Evaluation & Monitoring
Vital Signs 6:00 8:00 8:30 10:00 11:00 12:00 13:00
Heart rate (Beat/min)
Respiratory rate (Breath/min)
SBP (mmHg) 120
DBP (mmHg) 80
Mean BP(mmHg) 40
SaO2 (%) 99 Room air
Temperature (°C) 36.9
PEFR(L/min)
Blood glucose(mmol)
Insulin Dose(Unit)
ECG
Intake
Method
Diet Served
Water(mL)
Intake
Method
Diet Served
Water(mL)
Response
Vital Signs 6:00 8:00 8:30 10:00 11:00 12:00 13:00
PR (Beat/min)
RR (Breath/min)
SBP (mmHg)
DBP (mmHg) 120
Mean BP(mmHg)
SaO2 (% on RA) 99 99.9
Temperature (°C) 36.9 36.9
PEFR(L/min)
Blood Sugar(mmol)
Insulin Dose(Unit)
ECG
Intake
Method Spontaneous PEG tube NGT (100mL) Syringing
Diet Served Pure carbohydrate diet Restricted fluid diet Low protein
Water(mL) 800
Response Finished Partially eaten Not eaten
Urine Output
Method Foley’s Catheter Condom catheter Spontaneous
Quantity 100mL/hr No output
Color Yellow Hematuria
Content Clotted blood Clear urine
Odor Smelly Not smelly
Bowel motion 6:00 8:00 8:30 10:00 11:00 12:00 13:00
Method Self voiding Rectal seal Diapers Colostomy
Frequency 1
Quantity 100mL
Color Brown
Content Blood
Consistency Semisolid
Odor
Wound Sore
Site
Size
Discharge Serous Sangui¬neous Serosangui¬neous Purulent Bloody
Discharge amount None Scant Small Moderate Large
Discharge consistency Low viscosity High viscosity
Discharge odor None Strong Foul Pungent Fecal Musty
Dressing Dry Soaked Leaking
Higher Function
GCS M3V4E5
Cognitive impairment Yes No
Visual impairment Yes No
Breathing
Method Tracheostomy O2 Mask CPaP Mech Vent Spontaneous
O2 Flow rate (L/min) 1LPM/hme 0.25L o2, 0.5L O2
Humidifier Yes No
Rt Upper Lobe
Rt Middle Lobe
Rt Lower Lobe
Rt Air Entry
Lt Upper Lobe
Lt Lower Lobe
Lt Air Entry
Suction*GI-Resp
Route Tracheal
Amount Moderate
Color Whitish Watery
Content
Consistency Loose
Odor Not smelly
General Care
Mobility impairment Yes No
Mobility impairment type Bedridden
Do not mobilize Lower limb
Fall risk
Fall History during last Yes No
Restraint
Do not take samples from
Dressing (site) Clean Soaked
IV site 1
IV status 1
IV drug library used 1
Bed Care
Position Supine On the right On the left Prone
Position changed to Supine On the right Lying on left side Prone
Pneumatic compression
Mattress compression
Musculoskeletal
Cast
Slab
External Fixation
Environmental Safety
Call bell available check Yes
Telephone available check None
TV remote control available check None
Bed light available check Yes
Trash bin available check Yes
Water available check Yes
Room lightning adequate and working Yes
Side rails up Yes
Patient is wearing non-skid footwear None
Reason for do not wearing Bedridden
Floors are clean and dry Yes
Trash bins are empty Yes
Laundry bags are empty None
Exit signs are visible Yes
Body measurements
Height (cm)
Weight (Kg)
Head circumference (cm)
Chest circumference (cm)
Abdominal girth (cm)
Hip circumference (cm)
Waist circumference (cm)
Rt thigh circumference (cm)
Lt thigh circumference (cm)
Rt leg circumference (cm)
Lt leg circumference (cm)
Procedure/Monitor
Chest tube Placed Removed Changed
IVC Filter