Answered step-by-stepRoom # Date of Care: Date of Admission:

Answered step-by-stepRoom # Date of Care: Date of Admission: Patient’s Initials: Height:… Room #                         Date of Care:                                                                         Date of Admission:Patient’s Initials:         Height:                        Adm. Weight:                                 Age:                                 Sex: Admission VS:                                                   Adm. Diagnosis: Surgery Date/Type:Comorbidities/medical history: TREATMENTS, TESTS, PROCEDURESFill in all that apply: MEDICATION ADMINISTRATIONNAME & ROUTESUpdate from MAR frequentlyActivity   Foley   Drsg. changes: Allergies: Diet   NG      VS   Drains     0700  O2       Procedures – date of care: 0800  Sat   SCDs     0900   Tx   PCA/Epi     1000  IV Site   Tele     1100  Solution   Today’s Wt.   Recent procedures/results: 1200  Rate   Other   1300  Type:       1400  Periph       1500  PICC       PRN Meds:Central         Laboratory Tests: What does this mean for this patient?                               Why is it altered?Nursing considerations?Lab Norms Date Results Date Results                                                                                                                                                Pt’s Weight: ________                                      MEDICATIONS: ALL MEDICATIONS INCLUDING PRNs                     NAMEGeneric & Brand  ACTION DOSE ROUTE FREQUENCYTimes of Admin. SIDE EFFECTS &SPECIAL INSTRUCTIONS CALCULATIONS#                 Recommended safe dose from the drug literature: Per day  Per dose  Child’s ordered dose:Per day  Per dose  Safe:     YES              NO #           Recommended safe dose from the drug literature: Per day  Per dose  Child’s ordered dose:Per day  Per dose  Safe:     YES              NO #           Recommended safe dose from the drug literature: Per day  Per dose  Child’s ordered dose:Per day  Per dose  Safe:     YES              NO #           Recommended safe dose from the drug literature: Per day  Per dose  Child’s ordered dose:Per day  Per dose  Safe:     YES              NO      NUTRITION NEEDSWeight  Percentile  Height Percentile FOC PercentileCalculation formula for Fluid Maintenance Requirements  Calculate Per day Calculate Per hourCalculation formula for Normal Urine Output Calculate Per Hour Calculate Per dayCalculation formula for Minimal Urine Output Calculate Per hour Calculate Per day****ACTUAL INTAKE / OUTPUT****Actual Intake: (your shift)Total  ml/hr:    Is Intake:  >  Maintenance  Maintenance  <  Maintenance            Actual Urine Output: (your shift)Total  ml/hr:    Is Urine Output:  Normal  > Normal  Minimal  Let the Experts Do Your Homework Now

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