PHYSICIAN ORDERS Sally Nelson DOB: 11/29/1941 HCP: Dr. Winters Age: 68 yrs. Height: 67 in. (170 cm) Weight: 145 lbs. (65.9 kg.) MR# PCS62800 Gender: F No Known Allergies Allergies & Sensitivities Diagnosis: Pancreatic Mass PCN, Sulfa, MS sensitivity with itching Date Time PHYSICIAN ORDER AND SIGNATURE (Current date) 0500 Admit to medical oncology for Dr. Winters Vital signs every 4 hours with pain rating and O2 saturation Foley catheter to straight drainage Intake & output and daily weight IV: D5 0.45% NS at 50 ml/hr Oral fluid restriction: 400 ml per 24 hours Activity as tolerated Diet as tolerated Call physician for: HR greater than 100 or less than 60; RR greater than 25 or less than 10; Temp greater than 38.5 C; Pain greater than 4/10 on current meds; Urine output less than 60 ml in 2 hours; SpO2 less than 91% Provide South Dakota Living Will information and 5 Wishes booklet. Consult palliative care team about hospice placement Medications: 1. Lorazepam (Ativan) 0.5 1 mg IV push every 6-8 hours PRN anxiety or sleep 2. Prochlorperazine (Compazine) 10 mg per suppository every 6 hours PRN severe nausea or vomiting 3. Tylenol 500 mg 1 or 2 tablets PO every 6 hours for mild pain; may use 650 mg suppository if client is experiencing nausea/vomiting. 4. MS Contin 30 mg PO every 8 hours as needed for moderate to severe pain. 1
Admitting Dx: Pancreatic Cancer Stage IV Weight: 58.2 kg Allergies: Penicillin, Sulfa; sensitive to IV morphine (itching, no hives, no respiratory distress) Sally Nelson DOB: 11/29/1941 Medical Record Number: PCS62800 HCP: Dr. Winters SCHEDULED & PRN MEDICATIONS N=NPO V=NAUSEA/VOMITING R=REFUSED H=HELD O=OFF-UNIT C=SEE CHART START STOP MEDICATION 0700-1459 1500-2259 2300-0659 MS Contin 30 mg PO every 8 hours prn pain Perchorperazine 10 mg suppository every 6 hours PRN nausea/vomiting Lorazepam 0.5 2 mg IV every 6-8 hours PRN anxiety Acetaminophen 500 mg, 1 or 2 tablets, PO every 6 hours PRN mild pain. May use 650 mg suppository if nauseated/vomiting Initials Legal Signature/Title Property of 2
Date / Time Physician Orders Patient: DOB 00/00/00 HCP: MR #: Date / Time Physician Orders Patient: DOB 00/00/00 HCP: MR #: Date / Time Physician Orders Patient: DOB 00/00/00 HCP: MR #: 3
Physician s Order Name: Physician: DOB: Age: Sex: MR Number: Date Test ABG Analysis Normal Patient ph 7.35-7.45 pco2 HCO3 po2 35-45 mmhg 22-28 meq/l 80-100 mmhg SaO2 95-100% 4
CBC with Differential Sally Nelson DOB: 11/29/41 Medical Record Number: PCS62800 Dr. Winters Allergies: Sulfa, Penicillin, sensitive to IV morphine Date Test Normal Patient Hct (M) 40-50% 48% Hbg. RBC (F) 35-45% (M) 14-18 g/dl (F) 12-16 g/dl (M) 4.5-6.0 m/mm3 (F) 4.0-5.0 m/mm3 12 g/dl MCV 80-90 µm3 MCH 27-31 pg MCHC 32-36 g/dl WBC (M)5,000-10,000/mm3 2,000 Neutrophils 50-70% 5
Eos <4% Basos <2% Lymphs 20-40% Monos 2-10% PLT 150,000-400,000/mm3 76,000 ESR (M) <15 mm/h (F) <20 mm/h 6
Complete Metabolic Panel Patient Name: DOB: Medical Record Number: HCP: Date CMP Normal Patient Na 135-145 meq/l K + 3.5-5.0 meq/l Cl 95-105 meq/l Mg 1.5 2.5 meq/l Glucose 70-110 mg/dl BUN 10-20 MG/DL Creatinine 0.2-1.0 MG/DL Calcium 9-11 MG/DL Total Protein Albumin 6.0-8.0 GM/DL 3.5-5.0 GM/DL 7
INTAKE and OUTPUT Beverage cup 200 ml Glass, juice 120 ml Glass, water 200 ml Broth 120 ml Cream soup 240 ml Gelatin 120 Creamer 10 ml Ice cream/sherbet 90 ml Ice cubes 1 cup 120 ml Milk carton 240 ml Pop small can 240 ml Pop regular can 360 ml Popsicle (whole) 74 ml Syrup 30 ml Time Intake (0600-1400) Time Intake (1400-2200) Time Intake (2200-0600) Total PO: Total IV: Total PO: Total IV: Total Total Total Total PO: Total IV: Time Output (0600-1400) Time Output (1400-2200) Time Output (2200-0600) Total Urine: Stool: color, character, amount Drain(s): Total Urine: Stool: color, character, amount Drain(s): Total Urine: Stool: color, character, amount Drain(s): Total Total Total 8
Patient Information Card Patient Name: Diagnosis: History: Type of operation: Height: Weight: Consultation: Age: Gender: Physician: Advanced directives: Diet: Fall precautions: Restraints: Isolation precautions: Allergies: Unit: Support person: Phone contact: Immunization status: Monitoring: I/O VS q _2_hours Telemetry SpO 2 q Neuro checks Neurovascular Blood Glucose Level q 1 hr b c d e Drains: Foley cath Nasogastric tube Wound drain Feeding tube Chest tube Dressing change Medication: _X_IV access _X_IV fluid ml/hr Regular insulin Oral medications prescribed IV medications prescribed IM/SQ medications prescribed Respiratory: Incentive Spirometry O 2 Nasal cannula Oxygen mask Nonrebreather mask Ventilator Nebulizer Activity of Daily Living: Independent Assisted Assistive devices Total care Diagnostic studies Lab X-ray Rhythm strip Telemetry 12 lead EKG CT scan/mri Social History: Teaching needed: Discharge Planning: 9
IV Flow Sheet Patient: Gender: HCP: DOB: Diagnosis: MR#: Date & Time Site IV Cath Solution Rate Site Lido 10
Nursing Care Flow Sheet Patient: Gender: HCP: DOB: Diagnosis: MR#: Date/Time Nurse s Notes 11
TELEPHONE NUMBERS HCP: Laboratory: Radiology: Pharmacy: Respiratory Therapy: Family: 12
Nurses Shift Summary Report (Example) Patient: Age: Sex: MR# Date: Physician: Nurse to Physician Communication: **S Primary Diagnosis: Past Medical History: **B Story of Diagnosis: Where patient came from: Fall Risk: Level of assistance Isolation: Shower/Comfort/Bath: Dentures/Hearing Aides: **A Pain Assessment WNL? Y/N Neurological Assessment WNL? EENT Assessment WNL? Cardiac Assessment WNL? Circulatory Assessment WNL? Respiratory Assessment WNL? Musculoskeletal Assessment WNL? Integumentary Assessment WNL? GI Assessment WNL? Genitourinary Assessment WNL? ** R Anticipated Discharge Date:?? Discharge Disposition:? 13
Any Special Needs: ** Nurse to Nurse Communication: (Any abnormal or critical labs, procedure follow-up, MD calls, etc.) Nurse Name: Initials: Nurse Type: 14