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Date & Time
Admit to Dr. Jones, North 7A East
Diagnosis
Condition
Allergies
Vital Signs
Activity
Nursing Orders
Daily Weight
NG (to low constant/intermittent wall suction)
Foley (to closed straight bag drainage)
* Incentive Spirometry / Chest Physiotherapy
Dressing Changes / Instructions
Alerts
Fever > 38.5 C
Urine Output < 30 ml/hr
Precautions
Restraints (include type & reason)
Seizures
Manipulations (do not move NG, no BP ® arm)
Diet
IV Solution
Medications
Fever-Headache (acetaminophen)
Antacid
Constipation (stool softener, stimulant)
Sleeping Pill (?)
Meds patient took before admission
Meds appropriate to admission diagnosis
* DVT Prophylaxis
Heparin or Low molecular weight heparin or "TED"s and "SCD"s (Sequential Compression Device)
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