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EMCC PATIENT CARE RECORD
Hospital

Desaster, Ima
DATE 11/19/2008 SHIFT 0700-1900
ASSIGNED NURSE: C. Barros RN RN COVERING LPN
ASSESSMENT TIMES 0900
CARDIOVASCULAR Rhythm Regular Antiemboli device TED hose
Heart Sounds S1S2 Pacemaker NO
RESPIRATION –CIRCULATION

Color: WNL Pale Cyanotic Mottled Jaundiced Ashen

Edema NO Skin Temp Warm
Peripheral Pulses: Present bilaterally equal
A-Line Left Femoral IABP NO
Other
RESPIRATORY Pattern Mechanical Ventilation 02 Therapy FiO2 50%
Breath Sounds Coarse and diminished bilaterally
Cough/Deep Breathe/Suction Suction PRN Inspirometer
Productive Non-Productive Needs Assistance Sputum Thick yellow, moderate amount
ETT: Nasal Oral Size 8F Placement 24cm @ lip Trach: Size NA Care NA Inner Cannula NA
Chest Tube Yes Location Left Chest Suction 20 CMH2O Waterseal Air Leak Fluctuation
Drainage Clear Dressing Occlusive
Other Vent settings IMV 10 TV 700 PS 10 +5 peep
ELIMINATION BALANCEFLUID-CHEM.NUTRITION- COMFORTPROTECTION

SKIN AND MUCOUS MEMBRANES Oral Mucosa Moist and Pink

Skin Warm, Dry, Color WNL
ISOLATION None Contact Respiratory Airborne Respiratory Document wounds dressings/drains on skin risk/assessment
Hygiene: Oral q, 2 hours Back Care q 2 hours Peri Care PRN
Bath PRN and on Night shift
SAFETY Call Light Within Reach: Yes No Reason Alarms Risk for Fall
Bed Position: Low Wheels Locked Side Rails: UR LR UL LL
Other Restraints Document on 24 hr. Restraint Assessment

NUTRITION Diet NPO Fluid Restriction_NO__________________ % Taken: Bkfst Lunch Dinner TPN □
Feeding Tube: Location Left Nare Size 8F Type DT Tube Feeding Solution Pulmocare @ 60 cc/ hour
Residual 50 mL.
Other Full Code Allergic to morphine

GASTROINTESTINAL Abdomen: Soft Firm Distended Tender Gastric Tube: Location Size
Bowel Sounds: Normal Hyperactive Hypoactive Absent Flatus Drainage Type
STOOL Continent Incontinent Color Brown Consistency Soft
URINARY Continent Incontinent Color Yellow Character Clear Foley: 16F
Other

NEUROLOGICAL L.O.C.*_____Sedated Pupils Equal and Brisk Right 3 Left 3

NORMALCY

Ventriculostomy NA
Motor Response* Rt. Arm 4 Rt. Leg 4 Lt. Arm 4 Lt. Leg 4 Communication/Speech Sedated
Emotional Support: Active Listening Reassurance/Comfort Relaxation Techniques Coping Skills Review Visitors
Other
RESTACTIVITY-

MUSCULOSKELETAL Traction NA
Independent Requires Assistance X’s 2 Rest/Sleep Sedated
Activity/Tolerance Passive ROM and repositioned q2 hours
Other

PHYSICIAN CONTACT ADDITIONAL SHIFT COMMENTS

Physician Visit Call Placed Reason/Problem Call Rec’d
Important 1145

INITIAL SIGNATURE/TITLE
CBB C. Barros RN TRANSFER: TO FROM PER TIME
CONDITION: GOOD FAIR SERIOUS CRITICAL
RECEIVING RN
EMCC PAIN MANAGEMENT/
Hospital SKIN ASSESSMENT

DATE 11/19/2008

Plan for Pain Management to Increase patient’s comfort and function

Patient’s goal for pain: (0-10) Less than 2
ADL Observation Scale: (nurse may use for non-verbal patient
Ambulation Sleeping grimacing moaning restless constant
Physical Therapy Calm/relaxed with with moaning
Not agitated movement movement without stimuli
Other
Document the pain/symptom, intervention and follow up evaluation below.

Duration: 10. Continuous

4. Stabbing 7. Cramping 11. Variable 3 Frequently drowsy E. Spiritual Assistance
5. Tingling 8. Numb easy to arouse F. Back Rub
6. Sharp 9. Radiation (Where?) 4 Somnolent G. Music
H. Other (describe)
SKIN RISK: Check all that apply and total score (to be done daily)

GENERAL PHYSICAL CONDITION MENTATION INCONTINENCE (Bowel and Bladder)

0 Good (minor) 0 Alert 0 No Incontinence
1 Fair (major but stable) 1 Lethargic 2 Occasional Incontinence (less than 2 times / 24 hrs)
2 Poor (chronic/serious, 2 Semi-comatose 4 Usually Incontinent (more than 2 times / 24 hrs)
not stable) 3 Comatose 6 No Control
ACTIVITY MOBILITY NUTRITION
0 Ambulatory 0 Willing and able to move self 0 Appetite good
2 Needs Assistance 2 Needs assist to turn 1 Occasionally refuses meals (eats 50%)
4 Chairfast 2 Cast on extremity or pain w/joint movement 2 Enteral tube feedings
6 Bedfast 4 Patient does not tolerate turning Hyperalimentation
4 Physical condition does not permit turning 3 Seldom eats a meal / NPO
5 Total immobility, quad, para
Total score: 19 The patient scoring 11 or more Special Bed Referral and/or Nutritional Referral Reassessment
SKIN IMPAIRMENT: Document in this section when a skin impairment is noted on assessment

Diagram Skin Impairment (ie: surgical Color (ie: pink, red, Odor/Drainage (ie: Interventions/Comments (ie: dressing clean, dry, and intact, use
Number incision, drains, pressure yellow) none, foul, purulent, of incontinence products, frequent repositioning, heels elevated on
ulcer, hematoma, burn, rash, serous, bloody) pillows, dressing changes, wound care, specialty bed, wound care
excoriation) consult)
1 Chest tube (left) Dressing CDI

INITIAL SIGNATURE/TITLE INITIAL SIGNATURE/TITLE

CBB C. Barros RN

EMCC
HOSPITAL Patient Care Record Desaster, Ima

Date 11/19/2008
HEALTH DEVIATION NEEDS
TEACHING
Acute Respiratory Failure to Patient’s family, verbalized understanding 2/3 TEACHING TO INCLUDE:
DISEASE PROCESS  Who was taught
 What was taught
 Response to teaching
MEDICATIONS

PT/FAMILY TEACHING RESPONSE

ACTIVITIES CODES
1 = Received Literature
2 = Communicates Understanding
NUTRITION/FLUIDS 3 = Requires Reinforcement
4 = Previous Experience
PRE-OP/PROCEDURES 5 = Return Demonstration
6 = Objective Achieved
7 =Referral Initiated
8 = Refused
MISCELLANEOUS 9 = Preprinted Teaching Protocol
10 = Preprinted Teaching Protocol
DISCHARGE PLANNING CATEGORIES (Document daily) REFERRAL / ACTION

1. Clear mentation Perform ADL’s and ambulation independently or with minimal

assistance Normal activity with effort Adequate support system
2. Alert In/out of confusion Moderate/Maximal assist with ADL’s and mobility
Potential HHC evaluation, ECF placement, or transfer to other facility
3. Markedly debilitated Complex social situation Recent discharge Requires
ongoing therapies/extensive teaching
PLAN OF CARE: Initiated
4. Re-evaluate later.
Reviewed Revised
IV THERAPY
CATH SITE
Site DATE/TIME SITE TYPE/ TUBING APPEARANCE D/C’d COMMENTS
# INSERTED LOCATION SIZE IV SOLUTION RATE/DEVICE CHANGE 7-3 3-11 11-7
1 11/19/08 RAC 18 g. 0.9 NS 100 mL/hr Due 11/22/08 1

INITIAL SIGNATURE/TITLE
IV CODES APPEARANCE
Site Location Catheter 1=Asymptomatic CBB C. Barros RN
L = Left AC = Antecubital UAF = Upper S.G. = Swan Ganz 2=Red
R = Right UA = Upper arm Anterior H.D. = Hemodialysis 3=Swollen
S = Scalp UPF = Upper Forearm Hick = Hickman 4=Ecchymotic
Ft = Foot Posterior LAF = Lower G = Groshong 5=Warm
F = Femoral Forearm Anterior Port = Port-A-Cath 6=Cool
H = Hand LPF = Lower Forearm or other 7=Draining
W = Wrist Posterior IJ = Internal implanted 8=Leaking
Forearm Jugular port
SC = Subclavian I = Introducer Lumen
PP = Pace Port d=distal
m=middle
p=proximal
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