ADDRESSOGRAPH
WORKLOAD MANAGEMENT SYSTEM FOR
ENTER
NURSING - GENERAL WORKSHEET
DATE, RN
INITIALS,
AND LAST
ENTER DATE, RN INITIALS,
FOUR SSN
AND LAST FOUR SSN
ACUITY
POINT
ACUITY
POINT
SECTION I - CRITICAL INDICATORS
SECTION I - CRITICAL INDICATORS (Continued)
CODE
VALUES
CODE
VALUES
1. VITAL SIGNS (Manual TPR, BP)
3. ACTIVITIES OF DAILY LIVING (Continued)
1
Vital signs qid or less
1
26
Care - age 6 or more - Complete
14
2
Vital signs q4h or x 6
2
27
Care - age 6 or more - Total
32
3
Vital signs q3h or x 8
3
28
Extra linen change and partial bath x 2 per shift
4
4
Vital signs q2h or x 12
4
29
Turning frame (2 staff members) q2h
14
5
Vital signs q1h or x 24
8
30
Peds recreation/observation - age 0 - 12
8
6
4. FEEDING
Rectal or axillary temp or apical pulse
qid or more
2
31
Spoon feed meals - age 6 or more - x 3
6
7
32
Spoon feed meals - age 5 or less - x 3
10
Femoral, pedal or popliteal pulses or FHT
qid or more
2
33
Infant/neonate bottle x 1 feeding
2
8
Tilt test q4h or more
2
34
Infant/neonate bottle q4h or x 6
12
9
35
Infant/neonate bottle q3h or x 8
16
Post-op, post-partum, post-delivery
(newborn VS)
6
36
Tube feed bolus q4h or x 6
5
2. MONITORING
37
Tube feed bolus q3h or x 8
8
10
Intake and output q8h
2
38
Tube feed bolus q2h or x 12
10
11
Intake and output q2h
8
39
Tube feed - adult/child/neonate -
(continuous) q bag change
12
Circulation or fundus checks q2h or x 12
2
2
13
Neuro checks q4h or x 6
3
5. IV THERAPY
14
Neuro checks q2h or x 12
6
40
Start IV
2
15
CVP or ICP (manual) q2h or x 12
2
41
Change bottle/bag/volutrol bid or less
4
16
42
Change bottle/bag tid or qid
6
Cardiac/apnea/temp/BP monitor
(not cumulative)
6
43
Change bottle/bag x 5 or more
8
17
Transcutaneous monitor/oximeter
6
44
Heparin lock or Broviac q4h or x 6
4
18
A-line or ICP monitor or Swan Ganz set-up
4
45
IV Medication q8h or x 3
2
19
A-line or ICP monitor reading q2h or x 12
2
46
IV Medication q6h or x 4
3
20
47
IV Medication q4h or x 6
4
Swan Ganz PAP/PA wedge reading
q4h or x 6
2
48
Blood products per unit
2
21
49
Infusion controller/pump (each)
2
Swan Ganz PAP/PA wedge reading
q2h or x 12
4
6. TREATMENTS/PROCEDURES/MEDICATIONS
22
Cardiac output tid or x 3
2
50
Insert NG
2
3. ACTIVITIES OF DAILY LIVING
51
Pre-op prep/enema/Ace wraps/support hose
2
23
Care - age 5 or less (infant/toddler)
6
52
Catheterization - Foley/straight
2
24
Care - age 6 or more - Self/Minimal
2
53
Tube care (exclude Trach) x 2
2
25
Care - age 6 or more - Assisted
6
54
Dressing - simple 5 - 7 mins x 2
2
0
0
0
0
0
0
0
0
0
0
SUBTOTAL A POINT VALUE
SUBTOTAL B POINT VALUE
DD FORM 2551, FEB 92
Page 1 of 2 Pages
Replaces DD Form 2551 TEST, NOV 89, which may be used.
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