurses
notes

Initials SH

TIME: 1600
no
change

dry

TIME: 2000
no
change

YESTERDAYS
WT:_______

Risk Assessments & Nursing Care

Time
PAIN ASSESSMENT
Intensity (1-10/10)
Pain Type (see
legend)
Intervention (see
legend)
PATIENT POSITION
PO FLUIDS (ml)

Date: Day 1 0900-2100

Braden Scale Score: 20
Morse Fall Risk Score: 70
0 1 1 1 1 1
8 0 2 4 6 8

Date:
Braden Scale Score:
20
Morse Fall Risk Score: 70
2 2 0 0 0 0
0 2 0 2 4 6

2
A

1
A

2
A

1
A

1
A

2
A

1
A

1
A

1
A

1
A

1
A

1
A

See

See

National League for Nursing, 2015

I&

I&

IV SITE/RATE
CHECKED
PATIENT HYGIENE
WOUND
ASSESSMENT
WOUND BED
WOUND DRAINAGE
WOUND CARE
Nurse Initials
Initial
TW

LEGEND:

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

TW

TW

TW

TW

TW

TW

SH

SH

SH

SH

SH

SH

Nurse Signature
Terrence Williams, RN

Initial
SH

Nurse Signature
Scott Hansen, RN, BSN

*= see nursing notes

PAIN TYPE:
A- aching
T- throbbing
ST- stabbing
B- burning
SH- shooting P- pressure
PAIN INTERVENTIONS:
1- Relaxation/Imagery 2 - Distraction
3- Reposition
4-Medication
WOUND ASSESSMENT
# 1-4 Pressure Ulcer stage
I Incision
R Rash
SK skin tear
E Echymosis
A Abrasion

POSTIONING:
B- back
R- right
L- left
C- chair
A- ambulatory

WOUND BED:
D Dry & intact
S Sutures/ staples
G Granulation tissue
P Pale
Y Yellow
B- Black

PT. HYGIENE:
b- bedbath
p- partial bath
g- grooming
f- foot care

WOUND DRAINAGE:
0 none
S Serous
P Purlulent
S Serosanguinous
B Bright red blood
D Dark old blood

a- assist bath
sh- shower
m mouth care
n- nail care

WOUND CARE:
C Cleaned with NS
G Gauze dressing
W Gauze wrap
A ABD pad
M Medication
O other **

National League for Nursing, 2015

10

 National League for Nursing, 2015

11