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Electronic Nursing Documentation

Electronic Nursing Documentation. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #:. Nursing Unit. General Admission.

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Electronic Nursing Documentation

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  1. Electronic Nursing Documentation

  2. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  3. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Personal Details: Mr / Mrs / Miss / Ms Surname......................................................................................................................................................... Given Name: ............................................................................... Middle Name/s: ........................................................................... Gender: Female Male Date of birth ........../........../.......... Age:........................... Medicare Number: ........................................................................................................................ Expiry date: ........./........./.......... The number next to your name on the medicare card: .................... Telephone No.: (Home) ......................................... (Business) ......................................... Mobile No.: .......................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  4. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Email address:................................................................................................................................................................................... Country of birth: ................................................................................... Language spoken:.............................................................. Interpreter Required? Yes No Aboriginal origin Yes No Torres Strait Islander origin Yes No Marital Status: Married Defacto Never married Widowed Separated Divorced Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  5. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Religion: ................................................. This information enables us to provide appropriate services to you whilst you are here and is generally available to accredited chaplains at this facility. If you want your religion withheld from the chaplaincy service please tick this box Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  6. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Permanent Address: Street number or property name:................................................ Street Name: ............................................................................... Suburb/Town: ............................................................................. State: .............................................. Postcode: ......................... Temporary Address for Visitors (Overseas or Country Patients): Street number or property name:................................................ Street Name: ............................................................................... Suburb: ...................................................................................... State: .............................................. Postcode: ......................... Telephone No.: (Home) ......................................... (Business) ......................................... Mobile No.: .......................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  7. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission General Practitioner / Local Doctor: Surname: ................................................................................................ Given Name:.................................................................... Address: ............................................................................................................................................................................................ Telephone No: ........................................................................... Fax No:......................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  8. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Hospital has an active Mailing Program. Would you be happy to receive this information? Yes No Signature: ................................................. Date: ........./........./......... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  9. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission P.A.C. date: ........../........../.......... Ward: ................ Initial Admission date: ........../........../.......... Updated on Computer Office Use Only Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  10. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission FINANCIAL DETAILS 1. Centrelink No:................................................ (if applicable) 2. Private Health Fund Information: Are you a member of a Health Fund? Yes No Name of Fund:....................................................................................................................................................................................... Membership No.: ............................................................................... Table of Cover Basic Top Cover Date joined Fund: ........../........../.......... Date joined current Table of Cover: ........../........../.......... Excess Payable? No Yes Amount: Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  11. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Person Responsible for Account (contributor): Relationship to Patient:.......................................................................................................................................................................... Mr / Mrs / Miss / Ms Surname: ............................................................................................................................................................. Given Name:.......................................................................................................................................................................................... Home phone: ............................................................................. Other phone:..................................................................................... Street No. or Property Name: ................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  12. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Your Preferences: Have you elected to be treated as a Private Patient? Yes No If yes, please specify your preferred accommodation. Single Shared Whilst every effort will be made to provide the accommodation you request, this is subject to availability at the time of admission. Accommodation costs will be billed to the actual accommodation occupied. Thank you for supporting Hospital. Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  13. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Veterans’ Affairs: Are you a Veterans’ Affairs patient? Yes No Do you need DVA transport Yes No Veterans’ Affairs Card Number: ................................... Card colour: White Gold Orange Serving Unit: ................................................................ (eg. 2nd / 1st InF BN) Veterans who do not wish to receive a visit by an Ex-service/Volunteer organisation representative (ESO) must advise the hospital. If you want the above information withheld from the ESO please tick this box Army R.A.A.F. P.O.W. Europe Navy T.P.I. Veteran Japan Other Vietnam Veteran Korea War Widow Vietnam Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  14. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Workers’ Compensation / Third Party Liability Claims: Are you entitled to Third Party Liability Claim? Yes No Are you entitled to Workers’ Compensation (approval required)? Yes No Did the accident occur in the course of your employment? Yes No Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  15. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Employer Name:.................................................................................................................................................................................... Employer Address:........................................................................................................................................... Postcode: .................. Contact Name:....................................................................................................................................................................................... Claim Number:....................................................................................................................................................................................... Insurer Name:..................................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  16. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Date of Injury: ........../........../.......... Solicitor’s Name: ................................................................................................. Telephone No.:........................................................ Address: ................................................................................................................................................................................ Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  17. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Overseas Visitor: Are you a member of a health fund / Travel Insurance? Yes No (If yes, complete Health Fund details in paragraph 2, and bring documentation of your insurance with you) Overseas Address:........................................................................................................................................................................... Town / City: ........................................................................... Postcode .................... Country:..................................................... Passport number: ............................................................................................................. Date of entry visa ........../........../.......... Reciprocal Rights: Yes No Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  18. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Person to Contact: Relationship to patient: ................................................................................................... (eg. neighbour, wife, sister, partner, etc.) Surname:.......................................................................................................................................................................................... Given Name: .................................................................................................................................................................................... Gender: Male Female D.O.B.: ........../........../.......... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  19. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Street Address:.................................................................................................... Suburb / Town: .................................................. State:.......................................................................................................................................................... Postcode: ................... Home Phone Number: ..................................................................................................................................................................... Work Phone Number: ...................................................................................................................................................................... Mobile Phone Number: .................................................................................................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  20. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Next of Kin / Power of Attorney: Relationship to patient: ............................................................................................. (eg. husband, wife, other relative, child, etc.) Surname:.......................................................................................................................................................................................... Given Name: .................................................................................................................................................................................... Gender: Male Female Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  21. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission D.O.B.: ........../........../.......... Street Address:.................................................................................................... Suburb / Town: .................................................. State:.......................................................................................................................................................... Postcode: ................... Home Phone Number: ..................................................................................................................................................................... Work Phone Number: ...................................................................................................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  22. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission COMMENTS: ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  23. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission .............................................................................................. ........../........../........ Patient’s/ Guardian Signature Date Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  24. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission CANCELLATION / DEFERMENT FORM Surname: Given Name/s: Address: Date of Birth: ......../......../........ Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  25. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Deferment of Admission: I request that my admission be deferred. My reason for requesting deferral is: I am going away on holidays. Inconvenient at this time. Work commitments prevent me from being admitted. Home support not available. Other (please specify) ............................................................................................................ Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  26. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission I will be available after ........./........./......... Please note: If you defer your admission on TWO occasions for non-medical reasons your name will be removed from the waiting list. Signature:.................................................... Date ........./........./......... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  27. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Cancellation of Admission: I request that my admission be cancelled. My reason for requesting cancellation is: I have had the procedure done elsewhere. My doctor advises that the procedure is not necessary. I do not wish to have the procedure performed. Other (please specify) ............................................................................................................ ............................................................................................................ Signature:.................................................... Date ........./........./......... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  28. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Official Use Only Previous Admission Date Previous Procedure Date Previous PAC Date Cancellation/Deferment Acknowledged Visit ID WARD Fin Class Signature:................................... Date: ...../...../..... New Admission Date Procedure Date New PAC Date Signature Patient advised by: Transport Arrangements Signature / Date Phone / Letter / Fax / Rooms SPECIALIST PROCEDURE Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

  29. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment OXYGEN: CardiovascularRespiratory Skin warm to touch? Respiratory rate      Rhythm      Skin color      Audible breath sounds      Color of nail beds      Dyspnea - at rest on exertion Temperature      Location      Cough Sputum None Radial pulse rate       Rhythm       Smokes Packs per day   Apical pulse rate      Rhythm       * Medications      BP: Location     Position       Laboratory data       Peripheral Pulse       Pulse ox      Equipment in use (O2 , flow rate)      Pain Scale # NU FA Additional data:       Capulary Refill      

  30. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment FLUIDS AND ELECTROLYTES: Skin turgor - Normal Poor Presence of thirst some, does not drink water Tongue and lips      Nausea or vomiting Mucous membranes      Presence of edema none Fluid intake for previous 24 hrs       *Medications      Fluid restriction (Note amt q 224 hrs & distribution q shift) Laboratory data       Equipment in use       Additional data:     

  31. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment NUTRITION: Ht     Wt       Dentures? Upper Lower Partial Ordered diet      Recent change in weight?       Preferred foods      Problem chewing? Swallowing? Heartburn? Indigestion? % of meal consumed      *Medications      Dietary supplement       Laboratory data      Assistance with meals       Equipment in use (N/G tube, PEG tube, G tube, etc.)      Additional data:     

  32. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment ELIMINATION: Urinary: Bowel sounds      Abdominal distention Amount     Color       Frequency       *Medications      Bathroom Commode Bedpan Incontinent Laboratory data      Total output for previous 24 hrs    ml Equipment in use      Bowel: Amount      Color      Frequency      Additional data:      Normal for client Constipated Diarrhea Incontinent

  33. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment MOBILITY AND ACTIVITY: Fall Assessment Score      Muscle strength - Handgrips equal Fall risk - High Moderate Low Foot pushes equa l Physical therapy working with client?      ROM - Normal Limited Severely limited *Medications      Ability to move in bed - Self Assist Immobile Laboratory data      OOB - Chair Wheelchair Geri-chair Equipment in use (assistive devices)       Ability to transfer - Self Assist      Additional data:      Distance able to ambulate       Gait     

  34. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment REST, SLEEP AND PAIN: Reported quality of sleep in hospital      Observable signs of pain - Grimacing Posturing Moaning C/O Pain - *Medications_____________________________________________ Location       Pain Scale # NU FA Intensity      Additional data:      Duration     

  35. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Vision: Skin integrity: Able to see without glasses Needs glasses Intact Able to read own menu Reddened Location      Watches TV from      ft Blancing erythema Non-blancing erythema *Medications      Incision/Lesion/Wound Location      Approx. size in cms      Hearing: Appearance      Responds to normal voice tones Treatment (dressings, etc.)      Hearing aid Deaf *Medications     

  36. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Speech: Allergies      Clear Garbled Incomprehensible Laboratory data      Mental status: Environment: Alert Lethargic Unresponsive Physical surroundings      Oriented to - Person Time Place *Medications      *Medications      Additional data:      Braden/Norton Score #       Risk: High Moderate Low

  37. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Client report of family/friends      Next of kin (chart)             Religious affiliation      Indicators - Cards Flowers Family pictures Additional data:     

  38. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Family role       Grooming equipment at bedside:      Occupation      Brush/comb Toothbrush Toothpaste Interest in appearance      Other personal toiletries Additional data:     

  39. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Client report of satisfaction with life       Additional data:      Independence      Creativity     

  40. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Nursing Admitting History

  41. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order REQUIRED INFORMATION FOR REFERRAL Patient’s Medical Record Number OR Patient First Name _________ _____________________________________ Patients Last Name ________________________ Select Appropriate Facility : _____________________________ Gender:  Female  Male Name of Patient’s Parent/Legal Guardian _________________________________________ Nursing Assessment

  42. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order Chief Complaint/Reason for Referral: ________________________________________________________________ Refer To:  Emergency Medicine  Emergency Medicine + consult  Sub specialist/other  Test Only You must notify any consultants/sub specialists before initiating a referral to the Emergency Department. Sub specialist/Consultant Name: ______________________________ Service: ____________________________ Pager/Phone Number: _______________________________________ or  page on-call physician/resident Nursing Assessment

  43. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order Referring Physician: ________________________________________Office/pager (_______)______________________ After Hours ____:____ AM/PM Call (_______)______________________________ Callback Instructions:  After MD assessment (prior to labs and tests)  After ED evaluation  Only if concerns or admitted  No callback requested Callback Physician:  Same as referring physician  On call for practice Callback Phone Number:  Same as office number  Same as after hours number  Other (_______)____________________________ Nursing Assessment

  44. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order Call back after six hours if patient does not arrive? (Calls are made between 9 AM and midnight)  Yes  No Patient Transferred From:  Home  MD office  Other: _________________________________ Clinical information (use additional sheets if necessary): ___________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________ Nursing Assessment

  45. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order Labs/X-rays/Treatments  CBC  Blood culture  Urinalysis  Urine culture  Lumbar puncture  Electrolytes  Chest-x-ray  IV fluids  Other______________________________ Nursing Assessment

  46. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Protocol Per Diagnosis Myocardial Infarction inbalance Oxygen (O2) demand supply Asses the severity, location & duration of pain (report) Administer O2 with semi-fowler's position Obtain a 12 lead ECG during pain Monitor vital signs Administer Nitroglycerine & Narcotic analgesics as ordered Administer & Monitor Thrombolytic therapy Ensure rest & sleep, provide a comfortable environment Monitor patient's response to drug therapy Nursing Assessment Physicians’ Order

  47. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Protocol Per Diagnosis Myocardial Infarction decrease cardiac output Monitor cardiac rate, rythm & conduction (report any change) Observe vital signs, ECG, urine output, skin temp & colour Administer prophylactic anti-arrhythmic & other drugs as ordered Administer IV fluids Promote physical & mental rest & comfort Monitor laboratorium result Keep anti-dysrhythmic drugs & defibrillator ready Nursing Assessment Physicians’ Order

  48. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Protocol Per Diagnosis Myocardial Infarction respiratory difficulties (dyspnoea) Asses for any dyspnoea, abnormal breath sound (report) Ensure propped up position, rest & comfort Administer O2 & drugs as ordered Psycological support, give liquid diet Nursing Assessment Physicians’ Order

  49. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Protocol Per Diagnosis Myocardial Infarction anxiety & fear of death Encourage patient & family to express fear or anxiety by interest, listening, caring Explain the procedures being done on him Psycological & spiritual support Administer morphine or other anti-anxiety drug Nursing Assessment Physicians’ Order

  50. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Plan of Care Problem/Need COGNITIVE AND COMMUNICATION Altered level of cognitive function due to dx of patient has: memory problems impaired decision making skills impaired ability to comprehend difficulty understanding what is being said as well as being understood

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