SITUATION & BACKGROUND

PATIENT INITIALS: GT_ AGE: 60_ ADMIT

DATE:_02/15___

ADMIT DX/CHIEF COMPLAINT/HX CURRENT

ILLNESS: _Bowel Obstruction
_____________________________________________
_HTN, cardiomyopathy, Renal calculi,
Schizophrenia, Bipolar disorder,
Inguinal hernia, CHF (15% EF),
Osteoarthritis._____________________________
__
PAST MEDICAL/SURGICAL HISTORY: __
Hepatitis C, Recovering alcoholic and
substance user.
_____________________________________________
Neck Surgery 1987, ruptured disk 1996.

REVIEW OF SYSTEMS (INITIAL

SHIFT ASSESSMENT)
VITAL SIGNS: HR_60_ B/P_122/64 _MAP N/A RR_18 _
TEMP_97.6

PAIN: rating_4/10_ locat._All over__

descript_Dull/aching__

NEURO:
Orientation (LOC):___A&O X3________________ GCS:__15____
PERRLA _X_Y _OR____N__ Pupils (size/reaction)__3.
Appropriate______
Upper/Lower Motor Strength(equal/un;
weak/strong)__Strong_______
Paralysis? Where? _None_______ Fine/gross motor?
__Gross________
Facial drooping?__No____tongue midline?__Yes___swallowing?
_Yes____
C-collar?__No_____ Halo?____No________ TLSO brace?
__No_____
Numbness?___No_________Headache?__No___Seizures?
__No____

CARDIAC:
Heart sounds:__Slow and strong_____ murmurs/extra
sounds?__No____
EKG rate/rhythm:__60bpm-Ventricular________
PR:_176__QRS:102____
Pulses: radials___60______ dorsalis pedis__60____post.
Tib.__60____
Cap refill:__> 3 seconds___edema?_None_____turgor:__No
tinting______
DVT?__No____Art. Line?
_N/A_Waveform/Correlates__N/A____________
Pulm. cath?__N/A_____CO/CI_N/A__ PAP_N/A__SVO2 N/A
PCWP__N/A__
Balloon Pump?_N/A_______Potent Drips?_N/A______________
Pacemaker?___Yes____ Settings?_Battery died 6 months
ago_
Cardiac enzymes?__N/A________echo? EF?_N/A___cath?
_N/A______

Example of completed form

Coags?__N/A_________Lipid panel?____N/A________________
Bleeding?__N/A___________H/H?__117/136___Blood Prod.?
_N/A___

RESPIRATORY:
Lung sounds:_Diminished and clear____________Oxygen?
__No_______
Effort/chest symmetery:__Equal bilaterally________O2
sat_95%_____
Cough?__No___Prod/non-prod?___N/A____ sputum?
__None________
Chest Tubes? Location/site descript./suction? Drainage?
_________________
________________N/A___________________________________
Artificial Airway? Type:__N/A____location:_N/A___
size/depth:__N/A___
Ventilator? Mode_N/A rate(d/t)_N/A_ vt_N/A_ fio2_N/A_
p_N/A_ ps_N/A_
ABGs? pH_N/A___pco2_N/A____hco3_N/A___po2__N/A___
be__N/A__
Chest xray?
Findings__N/A______________________________________

GASTROINTESTINAL:
Abdomen __Distended______Bowel sounds: Hyperactive. All
4 quadrants
Tubes/drains? Location/ site descript./ output/
suction/gravity/clamped?
___N/A_____________________________________________________
last BM?__2/17_____characteristics?_____Soft__________C-Diff?
__No___
Diet type:__Clear liquid________ %consumed:__100____ N/V?
__No____
If tube feedings: type___N/A____
rate(current&goal)__N/A_________
residuals? _N/A____free H20?__N/A_______ Bolus?
_N/A_________
Blood sugars?___96_________treatment:___N/A______________

REVIEW OF SYSTEMS (continue)

GENITOURINARY:
Voids? Foley?Size?__Void_______ urine
characteristics(color/clarity/amt.?
_____Yellow, clear________________________________________
Irrigation?______N/A___________Dialysis?__N/A_______________
Electrolytes:______N/A_____________________________________
Treatment:____N/A__________________________________________

MUSCULOSKELETAL:
Fall risk?_Y_ precautions:__Side rails___
ROM: All
extremities Activity ordered:Ad lib_ observed: frequent
ambulation ___how tolerated_Well___
Restraints? Where?____N/A__________Why?_N/A_________
Ambulatory Aid?
______None___________________________________
Contractures?Casts?Traction?_No
_______________________________

INTEGUMENTARY:

Braden scale:20_Skin descript. Color/temp/moisture_warm /

moist_______
Wounds/Incisions/Breakdown?
____None_____________________________________________________
____________________________________
Wound Vac/Dressings or other
Treatments:____None________________
_______________________________________________________________
_______________________________________________________________
IVS? Site location & description/size/whats running
continuously (if potent/sedative/analgesic gtt the report in
dosage not ml/hr):
IV fell out this morning. Pt refusing to have another
one put in.
_______________________________________________________________

PSYCHOSOCIAL/SPIRITUAL:
Mood/affect:_Cheerful___________ support system:__Chaplin
__________
Disposition after discharge: ___home_____
Spiritual:__Yes______ Participates in care?
__Yes______Understands disease process?__Yes____

INFECTIOUS DISEASE:
Fever?_No____ WBC?_3.8_________ Neutropenic?____No______
Positive cultures? Where? What organism? Treatment?
Isolation?
_None____________________________________________________

MEDS(REVIEW HOME MEDS FOR

CONGRUENCY):
_______________________________________________________________
Nicotine patch, Protonix, Lasix, Colace, Lopressor, MS
Contin, Lactulose, Xanax, Milk of Magnesia, Dilaudid,
Restoril, Maalox.
_______________________________________________________________
_______________________________________________________________

Prioritized Plan of Care:

1.
2.
3.
4.
5.

Prevent Falls
Ensure pt is comfortable.
Ensure pt is in minimal pain.
Monitor ECG and pertinent labs. [Should be #1]
Monitor I&Os and weight daily. [Should be #2

Prioritized Top 3 Nursing Diagnosis:

1. Decreased cardiac output r/t altered heart rate AEB
bradycardia.__________________
2. Excessive fluid volume r/t decreased cardiac output
AEB diminished breath sounds.
________________________________________
3. Ineffective tissue perfusion r/t decreased cardiac
output. ___________________________________________________

MD ORDERS QUESTIONS/CONCERNS FOR

PHYSICIAN:

Follow up Care after

discharge?
_

Electrolyte replacement? Any

concerns?
SHIFT CARE PLANNING TIMELINE:
0700 - shift report/review labs, mar, x-rays,
orders
0800 - Initial assessment/vs/reposition/scheduled
meds/daily sedation wake-up/bundles
reviewed/zero/level pressure lines/verify alarm
limits
0900 - scheduled meds
1000 - vs/reposition/scheduled meds/oral care
1100 - scheduled meds
1200 - repeat assessment/vs/reposition/sched.
meds
1300 - scheduled meds
1400 - vs/reposition/scheduled meds/oral care
1500 - scheduled meds
1600 - repeat assessment/vs/reposition/sched.
meds
1700 - scheduled meds
1800 - vs/reposition/sched. meds/oral care/ shift
I&Os/ daily weight

OTHER ROUTINE CARE TO COMPLETE:

Bathing/linen change______________________q
24hrs
C-collar care______________________________q
shift
Trach care _______________________________q
shift
Peri/foley/rectal tube
care___________________q shift
Reposition oral ETT_________________________q
shift
Pneumatic compression
devices/stockings_______off at least 2hrs q
shift
AROM/PROM_____________________________q
shift
Normal Values
WBCs
RBCs
Hgb
Hct

5-10
4-5mil
12-18
35-45

value
s
3.8
3.97
11.7
35.9

Platelet
s
Absolute
Neutro

BUN
Na
K
Cl
CO2
Glucos
e
Creat
Ca

150400
2.9-9.1

229

8-20
135145
3.5-5
95-105

27.9
138

2.1

70-100

4.0
96
29
96

0.6-1.3
8.6-10
6.3-8.3

0.86
9.2
8.2

Alb
Mg
Phos
GFR
PT
PTT
INR

3.5-5
1.5-2.5
2,6-4.9
>90.0
11-16
25-35
0.76-3

4.4
N/A
N/A
N/A
N/A
N/A
N/A

pH

7.35-

N/A

Total
protein

CO2
PO2
HCO3
BE
CKMB
troponi
n
myoglo
b
Lipase
culture
s

7.45
35-45
80-100
22-26
0
0.5-3.6
0-.050

N/A
N/A
N/A
N/A
N/A
N/A

0-110

N/A
44

*Gray Required in CM for all

patients
IV Catheter Color/Gage Guide for JPS ICU *subject to change
18G
Green
20G
Pink
22G
Blue
24G
Yellow