Room: Full/DNR/Chem PMHx:

Pt:

MDs: NOK:

Admit Date: PCP:

Dx: Last PRNs: PRNs:

Isolation:

PIV CVC PICC Cardiac: Tele_________ Pulses 4/6 Edema: S1/S2/S3/S4 BPs JVD CR Angioseal? R/L Shoulder? R/L RT Q3/4/6/8 P Neuro: A&Ox__ Deficits? Q4/6/8 WBC RBC Hgb Hct MCH MCV MHCH RDW PLT Neutro Bands ANC: PT INR PTT U/A U C/S Sputum C/S Glu Na K Cl CO2 AGAP BUN Cr GFR Ca Mg Phos Bili Alk Phos Amy Lip Blood C/S Tchol LDL HDL Tgl Risk BNP D-D T&X MRSA Screen Resp: O2__________ CPAP/IPPD/CPT NPC/PC Lungs: Supp/TF GI: Last BM Abd: Diet:

inserted: GU: Foley Void Irrigate Diaper Skin: Braden Rash Wound Care:

IVF: PT/OT/SLP OOB/Assist Bedrest/Turn BRP/BSC/BP Cane/RW Mattress: Atmos Rental Drains:

Strict I&Os Daily Wt: 08: 07 08 12: 09 16: 10 11 Falls/Aspirate Restraints: Todays ToDo: Accuchecks: AC/HS/Q6/Q4 0730 1130 1200 1630 1800 Protocols: K < 3.8 < 3.9 Mg < 1.8 Phos < 2.5 Heparin New Orders: 12 13 14 15 16 17 18

PEG/G/J/NGT

PPD: Cdiff/Guiac D/C plan Home/HH/SNU/Rehab LTAC/NH/AL Eval/Accept