✳ - Refer to Outcome Notes - Present / Done 58602

FOR 12 HOUR SHIFTS, 2nd COLUMN MAY BE BLANK

DATE
TIME
1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd
Breath sounds
C - Clear W - Wheezes K - Crackles D - Diminished R - Rhonchi A - Absent
RESPIRATORY

Dyspnea
Cough Non-productive
Productive
Color C - Clear W - White R - Red G - Green P - Pink Y - Yellow B - Brown Consistency T - Thin TK - Thick FR - Frothy Amount S - Small M - Moderate L - Large
O2 Therapy
Liter Flow
Delivery method
Rhythm R - Regular I - Irregular

E
Telemetry reading NSR

Heart sounds Normal (S1, S2)

PL
CARDIOVASCULAR

Abnormal

M
Peripheral pulses

Nailbeds Pink / WNL

Peripheral edema None

Dialysis access device

Device 1 / Location
Bruit/Thrill
Device 2 / Location
SA
LOC Alert / oriented
Confused
Lethargic
Other
PERL
NEUROMUSCULAR

Speech Clear
Slurred
Aphasic
Gait Steady
Unsteady
Moves all extremities
Strength Normal
Weakness
Sensation

INITIALS
IHS1024 (9/04) IMMS # 58602
P
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NURSING FLOWSHEET T
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DATE

TIME

1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd
Bowel sounds Active
Absent
Hyperactive
Hypoactive
Abdomen Soft / nondistended
Distended
Firm
Nausea - N / Vomiting - V / F - Flatus
Stool C - Continent / I - Incontinent
D - Diarrhea / C - Constipation
GI

Ostomy / Urinary Diversion

NG tube
G-tube / J-tube
Suction in use

E
Feeding formula

L
Rate
Residual Time

P
Amount ml ml ml ml ml ml ml ml ml ml ml ml
Time

M
Amount ml ml ml ml ml ml ml ml ml ml ml ml
Braden Score

A
Color

S
N - No problem identified P - Pale J - Jaundice
Temperature Warm / dry
Cool / dry
Turgor
N - No problem identified TT - Taut TG - Tenting
Skin intact
Incision / wound
1.
INTEGUMENTARY

2.
3.
C - Clean and dry R - Reddened B - Bruised DR - Drainage S - Sutures / Staples SR - Sutures / Staples Removed SS - Steri Strips
Dressing
1.
2.
3.
Site I - Dry and intact C - Changed
Drains
1.
2.
3.
4.
Type JP - Jackson Pratt H - Hemovac P - Penrose T - T-Tube CT - Chest Tube

INITIALS
IMMS # 58602

NURSING FLOWSHEET Patient Name _____________________________________

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✳ - Refer to Outcome Notes - Present / Done FOR 12 HOUR SHIFTS, 2nd COLUMN MAY BE BLANK
DATE

TIME

1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd
IV SITE #1
Type / Gauge
Assessment
Attempts/Time
Tubing Change
Dressing Change
IV SITE #2
Type / Gauge
Assessment
IV THERAPY

Attempts/Time
Tubing Change
Dressing Change
IV SITE #3
Type / Gauge

E
Assessment
Attempts/Time

L
Tubing Change

P
Dressing Change
Type P - Peripheral S - Saline Loc C - Central IP - Implanted Port PI - PICC
Assessment P - Patent T - Tender R - Red D - Discontinued / Catheter Intact S - Swollen I - Infiltrated

M
Site 1 - (R) Hand 3 - (R) Wrist 5 - (R) Forearm 7 - (R) Antecubital 9 - (R) Upperarm 11 - (R) Jugular 13 - (R) Subclavian 15 - (R) Femoral
2 - (L) Hand 4 - (L) Wrist 6 - (L) Forearm 8 - (L) Antecubital 10 - (L) Upperarm 12 - (L) Jugular 14 - (L) Subclavian 16 - (L) Femoral

A
No complaint of
discomfort

S
Location of pain

Time

Description

Pain Level (0-10)

Intervention
PAIN / DISCOMFORT

Time of
Reassessment
Outcome after
intervention (0-10)
Location of pain

Time

Description

Pain Level (0-10)

Intervention

Time of
Reassessment
Outcome after
intervention (0-10)
Descriptions A - Aching B - Burning D - Dull S - Sharp SH - Shooting T - Throbbing P - Pulling
Interventions H - Heat Therapy C - Cold Therapy DB - Deep Breathing DT - Diversion Therapy TT - Therapeutic Touch MA - Massage
M - Medication MU - Music R - Relaxation RP - Repositioning TN - TENS O - Other

INITIALS
IMMS # 58602
P
A
NURSING FLOWSHEET T
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DATE

TIME

1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd
Bladder Nondistended
Urine Clear
Continent
Incontinent
GU

Ostomy
Foley Catheter
Suprapubic Catheter
PSYCHOSOCIAL

Sleep
A - Awake W - Well I - Intermittently P - Poor
Mood / affect
U - Uncooperative A - Angry AW - Anxious / worried D - Depressed HC - Hostile / combative F - Fearful
C - Cooperative FA - Flat affect UN - Unable to assess W - Withdrawn H - Hallucinating
History of Falling within 12 months
No - 0 Yes - 25
Secondary Dx
No - 0 Yes - 15

E
Ambulatory Aid
None / Bedrest / Nurse Assist - 0

L
MORSE FALL / RISK SCREENING

Crutches / Cane / Walker - 15

Furniture - 30

P
IV / IV Access
No - 0 Yes - 20
Gait

M
Normal / Bedrest / Wheelchair - 0
Weak - 10

A
Impaired - 20
Mental Status
Oriented to own ability - 0

S
Overestimates /
forgets limitations - 15
TOTAL
CHECK ONE:
No Risk 0 - 24
Low Risk 25 - 44
High Risk > 45
Action Initiated (If low/high risk, check one)
F = Fall Prevention
I = Individual Plan
KEY
BRADEN SCALE PAIN SCALE
Sensory Perception Moisture Activity Mobility
Completely limited 1 Constantly moist 1 Bedfast 1 Completely immobile 1
Very limited 2 Moist 2 Chairfast 2 Very limited 2
Slightly limited 3 Occasionally moist 3 Walks occasionally 3 Slightly limited 3 0 1-2 3-4 5-6 7-8 9-10
No impairment 4 Rarely moist 4 Walks frequently 4 No limitations 4 MILD MODERATE SEVERE

Nutrition Friction & Shear Skin Risk Category

Very poor 1 Problem 1 17 or above - No risk, continue to score daily
Probably inadequate 2 Potential Problem 2 16 or below - At risk, interventions required
Adequate 3 No apparent problem 3
Excellent 4 * If identified as “At Risk” implement facility policy
Init Name (print) Signature / Title Init Name (print) Signature / Title

IMMS # 58602

NURSING FLOWSHEET Patient Name _____________________________________

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