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Comprehensive Patient Care Checklist

The nurse report provides a comprehensive overview of a patient's background, including medical history, vital signs, and current health status. It outlines the patient's mobility, allergies, and various assessments across multiple systems such as neuro, cardiac, and respiratory. Additionally, the report details the plan of care, medications, and discharge plan for the patient.

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gc.ramoslopez
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580 views1 page

Comprehensive Patient Care Checklist

The nurse report provides a comprehensive overview of a patient's background, including medical history, vital signs, and current health status. It outlines the patient's mobility, allergies, and various assessments across multiple systems such as neuro, cardiac, and respiratory. Additionally, the report details the plan of care, medications, and discharge plan for the patient.

Uploaded by

gc.ramoslopez
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Nurse Report

PATIENT BACKGROUND
Name : Room # MD: Situation Precaution
Age : Sex : M F Code : Full DNR Limited Full Risk Alarm None Droplet
Confused Restraints Contact Airborne
Mobility : Indep Assist Bedrest Admit Date : Sucide Seizure
Allergies : Complaint :
MUSCLULOSKELETAL
MEDICAL HISTORY Normal Hypertrophy Atrophy
CAD BPH MI
SBA ADLIB Limb Alert L/R
CABG AFID Anxiety Diagnosis :
Device
AAA PVD Stroke
HTN HLD TIA CONSULTS
CHF DLD Depression GI PT/OT Psych Neuro Ortho
COPD ETOH GERD Tests/Procedures: Onco Nephro Pulmo Medi Urology
CKD DM PAD Pacemaker Cath ETT EKG Speech Surg Cardio

Echo X-ray MRI EGD CT


VITAL MEDICATION & TO DO
Temp BP HR RR Sp02 TIME TASK
NEURO
A&0 x Unconscious Confused
Power Reflex
RASS

CARDIAC
ACCU CHECK
Pulses Edema
AC HS Hourly
Cardiac Sounds Bilateral
Time BS Cover

RESPIRATORY
Pattern Chest Exp
Clear Diminished Crackles HOSPITAL COURSE
Breath Sounds Room Air CPAP

LABS BIPAP Vent

HGB WBC PLT GASTROINTESTINAL


PT INR PTT PLAN OF CARE
DIET Normal NPO Tube Feed
BUN CR NA
Intake Calories
K CA MG
Ostomy
Phos Glucose CO2
Last BM Hypo Normal Hyper
PH Troponin
Notes :

DRIPS/FLUIDS GENITOURINARY DISCHARGE PLAN


Output Voiding Anuria
Incontenance Urinal Catheter

Bedside Comm Bedpan

SKIN/WOUNDS
PIV PICC CVC HD NOTES
Intact
IV SITES Wound Location Size
Dressing
PIV PICC
Bedstore Location Size
Central Other Dressing

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