QUALITY CARE NURSING SERVICES, INC. EXTENDED HOUR NURSING FLOW SHEET NOTE Name: 1 of 2 M.R. #: Time In: Time Out: Emergency Equipment Check Total Hours: Date: Pt. ID Verified Consent Received Care Plan / MD Orders Checked AmbuBag / Extra Trach on site VITAL SIGNS Temp Time Infection Control Kit / Micro Shield Pulse Resp. Rate BP Last Date DME Equipment Check Weight Ibs. kg. OZ. NUTRITIONAL ASSESSMENT Verbal Non Verbal Semi-Comatose Sedated Alert Lethargic Comatose Yes No Appropriate for Age: Flaccid Jittery Rigid Tone: Active Sunken N/A Fontanel: Flat Tense Bulging Soft Suck Gag Grasp Blink Reflexes Present: Startle N/A Other: Yes No See Seizure Record Seizure Activity: .p n SA sy M ste PL m E .co NEUROLOGICAL w w w RESPIRATORY Regular Shallow Grunting Panting Labored Abdominal Nasal Flaring Retractions Mild Deep Clear Rales Rhonchi Diminished Breath Sounds: Wheeze Inspiratory Expiratory If other than clear indicate lobe or lobes adventitious Breath sounds auscultated: Non-Productive None Cough: Productive N/A Secretions: Amount: Small Moderate Large Thick Consistency: Thin Tenacious Frothy Yellow Clear Green White Blood tinged Color: Tan Frank Bleeding Delay Low Apnea Monitor Alarm Setting: High Pulse Oximetry: Continual Intermittent NC Mask Trach Oxygen: L/min via: Intermittent Continual Other: 02 Saturation: RESPIRATORY CARE Size: Cuffed Uncuffed Tracheostomy Type: Date last changed: RN MD Changed by: Other 1/2 strength H202 + H20 NS Warm soapy H 2 0 Trach. Care: Clean Sterile Technique: Trach. Ties Changed (Date) using clean Inner Cannula Changed: sterile technique Intact Redness Excoriation Drainage Trach. Site: Dry Supervisor Intervention: MD notified RN notified Other: VENTILATOR Type: TV. Rate: PEEP: Alarm Checked / Set At: High Equipment Cleaned Solution Used: Hrs. / Day on Ventilator: CARDIOVASCULAR Heart Tones: Strong Irregular Murmur Regular Other: Color: Pink Flushed Pale Dusky Cyanotic Jaundiced Warm Cool Skin Temp: Diaphoretic Clammy Cold Hot Edema: No Yes Site: LUE LLE RUE RLE Less than 3 seconds Greater than 3 seconds Capillary Refill: LUE RUE FILE LLE Strong Peripheral Pulses: Bounding Weak Thready Doppler Absent Other: LUE LLE RUE RLE HEAD (Circle R for Right or L for Left) Face: Symmetrical Asymmetrical Ears: Unremarkable Other: Low R L Eyes: Cornea: Clear R L Opaque R L Sclera: White R L Jaundiced R L Hemorrhage R L Patent Nose: Other: Mouth: Unremarkable Other: m Regular Restricted / Type: Diet: NPO Formula -Type: Other: Breast Frequency: Amount: No Restriction Fluids: Restriction LOW HIGH Nutritional Screening Risk: MED Poor Fair Appetite: Good CPAP: rate PIP: Low MUSCULO-SKELETAL Full ROM Comments: Contractures Limited ROM Reposition q 2hrs. SKIN CONDITION Intact Clear Peeling Rash No S/S infection Wound/Decubitus site: Size: Drainage: Type of Dressing: Wound Care: GASTROINTESTINAL Abdomen: soft Tense Flat Distended Present Bowel Sounds: Hyper Hypo Absent Feeding Tube: N/A NG Mickey Button J Tube G Tube Feeding Tube Care: 1/2 strength H202 + H20 NS Other: Warm Soapy H 2 0 Flushes: Solution , Amount , Frequency Intact GT Site: Dry Redness Excoriation Drainage No S/S of Infection Other GENITO-URINARY Unremarkable Discharge Circumcised Bladder Frequency: Odor: Urine: Color No Appearance: Yes Foley Cath Suprapubic Intermittent INTRAVENOUS Access: N/A Peripheral CVL PICC Port Location: Intact Site Condition: Without Redness or Swelling Dressing Changed using: Aseptic technique Sterile Transparent Other: Tubing Changed Bag Changed Cap Change Irrigated / Flushed with: Labs: N/A Tests: Site used: Labs Taken to: or Picked up by: Other: QUALITY CARE NURSING SERVICES, INC. EXTENDED HOUR NURSING FLOW SHEET NOTE Name: M.R. #: PHYSICIAN NOTIFICATION PATIENT EDUCATION MD Called Time: Orders received No new orders PAIN Yes Pain Behaviors: Moaning Grinding Teeth Topic: Taught to: Method: MD to call back Pt./Pcg. Response: Level of Understanding: No Crying Restless Irritable No Yes If yes, describe in narrative section INTAKE RECORD Fair Good Poor Needs Reinforcement Eval. Method: Verbal Return Demo Need for further teaching: Yes No Caregiver Lacks knowledge of: Equip. Therapies Disease process Medications Diet m Discharge Planning Reviewed N/A at this time Consults Needed: OUTPUT RECORD Total Hr. Urine Stool Blood Emesis Other Time: Total: w w w Time: PCG not available Patient Family Pcg. Other Discussion Demo Handout Video .p n SA sy M ste PL m E .co Intervention: Date: Night Shift / /teaching not appropriate Spoke with: To report: 2 of 2 Total: NURSING DOCUMENTATION / SHIFT SUMMARY: Nurse Signature: RN / LPN-LVN (circle one) Reviewed by: Pt. / Pcg. Signature: White - Medical Record Yellow - Patient Record QUALITY CARE NURSING SERVICES, INC. NURSING PROGRESS NOTES CONTINUATION Client's Name: SHIFT: w w w .p n SA sy M ste PL m E .co m TIME Name: Nurse Name / Title: Signature: Date: Nursing Progress Note Date of Service Florida Home Health Care Providers Time in: / M T W / Th Patient Name Patient Number Employee Name (print) Employee Signature/Title F Sa Su Left Right Lying Sitting / / Standing / / Pain intensity scale: 0 --1--2--3--4--5--6--7--8--9--10 (circle) Meds: Relief: / / LPN Supervisory Visit Following plan of care Y / N Activity: Walker/Cane Wheelchair Prosthesis Walls / Furniture Homebound Status Bedbound Chairbound SOB/DOE ___ feet Pain limits mobility Unsteady gait Other: (check all that apply) Uses assistive device: Taxing effort to leave home Unsafe to leave home unsupervised Medically contraindicated Needs assist ____ people to ambulate/transfer Elimination IV Site Assessment WNL WNL Colostomy Illeostomy Erythema Drainage Constipation Diarrhea Suture Out Induration Impaction Blood stool Rash Edema Incontinent Phelebitis Pain Rectal bleeding Location ______________ / / Last BM Gauge ______________ WNL Nutritional Status Inadequate fluid/food intake Insertion Date ______________ N/A Diet changed to Genitourinary System WNL Skill Instruction Frequency Polyuria Patient Caregiver Oliquiria Nocturia Retention Hernaturia Instructed on: _____________________ Burning/Pain Urgency ______________ ______________ Incontinence Diaper ______________ Catheter Type Size ______________ Urine Color: ______________ Odor: Appearance: ____________ Stents Urostomy _____________ WNL Genitalia ______________ ____________ Lesions Discharge ________________ Pain Bleeding _____________ Pelvic Pressure Itching _____________ Cyanosis _____________ ________________ WNL Endocrine System _______________ _____________ Polyuria Polydypsia ________________ Heat/cold tolerance _____________ Sweating ______________ Capillary BS _____ am/pm F/NF ___________________ ______________ Glucometer Calib ___ / ___ / ___ _______________ ________________ _______________ IV Dressing Assessment WNL .p n SA sy M ste PL m E .co Skin System WNL Petechiae Surgical incisions Jaundice Pruritis Poor turgor Dry/cracked Rash Pallor Clammy Bruises Flushed Sutures Skin tears Hyperpigmented Pressure areas: Open wound: Other: w Cardiovascular System WNL Tachycardia Arrhythmia Bradycardia Chest pain Cyanosis BB Change Distended neck veins Edema-RUE +1 +2 +3 +4 Edema-LUE +1 +2 +3 +4 Edema-RLE +1 +2 +3 +4 Edema-LLE +1 +2 +3 +4 Pitting Pacemaker Other implanted cardiac devices Capillary Refill >3 sec Weight: w Contractures Pain Trauma/Fracture Unsteady gait Amputation Decreased ROM PM x B/P: Mental Status WNL Confused Combative Comatose Depressed Agitated Disoriented Forgetful Lethargic Stuperous WNL Nervous System Headaches Diplopia Vertigo Numbness Unsteady Gait Seizures Tinnitus Tremors Hyperreflexia Paralysis: Location Sensory System WNL Impaired vision Impaired hearing Dysphasia Aphasia, expressive/receptive Respiratory System WNL Lung sounds: Left Right Rhonchi Decreased BS Inspiratory wheeze Expiratory wheeze Orthopnea SOB Hemoptysis DOE ___ Ft Cough Productive Dry Sputum color Sputum amount Oxygen L/min via SOB relieve by rest Musculoskeletal WNL PM m (circle) Po/Ax/ Pr Ap / Rd AM LPN RN Aide Supervisory Visit Patient Signature w Vital Signs Temp: Pulse: Resp: Pain Location: Type: Time out: AM Visit Type (mark all that apply) X I was seen by the nurse today. I am satisfied with the services I received. I confirm that the time in/time out are correct (Page 1 of 2) Peripheral Pulses Diminished WNL Absent Gastrointestinal System WNL Oral Stomatitis Ulcers Bleeding gums Lesions Dry mouth Cramping Coated tongue Stiffness Abnormal Mouth Odor Tremor Swelling Digestive System WNL Weakness Abdominal pain Abdominal distention Absent/Decreased bowel sounds Epigasric distress Dysphagia Nausea Vomiting Anorexia Feeding tube (type): Site: cm Ascites (abd.girth.) Odor wet Soiled Outcome: Missing Dressing Change Maintenance: Patient caregiver verbalized / demonstrated: Not done this visit Competent knowledge Hibiclense Minimal knowledge PVP / Oint / Swabs No knowledge Alcohol Swabs Pt./Cg unable to Gauze Steristrips retain knowledge due to: Transparent Dressing ___________ ______________ Skin Prep _______________ Tubing Change ________________ Extension IV N/A _______________ Florida Home Health Care Providers Nursing Progress Note Supplies Used: N/A Wound care supplies Gloves Glucose monitoring supplies Foley catheter Insulin administration supplies Irrigation kit Other: Needles / syringes (Cont.) Wound #1 Location: N/A Wound #2 Location: Wound #3 Location: Cleansed with: Cleansed with: Cleansed with: Rinsed with: Rinsed with: Rinsed with: Applied: Applied: Applied: Packed with: Packed with: Packed with: Covered with: Covered with: Covered with: Secured with: Secured with: Secured with: Notes on Abnormalities, Skilled Interventions and Patient Response to Treatment: All systems assessed Vital signs WNL Blood sugar checked Patient tolerated procedure well No C/G available who is willing/able to provide/learn to provide injection Patient unable to self-inject N/A Injection Management .p n SA sy M ste PL m E .co m Insulin administered per doctors orders Physical/mental limitations preventing patient from being able to self-administer __________ due to: ________________________________________________ Patient resides in ALF; Florida state regulations prohibit ALF employees/caregivers from administering injections to residents Patient able to self-inject insulin Wound #1 Location: Odor w Exudate: Color N/A Edges w w ____ L ____ W ____ D Wound #2 Location: Surrounding skin: Color Induration C/G willing to learn injection administration SN search for alternate C/G to administer injection ongoing ____ L ____ W ____ D Wound #3 Location: ____ L ____ W ____ D Surrounding skin: Color Surrounding skin: Color Induration Induration Edges Exudate: Color Odor Exudate: Color Edges Odor Observed standard / contact precautions Aseptic technique Biomedical waste disposed of per agency protocol Glucometer calibrated Clean technique Needles / syringes disposed of in sharps container Drug/Solution Dose/Volume Novolin 70/30 Forteo Regular Heparin Flush Saline Flush Labs checked N/A Medication Administration by Skilled Nurse uts/ml ml Site / IM / SQ / IV Pump program verified Route/Pump Rate/Time Start/Complete
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