Nursing Brain 2 Patient
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1Nursing Brains ~ 2 Patient v.3
Compliments of
LABS
ASSESS
Rm:
Age:
Initials:
Time
♀ ♂
Admit:
Dr.
Pain #:
Tol:
B/P
A&O :
Pupils: R_____/_____
Diet :
P
Allergy:
Lungs: A_____P____ Deep _____________
R
♥
:
CapRefil:
Dx:
O2
Hx:
Skin:
Edema:
T
Pain
Surg:
Grips/Pushes: UE____/____ LE____/____
Activity:
Pulses: R_____/_____ P_____/_____
Accu
✓
BS______ Time______ Units_____
Dr. Orders:
✓
Accu
BS______ Time______ Units_____
Abd_____ BS_____ Flatus_____ BM_____
IV Rate:
Meds: 07 08 09 10 11 12 13 14 15
∆
Drsgs/Wounds:
Site________ Gauge________
________
O2________ %@ ________ SVN________
Numb:
Nausea:
Isolation:
Misc:
Dizzy:
SOB:
C/DB:
Move Feet:
CT
JP
Penrose
Trach
G-tube
Notes:
J-tube
Teds
Plexis
T-Guards
TX’s:
I’s:
O’s:
Foley
Urinal
ISC
Comode
NG
LABS
ASSESS
Rm:
Age:
Initials:
Time
Admit:
♀ ♂
Dr.
Pain #:
Tol:
B/P
A&O :
Pupils: R_____/_____
Diet :
P
Allergy:
Lungs: A_____P____ Deep _____________
R
♥
Dx:
:
CapRefil:
O2
Hx:
Skin:
Edema:
T
Pain
Surg:
Grips/Pushes: UE____/____ LE____/____
Activity:
Pulses: R_____/_____ P_____/_____
Accu
✓
BS______ Time______ Units_____
Dr. Orders:
✓
Accu
BS______ Time______ Units_____
Abd_____ BS_____ Flatus_____ BM_____
IV Rate:
Meds: 07 08 09 10 11 12 13 14 15
∆
Drsgs/Wounds:
Site________ Gauge________
________
O2________ %@ ________ SVN________
Numb:
Nausea:
Isolation:
Misc:
Dizzy:
SOB:
C/DB:
Move Feet:
CT
JP
Penrose
Trach
G-tube
Notes:
J-tube
Teds
Plexis
T-Guards
TX’s:
I’s:
O’s:
Foley
Urinal
ISC
Comode
NG
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