Download EXTENDED HOUR NURSING FLOW SHEET NOTE 1 of 2 Name: M.R. #:

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:
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NEUROLOGICAL
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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:
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Time:
PCG not available
Patient
Family
Pcg.
Other
Discussion
Demo
Handout
Video
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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:
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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
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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:
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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
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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
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____ 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