Beruflich Dokumente
Kultur Dokumente
Cardiovascular Status
Apical and radial pulse equal and regular, strong
Peripheral pulses palpable and equal 2+
No tachycardia (>100) or Bradycardia (<60)
Nail bed capillary refill lass than 3 seconds
No edema
Extremities warm and dry
Respiratory Status
Respirations quiet and regular
Effort: easy or unlabored
Symmetrical expansion of chest
Denies any S.O.B. or difficulty breathing
Lungs sound clear to ausculation: Anterior
Posterior, and Lateral chest regions
ABNORMAL
Disoriented, forgetful
Responds to pain only
Unresponsive
Speech mumbled, slurred, aphasic
Gastrointestinal Status
Bowel sounds auscultated in all 4 quadrants
Passing flatus
Denies nausea
Abdomen soft,non-tender, non-distended
Bowel movements w/in client's normal pattern,
color and consistency: Last BM__________
Continent of stool
Diet Served:___________________________
Intake: % of food eaten on meal tray __________
Tolerance for food: no nausea/emesis
Oral fluid intake:__________________cc
Urinary Status
Urine clear, yellow to amber: By history or by
observation
Voids without difficulty
Continent of urine
No strong/unusual odor to urine
Output: ________________cc
Musculoskeletal Status
Ambulatory and independent
Balanced gait
AROM X 4 extremities: w/in client's norm &
symmetrical strength
Bilateral Homan's Sign: Negative
Able to perform leg exercises: ankle circle, toe
points & quadracept isometric contraction
Plexi-pulse, Pnuematic sequential TEDS or other
anit-thrombotic/embolic devices properly applied
and in use at the bedside
How far did they ambulate?__________________
Skin / Mucous Membrane Status
Color within client's norm
Skin warm, dry, intact, normal turgor
Non-ambulatory
Requires assistance:Specify amount/type
Gait unsteady
ROM_____ decreased_____ assymetrical
Contractures
Weakness:
Positive Homan's Sign:
Unable to perform leg exercises: reason:
Refuses to wear/use anti-thrombotic equipment
Incision Status
Location: ___________________________
Incision dry, intact, edges approximated with
Staples, sutures, or steri-strips
Free of drainage, erythema, edema, eccchymosis
Open to air or coverd with:___________________
Client instructed not to touch incision wth hands
Presence of protective dressing: Duoderm,
Elastogel, other:
Pain
Absence of acute and / or chronic pain
Location: ___________________________
No surgical pain
No headache
Description:
No backache
Interventions:
No leg pain
Medications PRN:
Venous Access
Type: Peripheral, CVC-TL, PICC, Port, Hickman
Infiltration S&S:__________________________
Infection/Phlebitis S&S:_____________________
#1:___________________________
#2:____________________________
#3:____________________________
IV site: clean, dry, intact; no redness, swelling
or pain at insertion site
Date IV needs to be changed: ______________
Date of IV tubing change:____________________
IV changed to INT: Y or N
IV intake ______ pump cleared Y/N Credit____cc
SAFETY
Chart where patient is left:______________________
Side rails (# up_____)
I&0
Restraints reapplied
Wound Care
HOB _____________
Other:
IV rates correct
Oxygen at proper flow rate____________
Bed in low position
Bed locked
Environment clean/fresh water/Kleenex/phone in reach
Enough gloves/equipment for next nurse
MAR & Nurses' notes in proper place
I&O and VS recordered on PCT sheet
Reported off to nurse
Misc:
Physician Visits
Labs and Diagnostic tests done:
Family:
Left floor to smoke?
Procedures Done