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

Physician Progress Notes

Allergies:

National League for Nursing, 2015

Date/Tim
e:
Day 1, 0900

Admit. Will see later in a.m.

Dr. Eric Lund

Nursing Notes
Date/Tim
e:
0200

Admitted to ER with daughter, stable; no bed available

0900

T. Wade RN
Admit to 6E. see flow sheet
Jean Larsen, RN, BSN

Medication Administration Record

Allergies: NKDA

Scheduled & Routine Drugs

Date
of
Orde
r:
Day 1

Medication:

Dosag
e:

Rout
e:

Frequenc
y:

Hours to be
Given:

Captopril

25 mg

po

0800, JL 1200 JL ,
1600 JL

Metoprolol
Furosemide

100 mg
40 mg

po

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

drops
Fosamax
Tramodol
Ciprofloxacin

250 mg

Acetaminophen
Celebrex

325 mg
200 mg

po
po

Date
s
Give
n:
Day 1

0800 JL
0800 JL, 1600 JL

Day 1
Day 1

0800 JL
0800, JL 1200 JL ,
1600 JL,2000 KC

Day 1
Day 1

0800 JL

Day 1

0800 JL, 2000 KC

Day 1

0800 JL

Day 1

National League for Nursing, 2015

day

Intravenous Therapy
Date of
Order:
Day 1

IV Solution

Rate Ordered:

IV fluids D5 .45 NaCl

20 mEq KCL

60ml/hr

Date/Time Hung:
Day 1, 0900 JL

Nurse Signatures
Initial
J.L.

Nurse Signature
Jean Larsen, RN, BSN

Initial
K.C.

Nurse Signature
Kathy Clark, RN, BSN.

Medication Administration Record

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

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

Allergies:

PRN Medications
Date
of
Order:

Medication:

Dosage:

Route:

Frequency
:

Date/Time
Given:
Date:
Time:
Site:
Initials
:

National League for Nursing, 2015

Insulin Administration
Date
of
Order:

Medication:

Dosage:

Route:

Frequency
:

Date/Time Given:
Date:
Time:
Site:
GMR:
Initials
:

Nurse Signatures
Initial
J.L.

Nurse Signature
Jean Larsen, RN, BSN

Initial
K.C.

Nurse Signature
Kathy Clark, RN, BSN.

Vital Signs Record

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

Day
1
0200
37.3

0600
37.2

0800
37.2

1200
37.3

1600
37.2

2000
37.1

156/8
8
78
96

160/88

148/86

146/90

80
94

80
96

76
96

138/8
0
78
96

136/7
8
72
94

14

12

16

14

14

14

TB

TB

JL

JL

JL

K.C.

National League for Nursing, 2015

Intake & Output Bedside Worksheet

0900-2100 INTAKE
ORAL
TUBE
IV
FEED
240
720
480
240
240

Total Intake this shift: 1920

IVPB

OTHER

URINE

OUTPUT
Emesis
NG

Drains
Type:

Other

500
750
650
250

Total Output this shift: 2150

National League for Nursing, 2015

2100-0900
ORAL
240

INTAKE
TUBE
FEED

IV

OUTPUT
IVPB

720

OTHER

URINE

Emesis

NG

Drains
Type:

Other

200
400
400

Total Intake this shift: 960

Total Output this shift: 1000

(This is a worksheet to be used at the bedside to keep track of each intake or output. The totals
will then be recorded on the 24 hour Fluid Balance sheet.)
Fluid Measurements:

Sample Measurements:

1 ml = 1 cc

Coffee cup = 200 cc

1 ounce = 30 cc

Clear glass = 240 cc

8 ounces = 240 cc

Milk carton = 240 cc

National League for Nursing, 2015

1 cup = 8 ounces = 240 cc

Small milk carton = 120 cc

4 cups = 32 ounces = 1 quart or liter= 1000

cc

Juice, gelatin or ice cream cup = 120 cc

Soup bowl = 160 cc
Popsicle half = 40 cc

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

see nursing
risk skin

TURGOR:
<3 sec
> 3 sec

LEFT:
clear
crackles
wheezes
decreased

RIG

absent
THORAX:
even expansion

National League for Nursing, 2015

ruddy
jaundiced
cyanotic
TEMP:
warm/dry
hot
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

uneven expansion

HAIR:
shiny
dry/flaking
balding
lesions
lice
see nursing notes

SMOKING:
cigarettes pk/day ____________
cigars
marijuana
cocaine

GASTROINTESTINAL/NUTRITION:
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 nursing

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

brain injury

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

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
National League for Nursing, 2015

scoliosis
OTHER:
CAST LOCATION:___________
TRACTION:_____________
CARDIOVASCULAR:

see nursing notes

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

murmur

see nursing notes

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

RADIAL:
regular
irregular
strong
faint

PEDALIS:
regular
irregular
strong
faint

nonpalpable

nonpalpable

EXTREMITY COLOR & TEMP:

warm
acyanotic
cool
cyanotic
cold
discolor
EDEMA:
none

PAIN ASSESSMENT:

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

TOES:
brisk
slow

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:

see nursing notes

NEEDS:___________________________________________
____________________________________________________
____________________________________________________
__________________________________
TYPE OF LEARNER:
visual
auditory
kinesthetic
EDUCATIONAL LEVEL: High school

National League for Nursing, 2015

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HX:
Pacemaker
HTN
CAD

CHF
PVD
Other: _________

FLUID BALANCE:
INTAKE:
PO

FAMILY PRESENT:
yes
no

see nursing notes

NURSE SIGNATURE: Jean Larsen, RN, BSN

TIME COMPLETED: 1000

IV
REASSESSMENT:

SOLUTION: D5 .45 RATE: 60 ml/hr

TIME: ________

SITE LOCATION: L FA
clean
patent
redness

swelling
cool
hot

pain
tubing change
dressing
change

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

no
change

see nurses
notes

Initials JL

see nurses
notes

Initials JL

see nurses
notes

Initials K.C.

TIME: 1600
no
change

dry

TIME: ________
no
change

YESTERDAYS
WT:_______

Risk Assessments & Nursing Care

Time
PAIN ASSESSMENT
Intensity (1-10/10)

Date: Day 1 0900-2100

Braden Scale Score: 20
Morse Fall Risk Score: 70
0 1 1 1 1 1
9 1 3 5 7 9
2

Date:
Braden Scale Score:
20
Morse Fall Risk Score: 70
2 2 0 0 0 0
1 3 1 3 5 7
1

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LAB TEST
WBC
Pain Type (see
legend)
HGB
Intervention (see
legend)
HCT
PATIENT POSITION
PO FLUIDS (ml)
NA+
IV SITE/RATE
CHECKED
K+
PATIENT HYGIENE
WOUND
GLUCOSE
ASSESSMENT
WOUND BED
WOUND DRAINAGE
WOUND CARE
Nurse Initials
Initial
J.L.

LEGEND:

RESULT

NORMAL RANGE

12,000
A A

9.9
3

32
C

240

480

3
A

240

240

240

480

240

240

149
Y

3.5
Y

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

JL

JL

JL

105

Nurse Signature
Jean Larsen, RN, BSN

Initial
K.C.

Nurse Signature
Kathy Clark, 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

12

UA

Urine color: dark

amber, cloudy
Specific gravity:
1.050
(normal 1.0051.035)
ph 6.0
(normal 4.5-8.0)
RBC - 9
(normal 0-2)
WBC - 150,000
(normal 0-5)

National League for Nursing, 2015

13