VAN WERT COUNTY HOSPITAL. Policy/Procedure: Departmental No.: N 1-11A. Issue Date: 5-90 By: Nursing No. of Pages: 5

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1 VAN WERT COUNTY HOSPITAL Policy/Procedure: Departmental No.: Issue Date: 5-90 By: Nursing No. of Pages: 5 Reviewed: 2-07, 1-05, 1-04 Revised: 1-11 Distribution List: All Nursing Departments Concurrence: Subject: Nursing Flow Sheet Purpose: To facilitate patient documentation in a timely manner To provide consistency in recording patient data To provide easy access to patient data May be performed by: RN, LPN, PCT where scope of care appropriate Equipment: 1. COW or downtime form 2. Stethoscope, sphygmomanometer, thermometer 3. Flashlight, if indicated Procedures: A. New form is initiated on admission and at 2300 hours for each hospital day 1. Place patient identification data on the upper right hand corner of all pages 2. Fill in diagnosis, allergies, and appropriate dates on first page, upper left hand corner B. First page of Flow Sheet, line: 1. Bath/Linen Change 2. Oral Hygiene - Write in - i.e.: toothettes/mouthwash, toothpaste 3. Back Care with - Write in - i.e.: lotion/powder 4. Foley Care - Items needed: warm soapy washcloth, towel - Use (*) if reference to Nurses Progress Notes needed - i.e.: excessive drainage, redness, swelling - Write d/c in square if discontinued

2 Page 2 5. Activity - Write in appropriate hourly square: A = Ambulate B = Bed C = Chair D = Dangle H = Hold - Use (*) if reference to Nurses Progress Notes needed - i.e.: amb. gait unsteady 6. HOB - Write in appropriate hourly square ^ for elevation and estimate degree of elevation : 0 or -- if no elevation 7. Turn R L B - Write in : R = right side L = left side B = back S = Self as per legend at bottom of page or write across squares if patient turning/moving self 8. Exercise ROM - Check appropriate hourly square or self if patient moving about per self. 9. Restraints Loose / Circ Check q2 hrs - Check appropriate hourly square - Use (*) if reference to Nurses Progress Notes needed - i.e.: restraints applied only when family not present 10. Hydration Offered - Check appropriate hourly square when fluids offered and taken 11. Fall Risk - Write in number of points using attached criteria form - Document nursing interventions in Nurses Progress Notes 12. Call Light Within Reach - Check hourly square when call light within reach of patient or bell given patient 13. Side Rails up x - Write in : 1, 2, 3, or 4 in appropriate square at beginning of shift following hourly squares checked unless number of side rails up changes 14. Night Light - Check hourly square night light in use 15. Cough / Deep Breathe - Check hourly square when patient coughs and deep breathes 16. Pulse Ox Probe - Write in "cont" beside pulse ox probe if cont. and percent and number - i.e.: 95 in hourly square; if cont., must write number in each square. - Write d/c in square when discontinued 17. Incisions - Write in number of incisions; check in hourly square if clean and dry - Write in according to legend: R = Red swollen S = Staples ST = Steristrips WA = Well approximated WT = Warm/tender - Use (*) if reference to Nurses Progress Notes needed - i.e.: weepy incision, or anything different than legend code

3 Page Dressing Check/Change - Write in number of dressings; check in hourly square if clean and dry. - Use (*) if reference to Nurses Progress Notes needed- i.e.: drainage, etc. - Use ( ) in hourly square when dressing changed - Write d/c in hourly square when dressing discontinued 19. Peripad Check /Change - Check appropriate hourly square when peripad checked - Use ( ) symbol in hourly square when changed - Use (*) if reference to Nurses Progress Notes needed for further explanation; i.e.: amount, color of drainage. - Write d/c in appropriate hourly square when discontinued 20. IV Site Check - Follow IV legend at bottom of page: - 0 = no redness / no swelling / no pain - 1 = painful / no redness / no swelling - 2 = redness / no pain / no swelling - 3 = painful swelling / redness - Write d/c in appropriate hourly square when discontinued; every hourly square should be filled in duration of IV. 21. IV Dsg Check - Check appropriate hourly square when checking dressing; every hourly square should be filled in duration of IV. 22. PCA/ Epidural Check - Check hourly square when assessed - Write d/c if discontinued 23. Ng Site R L (PO --- Irrigate) - Circle nares: R = Right L = Left - Check appropriate hourly square when assessed - (Disregard PO --- Irrigate) 24. Tube Feeding Rate - Write in number in hourly square - i.e.: 15 and check each hourly square of tube feeding 15cc/hr until rate changed; then write in number change - i.e.: 30cc followed by check marks until rate is changed or discontinued 25. Check Ng/TF for Residual #cc 26. Chest Tubes x R L - Write in number of chest tubes thru skin, then circle R for right chest or L for left chest - Check in appropriate hourly square when chest tube assesse - Write d/c in appropriate hourly square when chest tube discontinued

4 Page Chest Tube Suction Cm H2O - Write in appropriate setting ordered - i.e.: -20, -30 followed by check mark in appropriate hourly square until setting ordered changed 28. Hemovac - Write in number of hemovacs - i.e.: x 2, x 1. - Check in appropriate hourly square when assessed - i.e.: Hemovac in place but does not stay compressed 29. Jackson-Pratt - Write in number of JP's - Check hourly square when assessed - Use (*) when reference needed to Nurses Progress Notes 30. T-Tube - Check appropriate hourly square when assessed - Use (*) when reference needed to Nurses Progress Notes - i.e.: site reddened or drainage coming from site around T-tube 31. Buck's Traction/Abductor Wedge - Write in number of pounds of traction - Check appropriate hourly square when assessed. - Use (*) when reference needed to Nurses Progress Notes - Write d/c in square when discontinued 32. Overhead Frame - Check appropriate square when overhead frame used - Write in "trapeze" if used. 33. Hot Ice Machine (temp) - Check appropriate hourly square used and assessed - Write d/c in square when discontinued. - ( Disregard temp) 34. CPM indicate degree of flexion - Write in "on" and "off" in appropriate square plus degree of flexion - i.e.: on/70, off/ SEQ Compression Stockings - Check appropriate hourly square stockings on 36. TED Hose / A-V Impulse System Foot Pump - Check appropriate hourly square stocking / foot pump on - For Foot Pump, add to column beside TED Hose 37. Mansfield Heating Pad - Check appropriate hourly square when heating pad on - Write in where applied - i.e.: L shoulder

5 Nursing Flow Sheet Page Lab/EKG/X-Ray/ABG - Write in appropriate hourly square: CBC, CP, UA, H+H/UA, CBC/Chest, ABG/EKG when drawn/ complete 39. Results Call to Dr. - Check in appropriate hourly square 40. Initails - Place your initials in appropriate column 41. Diet/Appetite -Write in diet under Breakfast / Lunch / Dinner; i.e.: 1800 Cal ADA 42. Type - Write in: CL, FL, Soft or Reg. 43. % - Write in percentage of food intake and on bulletin board in patient's room 44. Doctors Visit - Write in name of doctor and time doctor in 45. Family Visits/ Emotional Support - Write in - i.e.: son in, friend in, minister here, priest in /anointed 46. Signitures - Required only once per page C. Second and third pages of flow sheet: 1. Sign at top of pages in appropriate box 2. Place obtained data in appropriate place under the hour performed 3. Use legend at bottom of page in area applicable D. Fourth page of flow sheet: 1. Place appropriate date at top of page 2. Complete Hospital Day and Post-op Day with correct number 3. See Focus Charting P&P N 1-11B