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 Lars

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
National League for Nursing, 2015

Date/Tim
e:
0630
Day 4

Pt out of bed this morning, slipped, almost fell. No visible injuries noted.
PCP and daughter notified. On all antihypertensives now, BP has
improved since admission, see flow sheet.
T. Wade RN
Discharged home accompanied by daughter.

1700

Jean Larsen, RN, BSN

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, JL 1200 JL ,
1600 JL

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

drops
Fosamax
Tramodol
Ciprofloxacin

250 mg

Acetaminophen
Celebrex

325 mg
200 mg

po

po
po

Date
s
Give
n:
Day 4

0800 JL
0800 JL, 1600 JL

Day 4
Day 4

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

Day 4
Day 4

0800 JL

Day 4

0800 JL,2000

Day 4

0800 JL

Day 4

National League for Nursing, 2015

Intravenous Therapy
Date of
Order:
Day 1

IV Solution

Rate Ordered:

IV fluids D5 .45 NaCl

20 mEq KCL

60ml/hr

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

Date/Time Hung:
Day 4, 0900 JL

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

Nurse Signatures
Initial
J.L.

Nurse Signature
Jean Larsen, RN, BSN

Initial

Nurse Signature

Vital Signs Record

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

Day
4
0200
37.1

0600
37.2

0800
37.1

1200
37.2

1600
37.2

128/7
4
72
96

160/88

148/86

146/90

68
94

72
96

76
96

138/8
0
76
96

12

12

14

14

16

TB

TB

JL

JL

JL

2000

National League for Nursing, 2015

Intake & Output Bedside Worksheet

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

IVPB

OTHER

Total Intake this shift: 2160

2100-0900
ORAL

URINE

IV

Drains
Type:

Other

Drains
Type:

Other

Total Output this shift:

INTAKE
TUBE
FEED

OUTPUT
Emesis
NG

OUTPUT
IVPB

OTHER

URINE

Emesis

NG

National League for Nursing, 2015

Total Intake this shift:

Total Output this shift:

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

see nursing
risk skin

TURGOR:
<3 sec

LEFT:
clear
crackles
wheezes
decreased

RIG

absent

National League for Nursing, 2015

pale
ruddy
jaundiced
cyanotic

> 3 sec

TEMP:
warm/dry
hot
cool
cold/clammy
diaphoretic

HAIR:
shiny
dry/flaking
balding
lesions
lice

NEUROLOGICAL:

see nursing notes

ORIENTATION:
person
place
time
RESPONDS TO:
name
stimuli
SPEECH:
clear
garbled
slurred

EYES:
PERRLA
unequal
drooping lid
HEARING:
WNL
HOH
HX:
seizures

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

FACE:
symmetrical
drooping

THORAX:
even expansion
uneven expansion

drooling
SIGHT:
no correction
glasses
contacts
blind
hearing aid

spinal injury

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

National League for Nursing, 2015

CVA
brain injury

MUSCULOSKELETAL:
GAIT:
steady

other

see nursing notes

type: ______________ rate:_________

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

nonambulatory
ASSIST:
x1
x2
lift
bed bound

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

catheter

APPEARANCE OF URINE:
clear
light yellow
amber
brown

BLADDER:
soft
firm/distended

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

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

dry

no
change

see nurses
notes

Initials JL

see nurses
notes

Initials JL

see nurses
notes

Initials K.C.

TIME: 1600
no
change
TIME: ________
no
change

YESTERDAYS
WT:_______

Risk Assessments & Nursing Care

Time

Date: Day 1 0900-2100

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

PAIN ASSESSMENT
Intensity (1-10/10)

Date:
Braden Scale Score:
20
Morse Fall Risk Score: 70

National League for Nursing, 2015

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
A

240

240

146
Y

3.6
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

JL

JL

JL

480

103

3
A

240

240

Nurse Signature
Jean Larsen, RN, BSN

Initial

Nurse Signature

*= 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

UA

Urine color: Clear,

yellow, cloudy
Specific gravity:
1.0350
(normal 1.0051.035)
ph 6.0
(normal 4.5-8.0)
RBC - 4
(normal 0-2)
WBC - 150,000
(normal 0-5)

National League for Nursing, 2015

11