หนังสือยนิ ยอมเข้ารับการบาบัด Date ……………………………………..Time ……………………….
ด้วยออกซเิ จนแรงดนั สูง HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
หนังสือยนิ ยอมเข้ารับการบาบดั ด้วยออกซเิ จนแรงดันสูง
ข้าพเจ้า ยนิ ยอมเข้ารับการบาบดั ด้วยออกซิเจนแรงดนั สงู (Hyperbaric Oxygen Therapy) ท่ศี นู ยเ์ วชศาสตร์ความดนั บรรยากาศสงู โรงพยาบาลธนบรุ ี
บารุงเมอื ง ซง่ึ .....................................................................แพทยเ์ วชศาสตร์ใต้นา้ หรือแพทย์เวชศาสตร์ความดนั บรรยากาศสงู ของหน่วยได้อธิบายถงึ ผลของการ
บาบดั ให้กบั ข้าพเจ้า
ข้าพเจ้าเข้าใจดีว่าการบาบดั ด้วยออกซิเจนแรงดนั สงู (Hyperbaric Oxygen Therapy) อาจบรรเทาสภาวะปัจจบุ นั ของข้าพเจ้าให้เปลยี่ นแปลงไปในทาง
ท่ีดขี นึ้ หรือแยล่ งได้ ข้าพเจ้าเข้าใจด้วยวา่ การบาบดั ด้วยออกซิเจนแรงดนั สงู อาจต้องได้รับเพ่ิมเติมอีก และไมส่ ามารถประกนั ผลสาเร็จของการรักษาในอนาคตได้
แพทย์และหรือเจ้าหน้าทท่ี างการแพทย์ได้อธิบายข้าพเจ้าถงึ อันตรายทเี่ ป็นไปได้ ซง่ึ อาจเกดิ ขนึ้ ในระหว่างการบาบดั ด้วยออกซเิ จนแรงดนั สงู (Hyperbaric
Oxygen Therapy) อาทิ เชน่
• ปวดไซนัส / ปวดหู / การสญู เสยี การได้ยนิ จากผลของความดนั ทเ่ี ปลยี่ นแปลง / การเปลย่ี นแปลงทางสายตาชว่ั คราว
• พิษจากออกซิเจน (อาการ เชน่ ชกั เจบ็ หน้าอก / ไอทเี่ กดิ จากการรักษาต่อเนื่องในระยะเวลาที่ยาวนาน)
• การบาดเจบ็ ปอดจากผลของการเปล่ยี นแปลงความดนั / ปฏกิ ริ ิยากบั ยาเคมีบาบดั บางชนิดโดยเฉพาะอยา่ งยง่ิ Bleomycin
• อคั คีภยั ภายในห้องปรับแรงดนั บรรยากาศสงู
ข้าพเจ้าเข้าใจว่าเจ้าหน้าท่ี ท่ีให้การดแู ลข้าพเจ้าในการบาบดั ด้วยออกซิเจนแรงดนั สงู ปฏิบตั ิตามแผนการรักษาและจะลดความเสีย่ งดงั กล่าวให้น้อยที่สดุ
ข้าพเจ้าเข้าใจถงึ บทบาทความรับผดิ ชอบของข้าพเจ้าทจ่ี ะปฏบิ ตั ใิ ห้สอดคล้องกบั แนวทางความปลอดภยั ของการรักษา
ข้าพเจ้าได้รบั โอกาสให้สอบถามข้อสงสยั ต่าง ๆ ท่ีได้กล่าวข้างต้นตลอดจนการรักษาทเ่ี กยี่ วข้อง
ข้าพเจ้าตระหนักดวี ่าผลของการบาบดั ด้วยออกซิเจนแรงดนั สงู ทอ่ี ย่ใู นขอบเขตจากดั
ข้าพเจ้าเข้าใจดีวา่ เป็นอานาจของข้าพเจ้าในการตดั สนิ ใจในการเริ่มต้นและการบาบดั ตอ่ เนื่องภายใต้คาแนะนาทางการแพทย์
ข้าพเจ้ามคี วามประสงค์จะให้คายนิ ยอมกบั เจ้าหน้าทีท่ างการแพทยข์ องหน่วงงาน ในการบาบดั ดงั กล่าว และให้การยนิ ยอมในการใช้ข้อมลู ทาง
การแพทย์ รวมถงึ อนญุ าตให้ถ่ายภาพ และใช้ภาพถ่ายท่ีข้าพเจ้าให้การยนิ ยอมเพือ่ ใช้ในการดแู ลรักษา และทางการแพทยอ์ น่ื ทเ่ี กีย่ วข้อง โดยเคารพสิทธิของผ้ปู ่วย
ตามสภาวิชาชพี กาหนดคาประกาศสิทธิผ้ปู ่วย
ณ ทีน่ ีข้ ้าพเจ้าขอแสดงความยนิ ยอมเพอ่ื รับการรักษา
ลงชือ่ ..................................................................ผ้ใู ห้คายนิ ยอม (ผ้ปู ่วย) ลงชอ่ื ...................................................................พยาน (ญาติผ้ปู ่วย)
(...................................................................) (...................................................................)
วนั ที่..............................เวลา........................ วนั ที่..............................เวลา........................
ลงชอื่ ..................................................................แพทย์ผ้ใู ห้ข้อมลู ผ้ปู ่วย ลงชือ่ ...............................................................พยานฝ่ายโรงพยาบาล
(...................................................................) (...............................................................)
วนั ท่ี..............................เวลา........................ วนั ที่..............................เวลา........................
การแปลและการให้ข้อมูลโดยผู้แปลภาษา
ข้าพเจ้าได้แปล หนังสือยินยอมเข้ารับการบาบดั ด้วยออกซเิ จนแรงดนั สูง รวมทงั้ ข้อมลู ซงึ่ แพทยไ์ ด้อธิบายให้ผ้ปู ่ วยทราบใน
ภาษา...................................................................................................................................................................................................................................
ช่อื ผ้แู ปล………………………….....................……………………ลายเซน็ ผ้แู ปล.........................................วนั ท่ี...................................เวลา..........................
PAGE 1/2 FM-HBO-011-00
หนังสือยนิ ยอมเข้ารับการบาบดั Date ……………………………………..Time ……………………….
ด้วยออกซิเจนแรงดนั สูง HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
ในกรณที ผ่ี ้ปู ่วยอย่ใู นภาวะทม่ี ิอาจยินยอมได้ตามปกติ* แพทย์ได้อธิบายข้อความดงั กล่าวข้างต้นให้แกผ่ ้แู ทนโดยชอบธรรมของผ้ปู ่วยท่ตี ดั สินใจแทนผ้ปู ่วย
ได้รับทราบแล้วและขอแสดงความ ❑ ยนิ ยอม ❑ ไม่ยินยอม เพอ่ื รับการตรวจรักษาดงั กลา่ วไว้ ณ ทีน่ ี ้
ลงชือ่ ..................................................................ผ้แู ทนโดยชอบธรรม (เกย่ี วข้องเป็น................................................................................ของผ้ปู ่วย)
(...................................................................) เลขทีบ่ ตั รประจาตวั ประชาชน/บตั รข้าราชการ...................................................
วนั ท่ี..............................เวลา........................
*ระบุสาเหตทุ ่ีทาให้ผ้ปู ่ วยมิอาจให้ความยินยอมได้ตามปกติ เพราะ :
❑ อายไุ มค่ รบ 20 ปีบริบูรณ์
❑ ผ้บู กพร่องทางกาย – จิต
❑ อน่ื ๆ ระบุ................................................................................................................................................................................................
PAGE 2/2 FM-HBO-011-00
Hyperbaric Oxygen Therapy Record Date ……………………………………..Time ……………………….
HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Hyperbaric Oxygen Therapy Record
Department …………………….……………………………………………………………………………………………………….……………..……
Diagnosis……………………..……………………………………………..…DMO………………………………………………………………………
US Navy Treatment Table HBO
❑ HBO 30 fsw 60 min ❑ HBO 45 fsw 60 min ❑ Other……………………………………………………….
Dive No Date Oxygen Therapy Record RS HBO Nurse Note DMO
Depth (Feet) Time LV Breathing(Gas) Time AR TTD
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature….......................................
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature…........................................
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature….......................................
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature….......................................
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature….......................................
Remark: Time LV – Time Leave – เวลาเริ่มต้น Time AR – Time Arrive – เวลาทถี่ ึงระดบั ความลกึ
RS – Reach Surface – เวลากลบั ถึงพืน้ ผิว TTD – Total time of dive - รวมเวลาทงั้ หมด
PAGE 1/2 FM-HBO-012-00
Hyperbaric Oxygen Therapy Record Date ……………………………………..Time ……………………….
HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Dive No Date Oxygen Therapy Record RS TTD HBO Nurse Note DMO
Depth (Feet) Time LV Breathing(Gas) Time AR Vital Signs : BP……………………mmHg. FM-HBO-012-00
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature….......................................
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature…........................................
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature….......................................
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature….......................................
Vital Signs : BP……………………mmHg.
T….….. ºC PR………/min RR…...../min
DTX……………………..……….........……
…………………………………...........………
…………………………………...........………
…………………………………...........………
RN's Signature….......................................
Remark: Time LV – Time Leave – เวลาเร่ิมต้น Time AR – Time Arrive – เวลาทถ่ี ึงระดบั ความลกึ
RS – Reach Surface – เวลากลบั ถึงพืน้ ผิว TTD – Total time of dive - รวมเวลาทงั้ หมด
PAGE 2/2
แบบบันทกึ ทางการพยาบาล Date ……………………………………..Time ……………………….
ขณะผู้ป่ วย On Chamber HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Allergy : No Known of drug allergy Side effect to………………………………………………..………………….…………
Allergies…………………………………………………………………………………………………………………………..…
Date/Time T P R BP O2 Sat DTX แบบบนั ทกึ ทางการพยาบาลขณะผ้ปู ่ วย On Chamber ผู้บนั ทกึ
FM-HBO-016-00
HBOT Physician Assessment Form Date: ………………………………….…..Time:………………....….…
HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
Referring department / Ward…………………………………………………………………………………………………………………......
Diagnosis :………………………………………………………………………………………………………………………………………..…
Underlying disease(s) :…………………………………………………………………………………………………………………………….
Indication(s) for HBOT Unchanged Changed
1. ……………………..………………………. 2. ……………………..………………………. 3. ……………………..…………….………….
Ear Status :……………………………...……Chest Status : Lungs clear Other :…………………………………………….
Pacemaker CXR : …………………………………………….……………………………………... Date :………………….……
EKG : ………………………………………………………………………………………………………... Date :………….……………
Other : ……………………………………………………………………………………………………..... Date :………….……………
Contraindication(s): Untreated pneumothorax Untested pacemaker
On any medications as follow: Doxorubicin(Adriamycin), Mefenide acetate(Sulfamylon), Bleomycin, Disulfiram, Cis-platinum
Patient cleared for HBOT: Yes No
Physician Order
HBOT protocol: HBOT 1.5 ATM Absolute 60 min
HBOT 2.0 ATM Absolute 60 min
HBOT 2.4 ATM Absolute 60 min
Other : …………………………………………………………………….………………………………………………..
Frequency………………………..time(s)/day x ……………….………… days/week Total : ………………….… times
Remarks :……………………………………………………………………………………………………………………………………………
TCOM before HBOT session Right leg Left leg Other: ……………………………………Date : ………………….….
TCOM after / during 10/15/20 sessions Date : 1. ……………………..…… 2. ……………………..…… 3. …………….…..….……
POST HYPERBARIC OXYGEN THERAPY EVALUATION
Patient Tolerated HBOT: Well Other : ………………………………………………………………………………….……..…..
Termination date : ……………..….……… Missed : ……………………………………………………………………..…….……………….
Remarks : ………………………………………………………………………………………………………………………...…………………
Continue HBOT: No Yes…………………………………………………………………………………………………………….
Change Protocol: No Yes…………………………………………………………………………………………………………….
Next HBOT starting date: ……………………………………
Attending physician…………………………….….……………..MD Code……………….…..Date…………….…Time……………..
FM-HBO-017-00
Check List HBO Date …………………..…….Time …………………
Patient Pre-Treatment Safety HN. …………………………. Room: ………………..
Name: ………………………Gender………………..
Birth Date: …………………. Age: …………………
Physician: …………………..…………………………
Allergies: ……………………..………………………
Diagnosis______________________________________________ Treatment day_________ _ ( Start date______/__________/_______ )
ความผดิ ปกตขิ ณะ on chamber กอ่ นหน้านี ้ ไมม่ ี มี ระบุ ____________________________________________ ____
HBOT protocol ____ _ATA length__ _ min x ____times
Yes NO Remark แบบประเมนิ ผู้ป่ วยก่อนเข้ารับการรักษาด้วยออกซเิ จนความกดบรรยากาศสูง
1.ผ้ปู ่ วยเข้าใจการรักษาด้วยออกซิเจนความกดบรรยากาศสงู และเซน็ ตย์ ินยอมเข้ารับการรักษา ก่อนเข้าเครื่อง
2.ผ้ปู ่ วยนอนหลบั พกั ผอ่ นอยา่ งน้อย 6-8 ชง่ั โมง ก่อนเข้าเครื่อง
3.ผ้ปู ่ วยสขุ สบาย ไมม่ อี าการ อ่อนเพลยี มีไข้ ท้องเสีย หรือเป็นไซนสั อกั เสบ ก่อนเข้าเคร่ือง
4.ผ้ปู ่ วยท่ีมีบาดแผล ปิดแผลโดยใช้ก๊อซชุบ NSS หรือ non-petroleum ก่อนเข้าเครื่อง
5.งดสบู บหุ รี่กอ่ นเข้าเคร่ืองปรับความดนั บรรยากาศอย่างน้อย 4 ชวั่ โมง ก่อนเข้าเคร่ือง
6.งดใช้เครื่องสาอางค์, โลชนั่ , นา้ หอม, นา้ มนั ใสผ่ ม, สเปรยฉ์ ีดผม รวมทงั้ ยาทาภายนอกที่มีสว่ นผสมของนา้ มนั หรือ
Vaseline กอ่ นเข้าเคร่ือง
7.ถอดและเก็บเคร่ืองประดบั , hard contact lens ,วิกผม ,ฟันปลอม และเคร่ืองชว่ ยฟัง วตั ถทุ ี่ทาให้เกิดการลกุ ไหม้
เชน่ หนงั สือ ไฟแช็ก chemical heat pad และอุปกรณ์ท่ีมีแบตเตอรี่ ถอดออกกอ่ นเข้าเครื่อง
8.สวมชดุ ของร.พ.หรือชุดผ้าฝา้ ย 100% ไมส่ วมถงุ น่องหรือถงุ เท้า และผ้าอ้อม ก่อนเข้าเครื่อง
9.ในกรณีท่ีผ้ปู ่ วยใสท่ ่อชว่ ยหายใจ หรือทอ่ ท่ีต้อง blow cuff ด้วย air ให้เปล่ียนเป็น NSS ก่อนเข้าเคร่ือง โดยปริมาตร
ท่ีใสต่ ้องน้อยกวา่ ปริมาตรของ air 1-2 ml และ suction ให้ clear ก่อนเข้าเคร่ือง
10.ในกรณีผ้ปู ่ วยใส่ NG tube ต้องเปิดปลายสาย และตอ่ ลงถงุ พลาสตกิ กอ่ นเข้าเครื่อง
11.ในกรณีท่ีผ้ปู ่ วยมีสาย drain หรือทอ่ ระบายตา่ งๆ สามารถเข้าเครื่องได้เฉพาะขวดพลาสติก และเทสารคดั หลง่ั
หรือปัสสาวะท่ีอยใู่ นขวดหรือถงุ ออกให้หมด และทาให้เป็นสญุ ญากาศมากท่ีสดุ ก่อนเข้าเครื่อง
12.ผ้ปู ่ วยเข้าใจและรับทราบ วิธีการปรับความดนั ภายในชอ่ งหูได้ดี (Valsalva maneuver) คือ วิธี บบี จมกู และการ
พยายามฝืนเป่ าลมออกจากจมกู ท่ีบบี โดยไมใ่ ห้แก้มป่ อง
13.รับประทานยาท่ีเป็นข้อห้ามในการเข้าเคร่ืองความดนั บรรยากาศสงู ได้แก่ Disulfiram (Antabuse), Doxorubicin
(Adriamycin), Cis-platinum และ Mafenide acetate (Sulfamylon) งดรับประทานยามาแล้ว วนั
14.กรณีผ้ปู ่ วยเบาหวาน ตรวจระดบั นา้ ตาลในเลอื ดก่อนเข้าเคร่ือง_______mg/dl
ระดบั นา้ ตาล 110-120 mg/dl ให้ดมื่ นา้ หวานครึ่งแก้วก่อนเข้าเคร่ือง
ระดบั นา้ ตาล 100-109 mg/dl ให้ดมื่ นา้ หวาน 1 แก้วก่อนเข้าเคร่ือง
ระดบั นา้ ตาล <100 หรือ >300 mg/dl ให้รายงานแพทย์ กอ่ นเข้าเคร่ือง
15.กรณีเป็นหวดั หรือไซนสั อกั เสบควรใช้ nasal spray decongestant 1-3 puff x 2 dose หา่ งกนั 15 นาที
ก่อนเข้าเครื่อง
ผลการประเมิน สามารถเข้าเคร่ือง HBO ได้ พบปัญหา ≥ 1 ข้อ ตามรายการด้านบน รายงายแพทย์___ เวลา______ น.
การแก้ไขระบุ
RN’s Signature______________ ____วนั ท่ี____________ _เวลา________
FM-HBO-009-04
Eye Screening Examination Report Date: Time:
HN:
Name: Room:
Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
การมองเหน็ Vision ไมใ่ ส่แว่น / คอนแทคเลนส์ (Without corrective lens)
ใสแ่ วน่ / คอนแทคเลนส์ (With corrective lens) ตาขวา (Right eye) ..................................................
ตาขวา (Right eye) .................................................. ตาซ้าย (Left eye) ....................................................
ตาซ้าย (Left eye) ....................................................
ตาบอดสี (color blindness)
ตาบอดสี Color Vision
ปกติ (normal)
ความดนั ลกู ตา Intraocular pressure :
ตาขวา (Right eye) ...................................... mmHg ตาซ้าย (Left eye) ....................................... mmHg
สรุปและคาแนะนา Conclusion and Recommendation :
ผลการตรวจโดยรวมอยใู่ นเกณฑป์ กติ แนะนาตรวจสขุ ภาพตา ภายในเวลา..............................................เดอื น
Normal eye screening examination, advise screening in ..................................................... months
ตรวจพบความผดิ ปกติ Abnormal finding :
..........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
ตรวจดกู ารเปลยี่ นแปลง Fol ow up 3 - 6 เดอื น months 1 ปี year
แนะนาปรึกษาจกั ษุแพทยเ์ พอื่ Consult Ophthalmologist for :
รกั ษา Treatment
ตรวจตาโดยละเอยี ดเกย่ี วกบั Ophthalmologic examination for :
.........................................................................................................................................................................
............................................................................................................................. .............................................
Physician’s Signature………………………………….…………MD.
(……………………..…….……....…..……)
Medication License No.………………………..……
Date………….…....…..………Time…………...…….
FM-EYE-001-00
Medication Administration Record Date: Time:
(MAR) HN:
Name: Room:
Order For One Day Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
Dose-Route-Frequency D/M/Y……….…...…... D/M/Y……….…...…... D/M/Y……….…...…... D/M/Y……….…...…...
Time Set Real Time Time Set Real Time Time Set Real Time Time Set Real Time
Site Codes For not given medicine Nurse’s Signature/Initials
FM-IPD-022-00
RU - Right upper quadrant N/V - Nausea/Vomiting A - Asleep
LU - Left upper quadrant U - Med/Patient unavailable N - NPO
W - Withheld per MD R - Refused
RT - Right thigh LT - Left thigh
RA - Right arm LA - Left arm
AB - Abdomen
Medication Administration Record Date: Time:
(MAR) HN:
Name: Room:
Order For Continuation Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
Dose-Route-Frequency D/M/Y……….…...…... D/M/Y……….…...…... D/M/Y……….…...…... D/M/Y……….…...…...
Time Set Real Time Time Set Real Time Time Set Real Time Time Set Real Time
Site Codes For not given medicine Nurse’s Signature/Initials
FM-IPD-023-00
RU - Right upper quadrant N/V - Nausea/Vomiting A - Asleep
LU - Left upper quadrant U - Med/Patient unavailable N - NPO
W - Withheld per MD R - Refused
RT - Right thigh LT - Left thigh
RA - Right arm LA - Left arm
AB - Abdomen
Graphic Intake & Output Record Date: Time:
HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
MD Code
Allergies:
Codes Instruction : ( ) = Temperature , ( x ) = Pulse Rate
Date
Days Adm.
After Op.
P - F C 2 6 10 14 18 22 2 6 10 14 18 22 2 6 10 14 18 22 2 6 10 14 18 22 2 6 10 14 18 22
160 105 .8 41
-
140-104 .0 40
-
120-102 .2 39
-
100-100 .4 38
-
80 - 98.6 37
-
60 - 96.8 36
-
40 - 96.0 35
Respiration
Systolic
BP
Diastolic
Wt. & Ht.
Diet
% Eaten
Intake / ml 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs
Tot al Tot al Tot al Tot al Tot al
Oral
NG
Parenteral
Bl. Product
Irrigation
Total
Output / ml 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24 Hrs 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs
Tot al Tot al Tot al Tot al Tot al
Urine
Emesis
Drainage
Total
Frequency 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs 06-14 14-22 22-06 24Hrs
Tot al Tot al Tot al Tot al Tot al
Urine
Stool
Remark : P = Pulse N = Nephrostomy C = Colostomy Vent = Ventilator
FM-IPD-001-00
Neurological Signs Records Date: Time:
HN: Room:
Name: Gender:
Date of Birth: Age:
Physician: MD Code
Allergies: FM-IPD-006-00
Date
Time
Coma Eyes Spontaneously 4
State Opening To Speech 3
To Pain 2
Best Verbal No Response 1
Response Oriented and Talk 5
Confused 4
Best Motor Inappropriate Words 3
Power Incomprehensible Words 2
No Response 1
Obeys Commands 6
Localise Pains 5
Withdrawal Sign 4
Flexion to Pain 3
Extension to Pain 2
No Response 1
Total Score
Normal Power
Arms Mild Weakness
F=Fracture
Severe Weakness
Abnormal Flexion
Motor Abnormal Extension
No Response
Power Normal Power
Legs Mild Weakness
F=Fracture
Severe Weakness
Abnormal Extension
No Response
Pupils Right Size
Pupil Scale (mm) Reaction
Size
Left Reaction
1 Pupil Reaction 240
220
R = Reaction 200
180
2 SL = Sluggish Vital 160
140
NR = Non Reaction Signs 120
100
3 C = Closed Eyes
80
H = Hippus >< 60
40
4 () 20
BP 0
5 (mmHg)
Pulse/min
6
Respiration/ Rate
7 min Type
RN's Signature
8
Employee ID
Note RTL = Reaction to light, RT = Right, LT = Left
Name: Date:
Age:
HN: Sex:
Date Of Birth :
Ventilator data sheet Room:
Physician:
Allergies:
Date
Time
Ventilator
Mode
Invasive FiO2
Tidal volume(ml)
Pressure support/Control(cmH2O)
Rate(BPM)
Ventilator Setting I:E/Peak flow(LPM)/Inspire time(Second)
PEEP(cmH2O)
Inspire time pause(Second)
Rise time/E-sense(Second/%)
Sensitivity
Non-Invasive FiO2
Rate(BPM)
CPAP(cmH2O)
IPAP/EPAP(cmH2O)
Inspire time/Rise time(Second)
Reseating the mask every 2 hours
Mask leak(LPM)
Tidal volume(Control/spontaneous)(ml)
Total rate(BPM)
Minute volume(LPM)
SpO2/HR(%/BPM)
BP(mmHg)
Patient Data Peak airway pressure(Control/Spontaneous)(cmH20)
Mean airway pressure(cmH20)
Intubation No. Tracheostomy tube
No. ET/Oral, Nasal/Mark (cm)
Non-Invasive mask size
Cuff pressure (cmH2O/ml)
Lung sound Right/Left *
Plateau pressure(cmH2O) **
Static Compliance(ml/cmH2O) **
Alarm High/Low peak airway pressure(cmH2O)
High/Low volume(ml)
High/Low minute volume(LPM)
High/Low PEEP(cmH20)
High/Low respiratory rate(BPM)
Time drawn AAAAAAAA
VVVVVVVV
pH
FM-ICU-003-00
Blood Gas PaCo2
PaO2
HCO3
BE
SaO2
Position Head of bed 30°
**
Patient's position
Register nurse/Respiratory care nurse signature
* Crackle or rales(C), Rhonchi(R), Whee ze s (W), Stridor( S)
** For Respiratory care nur se
Remark
A = Artery, V = Vein, I:E = Inspir ato ry:Expiratory, E = Expiratory
Hemodialysis : Record Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth:
Physician: MD Code
Allergies:
Topic Assessment Reassessment Volume assessment HD No…….…… OHDF No……..… Substitute Volume ……......litre
Pain Y N Y N Dry weight…………………...…...kg. Dialysate
Chest discomfort Y N Y N Previous BW………..…………….kg. Machine………… Test…………
Dyspnea Y N Y N Pre HD BW…………………...…..kg. Dialyzer…………. Area………..m² Na …………………....…..mmol/liter
K ……………………...…..mmol/liter
Fever Y N Y N Weight gain………………...…….kg. Anticoagulant Ca …2+ …………….…...…..mmol/liter
Headache Y N Y N Meal/drink………………...………kg. HCO 3………………...…..mmol/liter
Nausea/Vomit Y N Y N Post HD BW………………....……kg. Heparin Arixtra Dialysate flow rate……….…..ml/min
Sleep disturbance Y N Y N
Bleeding Y N Y N Weight loss………………...……..kg. Clexane Innohep Dialysate Temperature………...º C
Itching Y N Y N Loading……………....…...unit
Engorged neck vein Y N Y N Vascular access
Pale Y N Y N Maintenance………….…..unit RN’s Signature 1……………………
Lt Rt AVF AVG DLC
Fill volume A=………..ml. , V=……...ml. No heparin: Flush NSS…...…..ml. RN’s Signature 2……………………
Time…………….……. Time dialysis
Inflammation Y N
Enema Y N Y N Thrill Y N Duration……………………...hour(s)
RN’s Signature 1…………………..….. Time start…………………………….
Poor oral intake Y N Y N Bruit Y N RN’s Signature 2…………………..….. Time off………………………...…….
Psychosocial problem Y N Y N Continue Systolic
Other Y N Y N High risk of fall due to location: Perform high risk intervention: Transfer with safety technique
Nursing diagnosis : Nursing intervention : Expected outcomes :
Patient might have complication during HD Perform hemodialysis as treatment plan No complication during hemodialysis
Patient has waste and retention due to kidney Check vital sign every 1 hour during hemodialysis and as needed Patient has less waste and retention
dysfunction Observe complication during hemodialysis
Time P/mulisne /Rmin mBmPHg mBl/FmRin mVmPHg mTMmPHg ConmdSu/cctmivity mUFl/hRr Tomtal l Nurse’s Note
T………..….º C , Pre hemodialysis
Start hemodialysis
INTRA HD NSS 50% Glucose Extra-fluid Total fluid replacement Total UF Net fluid balance
FLUID GIVER ……………….…ml. …………….…ml. …………….…ml. …………………....…ml. …………ml. …………………....…ml.
Complication Nursing intervention Health education Medication during hemodialysis
No Complication Psychological Support Nutrition Medication /dose /Route Time RN’s Signature
Hypotension Trendelenburg position Vascular access Eprex/Hemax/Recormon………….….......…..unit, SQ / IV …………….…. …………....……
Muscle cr amp Venofer…………………………….…….....…….…………. ……..………… ………....………
Headache Monitor vital signs Exercise Vitamin C…………………………...…….....………………. ………….……. ……….......……
Nausea/vomit …………………………………………....…....…………….. …………..…… …….......………
Fever Pauseultrafiltration Personal hygiene …………………………………………………........……….. …………..…… …….......………
Hypertension
Chest pain Decrease dialysate tem perature Medication
Oxygentherapy Fluid control Physician’s Note
Hot compression KTpreparation
Strengthexercise
Arrhythmia Cold compression ………………………………………………………………………………………………………………………………………………………
Aspirate precaution ……………………………………………………………………………………………………………………………………………………….
Vascular access problem Monitor EKG ……………………………………………………………………………………………………………………………………………………….
Decrease BFR ……………………………………………………………………………………………………………………………………………………….
Other……………………. Monitor access flow ……………………………………………………………………………………………………………………………………………………….
Technical complication Change dialyzer Recommendation
Change blood line ………………………………………………………………………………………………………………………………………………………..
No Complication Notified physician ………………………………………………………………………………………………………………………………………………………..
Clotted dialyzer Other……………………….. ………………………………………………………………………………………………………………………………………………………..
Clotted blood line Next Appointment……………………………………………………………………….……………………….Time…………………………
Machine problem
Blood leak
Remark: Y = Yes , N = No , A = Arterial , V = Venous Physician’s Signature…………………....…………………. MD Code…………………..Date…………...Time……………
AVG = Arteriovenous graft , VP = Venous Pressure RN’s Signature…………………………………....………….Employee ID………….……Date…………...Time……………
N = Nikkiso , F = Fresenius
Page 1/2 FM-HDD-002-00
Hemodialysis : Record Date: Time:
HN:
Name: Room:
Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
Time Pulse R BP BFR VP TMP Conductivity UFR Total Nurse’s Note
/min /min mmHg ml/min mmHg mmHg mS/cm ml/hr ml
T………..….º C , Pre hemodialysis
Start hemodialysis
INTRA HD NSS 50% Glucose Extra-fluid Total fluid replacement Total UF Net fluid balance
…………………....…ml.
FLUID GIVER ……..…….…ml. ………………ml. ………………...…ml. …………ml. …………………..……....…ml.
Complication Nursing intervention Health education Medication during hemodialysis
No Complication Psychological Support Nutrition Medication /dose /Route Time RN’s Signature
Hypotension Trendelenburg position Vascular access Eprex/Hemax/Recormon……….….......…..unit, SQ / IV ………….... …………….......
Exercise Venofer…………………………….…….....…….…………. …………… ……………...…
Muscle cramp Monitor vital signs Personal hygiene Vitamin C…………………………...…….....………………. ……………. …………..…….
…………………………………………....…....…………….. ……………. ……………..….
Headache Pause ultrafiltration …………………………………………………........……….. ……………. …………..…….
Decrease dialysate temperature Medication
Nausea/vomit Fluid control
Fever Oxygen therapy KT preparation
Hypertension Hot compression
Chest pain Strength exercise Physician’s Note
Arrhythmia Cold compression …………………………………………………………………………………….………………………………………
Aspirate precaution
Vascular access problem Monitor EKG …………………………………………….………………………………………………………………………………
Decrease BFR ………………………………………………………………………………………….…………………………………
Other……………………. Monitor access flow
Change dialyzer
Technical complication …………………………………………………………………………………………….………………………………
…………………………………………………………………………………………….………………………………
No Complication Change blood line Recommendation
Clotted dialyzer
Clotted blood line Notified physician ………………………………………………………………………………………………………………..…….……
Machine problem ………………………………………………………………………………………………………………………...…
Blood leak Other………………………..
………………………………………………………………………………………………………………………...…
Next Appointment…………………..……………………….………………………. Time…………………………
Physician’s Signature...................................................................... MD Code..........................................Date……….....…...… Time………………
RN’s Signature………………………………...………………...…….. Employee ID…….…..……...……...…Date……….....…...… Time………...……
Page 2/2 FM-HDD-002-00
Hemodialysis : Demographic Data Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth:
Physician: MD Code
Allergies:
Address…………………………………………………………………………………………. ID Card Number : ……………………………………………….
……………………………………………………………….………………………………..… Alien ID Card Number…………………………………………..
Telephone Number……………………………………………………………...……………. Passport Number………………………………………………..
Mobile phone Number………………………….…………………………..………………… Nationality…………………………………………………………
Contact Person……………………………..………………………………..………………… Economic Status
Height…………..cm. Temperature…………… ° C Pulse……………../min Government refund
Weight…………..kg. Respiration……………../min Blood pressure…………..mmHg. Social Security
Others…………………………………………….
DIALYSIS INFORMATION
Vascular access : Date of operation :
Frequency (Time/Week) : Dialysis time (Hr/session) :
Dialysis buffer : Bicarbonate Acetate
Blood group : ABO Blood group Rh blood group Positive Negative
Date of beginning Hemodialysis :
CAUSE OF CHRONIC RENAL FAILURE
Diabetic Membranous nephropathy IgA nephropathy
Focal segmental glomerulosclerosis Membranoproliferative GN Chronic glomerulonephritis
Lupus nephritis Other secondary glomerular disease Other GN (specified)…………………………..…
Congenital cystic disease Obstructive uropathy Hypertensive nephropathy
Allograft dysfunction Analgesic nephropathy Chronic urate nephropathy
Unknown Other causes (specify)…………………………………………………………………………….
COMORBID CONDITIONS
Diabetes mellitus Dyslipidemia Chronic lung disease Chronic liver disease
Hepatitis B antigenemia Anti-HCV positive Anti-HIV positive Hypertension
Ischemic heart disease Valvular heart disease Peripheral vascular disease Cerebrovascular disease
Active tuberculosis Other (specify)……………………………………………………...……………………………………………………...
PREVIOUS TREATMENT
CAPD Start date : Hospital Name :
Discontinued date : Reason of discontinue :
Hemodialysis Start date : Hospital Name :
Renal transplantation Cause of graft dysfunction :
Date of 1 Transplantation at :
Date of 2 Transplantation at : Cause of graft dysfunction :
Renal transplantation plan No On waiting list for Living related/Cadaveric donor
Contact address at ……………………………………………………………………………………………………………...….
Nephrologist’s Signature…………………………………………………………..MD Code…………………………..Date………………...Time…………..
FM-HDD-007-00
Hemodialysis : Date: Time:
Current Medication List HN:
Name: Room:
Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
Medication Name Date: Medication: Dose, Route, Frequency
Date: Date: Date:
Physician’s Signature
MD Code
RN’s Signature
Employee ID
FM-HDD-008-00
Hemodialysis : Medication Order Date: ………………………………….…..Time:………………....….…
HN.:……………………………….….……Room:………………..........
Medication Name:……………………..…………...…Gender:………..……..…….
Antihypertensive drug (s) Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Drug related kidney disease Allergies:………………………………….………………………..……..
Other medication (s) Date / Prescription
Erythropoietin drug (s) FM-HDD-004-00
Intravenous fluid (s)
Nephrologist’s Signature
Dialysis Nurse’s Signature
Hemodialysis : Date:…......................................................T..i.m...e. :…..................................
Summary Laboratory Results HN:….........................................................R..o..o..m...:.…. .................................
Name:…....................................................G...e..n..d..er:…..............................
LAB / DATE Date of Birth:…..........................................A..g...e..:.….. ....................................
Monthly Physician:…..............................................M...D....C...ode:…...........................
HCT / Hb Allergies:…..............................................................................................
WBC
MCV FM-HDD-006-00
Platelet
FBS
BUN
Cr
Ca / P
Na
K
CI
HCO3
Alb
Every 6 month
HbA1C
Uric acid
Chol / HDL
Trig / LDL
Ferritin
SI / TIBC
T sat %
iPTH
Total protein
TB / DB
SGOT / SGPT
Alk. Phosphatase
Anti HIV
HBsAg
Anti HBs / Anti HBc
Anti HCV
LPRC Tx. / group
Kt / V
HD / Wk
Vascular
Dz. / Reuse
BUN pre / post
BW pre / post
BFR
Total UF
Kt / V
nPCR
URR
Yearly
CXR
EKG
Nephrologist's Signature
Dialysis nurse's Signature
Assessment : Nursing Inpatient Date: Time:
Admission (Adult) HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
Allergies: MD Code
** Admission Information
Arrival time on unit:
Mode of arrival: Ambulatory Ambulatory with cane Ambulatory with walker Ambulatory with other Wheelchair Stretcher
Phone:
Contact person name: Relationship:
ID Band: Present on arrival Applied on arrival
Stated reason for admission:
Information for this nursing admission assessment was obtained from: Patient Family Friend Medical record Other
Interpreter needed No Yes : Specify interpreter language
Actual
T: oc Pulse: /min R: /min BP: mmHg O2Sat: % Wt: Stated kg Ht: cm
with O2 LPM
From MR date
Allergies/Reactions (Drug/Food/Latex)
No known allergy New allergy Yes, as listed above & indicated on chart cover
Additional allergy
1. Reactions:
2. Reactions:
3. Reactions:
4. Reactions:
5. Reactions:
Food: Reactions:
Latex: Reactions:
If additional allergy notify pharmacist
** Past medical history/Chronic condition: (check only if applicable)
Unremarkable Immune disease Infectious disease
Arthritis Blood disorder
Hearing problem: Deaf (L,R) Tinnitus (L,R) Cancer Diabetes GI disorder
Other hearing problem: Heart disease Hypertension
Thyroid disease
Kidney disease Mental illness Respiratory disease Seizure disorder Stroke
Visual problem: Blind (L,R) Color blind Other visual problem: Other
Past surgeries/Anesthesia complications
Current medications: No Yes: use Medication Reconciliation form
Current smoking: per Current alcohol drinking:
per
Page 1 of 2 FM-IPD-004-00
Assessment : Nursing Inpatient Date: Time:
Admission (Adult) HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
Allergies: MD Code
Elimination
Bowel pattern frequency: Daily BID Every other day
Other
Last bowel movement:
Malnutrition risk screening Discharge planning
BMI kg/m2 Patient’s anticipated discharge concerns:
BMI < 18.5 kg/m2
Poor oral intake for at least 4 days prior to admission ADL Nutrition Medication Pain management
Unplanned weight loss more than 3 kgs within one month
Difficulty chewing Wound care or Incision care Medical equipment
Difficulty swallowing
Home tube feeding Other
Pressure ulcer from grade 2 and above
Non-healing wound Payment: Self Insurance:
Home parenteral nutrition
NSF Social status: Live alone
Live with ____________________________
Discharge to: Home
Hotel
Home with hemodialysis
Another hospital
If any Yes : Notify Dietician: Other
Date by RN
Nursing Diagnosis/Problems & Care Plan: refer to Multidisciplinary Care Plan Form
Completion by __________________________________ RN, ID code ____________ Date ___________ Time __________
Page 2 of 2 FM-IPD-004-00
Pediatric Patient Initial Date: ..............................................Time ......................
Nursing Assessment HN: .................................................Room.....................
Name: ........................................... Gender...................
Date of Birth ...................................Age .......................
Physician: ......................................MD Code.................
Allergies .........................................................................
Part I : Admission Information
Admission: Date…………………..…....…. Unit Arrival Time…………...………….…….. From ER OPD…………….…........………...…….….......
Mode of Arrival: Walk Wheel Chair Stretcher Carried Referral: No Yes, ……………...................…………………
Communication: Primary Language Thai English Other ..................................................................................................................
Interpreter need for patient or family: No Yes……...................................................................................................................................…........….
Informant: Patient Mother/Father Other Person; ……………..………………………………..............................................………………….…............…
Emergency notification: Name..................................................................... Relationship……………..........… Phone number…………….…..……...…….....
Payment: Self Pay Insurance Other ……………..…...............…........………………………………………………..…………………….…
Suspected abuse or neglect No Yes notify physician …………………………………………… By........................................................ RN.
Part II : ASSESSMENT
Vital Signs: at…................... T………….......°C Pulse………...../min R………...../min BP………...../..............mmHg. SpO₂……...….%
Admission Diagnosis ………………………………………………………………………………………………………………………………………………………..………..
Chief Complaint ……………………………………………………………………………………………………………………………………………………………………….
Present illness ………………………………………………………………………………………………………………………………………………………………..……….
…………………………………………………………………………………………………………………………………………………………………………………………..
Current Medication: No Yes, (See Medication Reconciliation)
Allergies: No Known of Allergies Allergies ;
Allergen……………………………………………………………………. Reaction…………………………………………………………………….
Reaction…………………………………………………………………….
Allergen…………………………………………………………………….
Health History
Development Milestones (New born - 3 years)
Question parents as to child's ability to perform at age appropriate level versus advanced or delayed development
Normal Delayed (Specify)…………………………………………………………………….………...........................................…………
Note : …………………………………………………………………………………………………………………………………………………………………..
School: No Yes Kindergarten Primary school Secondary school
Immunization: Completed Not completed (Specify)…………………………………………………………….………………..................................
Note : ……………………………………………………………………………………………………………………………………………….….……
Medical History: No Yes………………………………………………………………………………………………………………………………………......
Previous Surgeries: No Yes,……………………………………………………………....................................…………………………………………......…...
Family Health History: No Known Allergy Febrile Convulsion Cancer
Other ……………..…...............…........…………………………………...................................……………..…………………….…
Psycho - Social Assessment
Behaviour : Anxious Apathy Aggressive Whining
Crying Cooperate Uncooperate Other (Specify) ..................................................................................
Emotion: Angry Irritable Worry Fear Other (Specify) ..............................................
Sleep pattern: ……....................…...hours/day, Attachment: (pillow, blanket, bottle, doll, etc …………………………………………….......……………..………….....)
Bed wetting: No Yes Uncertain
Assistive Care: No Yes, by……....................................................................................................................................……………..........
Living Arrangements: With Parents With Caregiver Other (Specify) ......................................................................................................................
Any spiritual/ cultural (or family's spiritual / culture) believe to be followed during hospitalization?
No Yes............................................................................................................................................................................
Page 1/4 FM-PED-001-00
Pediatric Patient Initial Date: ..............................................Time ......................
Nursing Assessment HN: .................................................Room.....................
Name: ........................................... Gender...................
Date of Birth ...................................Age .......................
Physician: ...................................... MD Code.................
Allergies .........................................................................
Nutritional Assessment
Nutritional screening: Weight…………………….………kg., Height………………………...cm., HC……...................…….cms. (<1 year)
Changes of food intake: Normal Abnormal Decrease Increase
Weight: Unchanged Decrease ……..................….kgs. Increase ……................….kgs.
Typical Daily Food Intake……………………………………………………….…………........………..…… Fluid intake…………………………………........……………...
Food or eating: Normal Discomfort Difficulty swallowing Difficulty chewing Tube feeding TPN
Presence of Nausea, Vomiting or Diarrhea: No Yes
Type of milk: Breast Whole milk: formula brand (specify)………………………………………………………………..................………........................
Special Diet: No Restricted Yes, Specify :…………......................... Other.....................….............................................................………
Notify Attending Physician if the patient has any problems finding
Notified Physician: ………………......……………………………… Date ………………………..…...… Time…………:…..…..... By…………………………........….……
Screening / Pain Assessment
Pain: No Yes: if Yes continued assess by PAINED
P Place/Location: ………....………….. Time: All time Sometime Other (Specify) ......……………………………………..…
A Amount / Score :…………………….. Assessment Tool : NRS FRS FLACC NIPS
I Intensifiers: ……………………..……..................................................……………………………………………………….……………………………………..
N Nullifiers: Hot compress Cold compress Rest Elevate Sleep Exercise Medication
Other (Specify) ......……...............….………......……..................................................................................................................................
E Effect on ADLs: Nausea Vomiting Constipation Lack of appetite Itching Sweating
Nightmares Insomnia Other (Specify) ......…….....................................................................................
D Descriptors Sharp Stabbing Shooting Dull Aching Colic Other.........................................................................
Do you have pain? No Yes: If yes please see in pain management record
Fall Risk Assessment
Fall Precaution: High Risk Fall Precaution
Review of Systems / Physical Assessment
1 NEUROLOGICAL Headache: No Yes
Level of Conscious: Alert Drowsy Sedated Confused Agitate
Semi-comatose Comatose Other.........................................................................................
Speech: Normal of age Delayed On Endotracheal Tube Other.....................................................
2 EYES Ware; Glasses: No, Yes....................................................................................................................................................................
Vision: No Problems Impaired; Right/ Left / Both Blind; Right / Left / Both Cannot Determined
3 EARS Hearing Aid Used: No Yes; Right / Left / Both
Hearing: No problems Minimal Difficulty; Right / Left / Both Highly Impaired; Right / Left / Both
Tinnitus; Right / Left / Both Deaf; Right / Left / Both Cannot Determined
Other Communication Techniques Used………..................…………….…………………………………………………………………………………….
4 NOSE Normal Epistaxis Congestion Running Nose Other……...............................................................
Smell: No problems Impaired; ………………………………………………………………………………………………………..…......
5 LIPS & MOUTH Normal Dry Moist Gum Problems Other……………………………………………..……
Taste: No problems Impaired; …........................................... Cannot Determined
6 THROAT AND NECK Normal Sore throat Hoarseness Dysphasia Stiffness
Other……............................................................................................................................................................................
Page 2/4
FM-PED-001-00
Pediatric Patient Initial Date: ..............................................Time ......................
Nursing Assessment HN: .................................................Room.....................
Name: ........................................... Gender...................
Date of Birth ...................................Age .......................
Physician: ...................................... MD Code.................
Allergies .........................................................................
Review of Systems / Physical Assessment
7 RESPIRATORY Nasal Endotracheal Tube Tracheostomy Tube
Breathing: No Problems Dyspnea Tachypnea Orthopnea Apnea
Other................................................................................................................................................................................................................
Oxygen Therapy: No Yes, ………………….…….... Liters/min; Nasal canula Mask Other............................
Special Equipment: No Resuscitator Nebulizer Ventilator
Cough: No Yes Dry Productive Nonproductive
Secretion: No Yes; White Yellow Green Brown Other....................................................................................
8 CARDIOVASCULAR Congenital Heart Disease: No Yes; (specify)............................................................................................................
Pulse Rhythm: Regular Irregular
Cyanosis: No Yes; (specify)..................................................................................................................................................................
Edema: No Yes; Location: Facial Extremities Generalized
Pulse Rate: Normal Tachycardia Bradycardia
9 GASTROINTESTINAL No Problems Yes Diarrhea Constipation Nausea Vomiting Other……………………
Last Bowel Movement: Date……………; Normal Loose Stool Black Stool Bloody in Stool
Interventions: None Laxatives Enema Frequency…………............................................................................................
10 GENITO-URINARY
Urination: No Problem Polyuria Dysuria Nocturia Hematuria Other.................................................
Catheterization: No Yes; Other (specify)..............................................................................................................................
11 REPRODUCTIVE No Problems Itching Bleeding Discharge
FEMALE:
Menstruation: Normal Abnormal (specify).................................................................... Other........................................................................
Breast:
MALE: Normal Abnormal (specify)..................................................... Other.......................................................................................
No Problems Itching Discharge Other.......................................................................................
12 MUSCULOSKELETAL Normal of age Weakness Deformity Fracture Atrophy
Other................................................................................................................................................................................
Range of Motion (ROM): No Problems Limited; ………...................................................................................................……
Joints: No Problems Stiffness Other...........................................................................................................................
13 SKIN INTEGRITY Appearance Color: Normal Pale Cyanosis Jaundice Other...............................................................
Assessment: Warm Hot Cool Moist Dry Rash Edema Bruises
Wound: No Yes; Location………........................................……....................................................................................……………....
Abrasion Laceration Cutting Other.......................................................................................
Page 3/4
FM-PED-001-00
Pediatric Patient Initial Date: ..............................................Time ......................
Nursing Assessment HN: .................................................Room.....................
Name: ........................................... Gender...................
Date of Birth ...................................Age .......................
Physician: ...................................... MD Code.................
Allergies .........................................................................
Discharge Planning Needs
Discharge screening criteria:
Patient need post discharge assistance with activity of daily living / physical functioning:
No Yes;
(specify)..........................................................................................................................................................................................
Cultural/Religious practice which may impact learning:
No Yes;
(specify)..........................................................................................................................................................................................
Family capable and willing to provide assistance post discharge:
Yes No;
(specify)..........................................................................................................................................................................................
Need for discharge planning
No
Yes ○ Independent: May return home with education on medical plan: no additional resources needed.
○ Interdependent: May return to community with additional resources/services.
○ Dependent: Will return to or need placement in another facility.
Learning discharge planning need: Medication Environment and economic Activity / Ambulate
Disease process Health Diet Follow up / Referral
Treatment
Assessor………………………………………...................................………..... Date………............…........Time………………….
Assessor………………………………………...................................………......Date………............…........Time………………….
Assessor………………………………………...................................………...... Date………............…........Time………………….
Page 4/4
FM-PED-001-00
Nursing Notes : Diabetic (IPD) Date: ………………………………….…..Time:……………….......….…
HN.:……………………………….….……Room:…………………..........
Date Time Blood RN Signature Name:……………………..…………...…Gender :……….. ……..……….
Sugar Date of Birth:………………………..……Age:………….…………..……
Physician:…………………..……...……..MD Code:………..…..…....…
Allergies:………………………………….……………………….....……..
Medication Time RN Signature
Fasting blood sugarlevel > 250 mg% on 3 consecutive Low blood sugar level and any sugar orders by oral or IV
days
• Notify CNC DM.
• Notify CNC DM , Dietician on the third date. • CNC DM see and educate sign and symptom
• CNC DM/RN review medications,IV solution, diet
hypoglycaemia to the patient within 24 hours.
and food from outside.
• Food record 24 hours for 3 days.
• Provide instruction : CHO portion, action of insulin
(onset , peak and duration).
• Discussion with physician adjust the medication.
• Provide adequate oral / IV fluid.
• Fasting blood sugar decrease to < 200 mg% after
consult CNC DM 48 hours.
FM-IPD-027-00
Nursing Daily Note (Adult) Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies:
Assessment DEN Intervention DEN
( PN = Intervention done and then variance )
ADLs: Totally dependent for: Ambulate with assistance
Bathing or Mobility or Toileting Apply cold compress
Feeding Apply warm compress
Apply cooling blanket , Tepid Sponge
Need assistance for: Apply air mattress
Bathing or Mobility or Toileting Assist with ADL
Feeding Daily evaluation for central line removal
Drainage care
Arm: Lt, Rt; Unable to move/lift Fall prevention guideline
Lt, Rt; Swelling Getting up from bed with assistance
Lt, Rt; Tenderness
Lt, Rt; Weakness Keep warm
Maintain fowler position
Leg: Lt, Rt; Unable to move/lift Neurological signs check every 1-2 hour (s)
Lt, Rt; Swelling Offer bedpan every 1 to 1½ hour(s) at day and 3
Times at night
Neuromuscular/Skin Lt, Rt; Weakness Positioning with assistance
Numbness at: __________________________________
Skin temperature: Fever Provide care out of the unit
Cool Seizure precaution
Skin appearance: Dry or Fragile Total care for ADL
Turn position every 2 hours
Jaundice Wound dressing
Pale
Rash
Sweating
Vascular access device: 1._____________________
2.___ _____ ______ _____ _ 3.___ _____ ______ _____ __
Addendum assessment
Wound stage or Incision: ________________________
Wound stage or Incision: ________________________
Drainage: ___ _____ ______ _____ _____ _____ ______ ____
___ _____ ______ _____ _____ _____ ______ ____
Other _____________________________________
NSF
Urine: Burning sensation or Difficulty Bladder irrigation
Dysuria Catheter care
Hematuria Daily evaluation of Foley’s Catheter removal
Diaper change
Incontinent Digital evacuation
Retention Frequent linen change
Gastric lavage
Foley in place:Insertion date ___________________ Intermittent or placement of urinary catheter
Ostomy care
Cystostomy: Insertion date ___________________ Perineum care
Gastrourinary Ostomy: _____________________________ Addendum assessment
Dialysis: CAPD/HD/CRRT: Last dialysis date:______
Bowel sound: Absent
Abdominal: Ascitis
Distended
Tenderness
GI bleeding: Hematemesis
Stool: Bloody
Constipation > 3 days
Incontinent or Loose
Melena
Other _____________________________________
NSF
Page 2 of 3 FM-IPD-017-00
Nursing Daily Note (Adult) Date: Time:
HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
Allergies: MD Code
Assessment DEN Intervention DE N
Pre Natal Pregnancy GA________wks ( PN = Intervention done and then variance )
FHS monitoring
FHS: ________ Uterine contraction: ___________ Observe bleeding
Other______________________________________ Perineum care
NSF
Addendum assessment
Perineum: Edema
Hematoma Education on post natal care and breast feeding
Emotional care (Post partum blue etc.)
Postpartum Lochia: Abnormal in: ______________________ Fundus firm checking
Fundus: Soft or Unpalpable Observe lochia
Perineum care
Breasts: Tender Lt
Rt Addendum assessment
Sore nipples Lt
Rt
Breast feeding problem
Other _____________________________________
NSF
Reason for a ssessm ent: Admission assessme nt (A), Daily a ssessmen t (D), Transfe r from di fferent level o f ca re (T), Chang e in status (C), Following a fal l (F)
Braden scale 1 2 3 4
Sensory perception Completely limited Very limited Slightly limited No impairment
Moisture Constantly moist Moist Occasionally moist Rarely moist
Activity Bedfast Chairfast Walks occasionally Walk frequently
Mobility Immobile Very limited Slightly limited No limitations
Nutrition Very poor Inadequate Adequate Excellent
Potential problem
Friction shear Problem No apparent
problem
Braden scale 19 consider to be risk Total
Nursing interventions/Time 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6
Patient ch eck
Equ ipment check/Ala rm on (Infusi on pump,P CA ,etc.)
Position ch ange: Rig ht(Rt)/Left(Lt)/Supin e(S)
Trifl o (T)/Percussion (P)/Co ugh: Deep br eathing (C)
Left: peda l/rad ial pulse che ck
Right p edal/radia l pu lse check
Restraint: Lt/Rt; A rm or Lt/Rt; Le g o r Body
1. Reasse ssment re straint need
Loo sen /Re-position (at le ast eve ry 2 hrs)
2. Circulation ch eck (at lea st e ver y 2 hrs)
3. ROM for 10 mins (at least every 2 hrs)
Ora l care: Mo uth care (M)/Remove plaqu e ( R)
Suction: Direct (D)/Open (O )/Close (C)/A id ( A)
NG tub e care : Positi on che ck ( P)/p H (value)
ET/Tra ch: Positio n (P )/Tape (T)
Remark: ( P) Intervention done RN's Signature RN's Signature RN's Signature
…………………………….…. ……………………………. …………………………..
( x ) Cannot perform cause from
patient factor. Employee ID Employee ID Employee ID
……………………………..... …………………………..... …………………………..
(Day) (Evening) (Night)
Page 3 of 3 FM-IPD-017-00
Nursing Daily Note (Adult) Date: Time:
HN:
Name: Room:
Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
Assessment DEN Intervention DE N
( PN = Intervention done and then variance )
Speech: Aphasia
Education on cognitive and coping
Dysphasia Facilitate prayer, making special arrangements
LOC: Comatose Pain management
Confuse
Drowsy
Cognitive/Coping Semi comatose
Person Taking extra time to answer patient and family need
Place
Time
Memory: Memory loss
Visual: Blur vision
Double vision
Anxious Addendum assessment
Denial
Social: Lack of visitors or family support
Have pain now: (If ye s, u se Assessment : Pain In ten sity)
Other _____________________________________
NSF
Nose: Congestion Aspiration precaution
Nasal flaring Close monitoring of bleeding and drop of Hct
_________
Cardiovascular/Respiratory Not clear Head of bed > 30 degrees
Lung sound: Rt ; Absent Oxygen administration and suction as needed
Nutrition/Metabolic
Not clear Pacemaker (Temporary or Permanent) care
Cough: Productive ; Sputum color _____________
Maintain isolation precaution
Non Productive
Addendum assessment
Rate irregular
Hypertensive Assist with meal or tube feeding
Force oral fluid
Lt ; Intake and output monitoring
Weak IV therapy
Mucositis care
Rt; Parenteral nutrition
Weak Addendum assessment
Pedal pulse: Lt;
Weak
Rt;
Weak
Non pitting: Location__________ Size _____
Edema:Pitting: Location______________ Size _____
Other ___________________________________
NSF
Mouth: Mucositis (Use Oral Mucositis Nursing assessment)
Feeding: NG or Gastrostomy
NPO
Appetite: Nausea
Vomiting
Poor
Other ____________________________________
NSF
Remark: D= Day E= Evening N=Night
Page 1 of 3 FM-IPD-017-00
Nursing Progress Note Date : ……………………………… Time : ………………………
HN : ……………………………….. Room : …………………….
Date Focus Name : …………………………….. Gender : ………………......
Time Date of Birth : ………………...…… Age : ………………………
Physician : ………………………… MD code : ………………..
Allergies : …………………………………………………………..
Nursing Progress Note
A = Assessment I = Intervention E = Evaluation
FM-IPD-009-00
Nursing care / Intervention Record Date : ……………………………… Time : ………………………
HN : ……………………………….. Room : …………………….
Name : …………………………….. Gender : ……………..…....
Date of Birth : ………………...…… Age : ………………………
Physician : ………………………… MD code : ………….……..
Allergies : …………………………………………………………..
Nursing care / Intervention D/M/Y……….…...…... D/M/Y……….…...…... D/M/Y……….…...…... D/M/Y……….…...…...
Time Set Real Time Time Set Real Time Time Set Real Time Time Set Real Time
FM-IPD-031-00
Frequent Monitoring Record Date: Time:
HN: Room:
Name: Gender:
Date of Birth: Age:
Physician: MD Code
Allergies:
Instruction: For use post recovery, blood transfusion, post bedside procedure and frequent checks vital signs (more often than every 2 hours)
Obstetrical Legend Intervention lists of post procedure
Bre asts Maintain airway/O2 satu ration Pain assessment OB only
S - Soft F - Firm E - Eng orged IV thera py Emotional suppo rt Per ineum car e/Ice p ack prn
Fundus/Placement O2 therapy Sur geon/Anesthetist notifie d (a s need ed) Emotional care
S - Soft F - Firm Secure the ca the ter Medication administr atio n: pain , antibiotics
Lochia H - Heavy Assess and reassess__ _ Pro vide or al fluid (Po st p artu m blue )
M - Modera te S - Small Orie nt patient Fundus firm checkin g
Per ineum (pun cture/wound site /foot p ulses) Pro vide assurance to pa tie nt Observe blee ding/lochia
E - Ede ma C - Clean/Inta ct Recognizing the early signs of complications Assist to void Initi ate Bre ast fee ding with
assistance
Aler t (e.g. shock, bleed ing)
Orie nte d Observation of skin colo r Negative outcomes
Able to fol low command Physica l comfort
Minimal or no bleed ing
Vital sig ns within normal limits Positive outcomes
O2 Saturation < 93 % o n r oom ai r
No tran sfusion reaction No pain or Pain controlled OB only Drowsy or Stu por OB only
Tolerate oral fluid Per ineum: minimal edema Blee ding or heavy dr ainage Per ineum: he matoma/
Warm, dry skin Lochia : mo derate rubra Difficulty brea thin g severe edema
Urine output > 3 0 mL per hou r Fundus: midli ne firm Exhibit sig ns of shock Lochia : Bleed ing col or
Inta ke and output balancing Has minimum 8 B reastfeed ing Nausea/Vomiting Fundus: soft / shift fr om
Maintenan ce ade quate circula tion contacts in 24 ho urs Inco mp rehensible spee ch midline
Void ing wi tho ut difficulty Unresponsive Post pa rtu m blue
Nursing Assessment (Post operation/procedure only)
Level of conscious: Alert Disoriented Sedated Drowsy
Have pain now: No Yes; see Assessment : Pain intensity
Cardiovascular/Respiratory: NSF Other; specify ________________________________________
Neuromuscular/Skin (Exclude Wound/Incision): NSF Other; specify ________________________
Genito Urinary: NSF Other; specify _________________________________________________________
Other: N/A ______________________________________________________________________________________
Date T Pulse R BP Sp Obstetrical Intervention lists / Note Outcomes RN’s
signature
Perineum
Time Fundus/
Placement
Lochia
Breasts
FM-IPD-005-00
Assessment : Pain Intensity Date: ………………………………….…..Time:………………....….…
HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
Location Assessment details
Circle and Number Character : A = Aching B = Burning C = Cramping CR = Crushing D = Dull
to identify area of pain :
H = Heaviness P = Pressure PR = Prickling S = Sharp SQ = Squeezing
Anterior Posterior
ST = Stabbing T = Throbbing TI = Tightness
Frequency of pain
C = Constant I = Intermittent Alleviating Interventions : 1 = Hot Compress 2 = Cold Compress 3 = Rest 4 = Elevation
Patient's pain assessment tool:
1 = NRS 2 = Faces 5 = Sleep 6 = Exercise 7 = Reposition 8 = Meditation 9 = Medication 10 = Other
3 = FLACC 4 = MIPS
5 = NIPS Patient’s acceptable pain level:………. RN’s Signature…………………….….Employee ID…..........................…
Date Acceptable pain level is changed to…………………………………………………………………………….……
Location Pain
RN’s Signature……………….………..….Employee Id…………………………..Date………….…Time…………..…
Time No. Duration
Instructions
- Assessment and Reassessment followed by Pain Management . Then pain will be reassessed every 8 hours
in Nursing daily note.
- Pain duration (How long from the recent onset) will be identified once on initial assessment and every time if
any new pain occurs or increasing in pain level.
- For IV medications, the nurse will reassess effectiveness within 30 minutes
- For PO and IM medications, the nurse will reassess effectiveness within 90 minutes
- Encourage patient to communicate presence of pain.
- Assess knowledge of pain management methods and educate if needed.
- If pain is not relieved by alleviating interventions or patient does not indicate either verbally or non-verbally
that pain is at a tolerable level, the physician should be notified.
- Use interdisciplinary education form to document patient / family education
Pain Pain
Pain Tool (Score) Character Alleviating Interventions RN’s Signature
Frequency Used 0 - 10
FM-IPD-030-03
Nursing Note : Date: Time:
Blood Transfusion Record HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
MD Code
Allergies:
Indication for transfusion (Check one or more boxes. Fill in most recent lab results.)
Blood loss amount (est) ml Anemia hemoglobin g/dl Hemostasis defect platelet count ul
Hypovolemia BP PT sec PTT sec Other
Transfusion consent form signed: Yes, proceed
No. Blood Blood Rh Donor Volume * Issued Start Transfusion by Double
component group time checked by
No. (ml) time
We certify that before starting this transfusion, we have checked the blood unit label, the Blood Bank label, the
patient's wristband, and have verified the patient's name and HN on the label against the wristband.
Time T Pulse R BP During transfusion, observe patient for the following
symptoms of allergic reaction
(oC) (/min) (/min) (mmHg)
Unit No. Date urticaria, itching YES NO
Start transfusion time Date
5 mins after transfusion Date temperature elevation of 1.1oC or more, severe shaking, chills,
15 mins after transfusion flushing
60 mins after transfusion
Completed transfusion nausea/vomiting, headache YES NO
Unit No. increased pulse rate of more than 20 beats per minute above
Start transfusion time
5 mins after transfusion base line
15 mins after transfusion
60 mins after transfusion Treatment If any of above symptoms occur:
Completed transfusion
Time RN's
Unit No. Signature
Start transfusion time
1) STOP transfusion. Then disconnect
transfusion administration set
2) Keep IV open with 0.9% NSS
3) Notify physician STAT
4) Notify LAB staff to process return
blood product
List symptoms/Remark:
5 mins after transfusion
15 mins after transfusion
60 mins after transfusion RN’s Signature Date Time
Completed transfusion Employee ID
Notes: * Issued time: Issued time from blood bank
1. Flush the IV access with 10 ml of 0.9 NSS before and after the transfusion.
2. If blood cannot be started immediately, return to Blood Bank within 30 minutes of sign out time. (Do not put blood in
unit refrigerator)
3. For each unit transfusion should be completed within 4 hours. (within 30-60 minutes for plasma or platelet)
4. Vital signs will be recorded before the start of each unit of blood or blood component 5, 15, 60 mins after the start and at the
the end of transfusion.
FM-IPD-010-00
แบบฟอร์ มการให้โลหติ Date: ............................................. Time ........................
และส่วนประกอบของโลหติ HN: ................................................ Room.......................
Name: ............................................ Gender....................
Date of Birth .................................. Age .........................
Physician: ...................................... MD Code.................
Allergies ..........................................................................
แบบฟอร์มการให้โลหติ และส่วนประกอบของโลหติ
วันท่ี .........................................................
ขอให้เจ้าหน้าท่ที าเคร่ืองหมาย ( ✓ ) ในช่อง
1. ตรวจสอบเลอื ด
รายการเลอื ดและ/หรือสว่ นประกอบของเลอื ด: .......................................................................................................................................................................
Blood number: ………………………………………………...… Blood group: ………… Rh: ………………………. ปริมาณเลอื ด: ……………………. Ml.
ผ้ตู รวจสอบคนที่ 1 ………………………………………………………………….………… วนั ที่ …………………..…………….. เวลา ………………………..น.
ผ้ตู รวจสอบคนท่ี 2 ………………………………………………………….………………… วนั ท่ี …………………………......….. เวลา ………………………..น.
2. ระบุตัวผู้ป่ วย ชอ่ื -นามสกลุ ของผ้ปู ่ วย วนั เดือน ปี เกิด Wristband
Vital Signs กอ่ นให้เลือด 15 นาที T ………….ºC PR ……..……/min RR ……..……/min BP ……….…/……….…. mmHg. O₂ sat …………%
ผ้ใู ห้เลอื ด .………………………………..……………………….............… วนั ท่ี …………………………….. .เร่ิมให้เลือด เวลา ……………………….........….น.
3. Record Vital Sign หลงั ได้เลอื ด 15 นาท,ี ประเมนิ ระหว่างการให้เลือด ทกุ 1 ช่ัวโมง จนกว่าเลอื ดจะหมดและประเมินหลังเลอื ดหมดทนั ที
ครัง้ ท่ี เวลา T (ºC) PR (/min) RR (/min) BP (mmHg.) O₂ sat (%)
4. ภาวะแทรกซ้อนจากการให้โลหิตและ/หรือส่วนประกอบของโลหติ
*ขณะให้เลือดกับผ้ปู ่ วย หากพบว่าผ้ปู ่ วยมีอาการดังต่อไปนีใ้ ห้รีบหยุดให้เลือดทนั ที แล้วรีบรายงานแพทย์ให้รับทราบ*
ไข้ หนาวสนั่ ผ่ืนคนั หายใจลาบาก
Cyanosis เลือดออกผิดปกติ BP drop
อาการปวด เชน่ ปวดท้อง ปวดหน้าอก ปวดหลงั ปัสสาวะออกน้อยลงผิดปกติ
รายงานแพทย์ ....................................................................... เวลา ......................... พยาบาลผ้รู ายงาน ...............................................................
ไมม่ ีอาการผิดปกติ เลือดหมด เวลา ....................................... น.
พยาบาลผ้ทู าการบนั ทกึ ………………………………………………………….…………..………วนั ท่ี …………………………......….. เวลา …………………..น.
FM-NSO-012-00
GI Endoscopy : Nursing Notes Date: ......................................................Time: ............................
Recovery Room HN: ….....................................................Room: …......................
Name: …................................................Gender: …....................
Date of Birth: ....................................... Age: …..........................
Physician: …..........................................MD Code: …................
Allergies: …....................................................................................
Time in Recovery Room : Procedure :
Surgeon : Assistant : Anesthesiologist :
Anesthesia : □ General □ Spinal □ Epidural □ LA □ IV Sedation □ Other_______________________
Time
mmHg
220
200
• PULSE • RESP > < BP 180
160
140
120
100
80
60
40
20
0
O2 Sat
Intake Output
Time IV Fluid & Blood/Blood Product Volume Volume Oral Irrigate Blood Urine Vomit Drain NG Irrigate
Tube
In Left loss
Total
Page 1/2 FM- GID-014-00
GI Endoscopy : Nursing Notes Date: ......................................................Time: ............................
Recovery Room HN: ….....................................................Room: …......................
Name: …................................................Gender: …....................
Date of Birth: ....................................... Age: …..........................
Physician: …..........................................MD Code: …................
Allergies: …....................................................................................
Aldrete score Admit 15 min 30 min 60 min Discharge Medication
Voluntary movement of all limbs to command = 2 Time Medication Dose Route RN
Voluntary movement of two extremities to command= 1
Unable to move =0
Breathe deeply and cough =2
Dyspnea, hypoventilation =1
Apnea = 0
BP ± 20 % of preanesthetic level =2
BP ± 20 - 50 % of preanesthetic level =1
BP ± 50 % of preanesthetic level =0
Fully awake =2
Arousable =1
Unresponsive =0
Pink = 2
Pale, blotch =1
Cyanotic =0
Total
Discharge criteria to home Yes No N/A Transfer Summary
Vital signs stable Airway : Clear Other ________________________________________
Aldrete score of 9 Level of conscious : Alert Drowsy Unconscious
No Evidence of active bleeding
Tolerting per oral fluid well General condition : Stable Unstable transfer to _________________
Pulse rate___________/min Respiratory rate ___________/min
(Pediatrics - under 12 months swallow reflex intact) BP_________/___________mmHg. SpO2___________%
Patient discharged with designated , responsible adult Items brought to unit : Film Other______________________________
Discharge Summary (For Patient) copy given Recommendation : ______________________________________________________
No Nausea / Vomiting ________________________________________________________________________
Patient meets discharge criteria Yes No _____________________ Hand off communicated to : ________________ RN at ward _________________
Discharge time : ____________________________________________________Transfer time : _________________ to _____________________________________
Discharge RN's Signature_____________________________________________________________________________________ Employee ID___________________________
Nurse's Note: ______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
RN's Signature________________________________________________________________________________________________ Employee ID__________________________
Page 2/2 FM- GID-014-00
Safety Checklist : Surgery / Procedure Date: Time:
HN:
Name: Room:
Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
In holding area/Procedure room : Nurse actively confirms
Patient Identification according to policy Yes
Procedure and Procedure site Yes
(Verification) Consent (s) Yes
Surgical marked site Yes N/A
Pre anesthesia assessment
Yes N/A : In case under LA procedure
Lab / Radiology test results (please specify……………………………………….......) Yes N/A
Blood products (please specify……………………………………………….…….......) Yes N/A
Special equipment, Medical device, Implant (please specify…………………..…… Yes N/A
………………………………………………………………………………………..….......)
Nurse’s Signature ………………..……………………………..…….….….. Employee ID …….……………… Date…………… Time…….……..
Confirmed by Anesthesiologist and Circulating nurse/Scrub nurse : N/A : In case under LA procedure
Difficult airway, any aspiration risk Yes; equipment for airway No
Procedure marked site reconfirmed management available N/A
Yes
(Sign In) Risk of blood loss (> 500 ml for adult or ≥ 7 ml/kg for pediatric) Yes; adequate intravenous No
access and fluids planned N/A
Pulse oximeter on patient and functioning Yes N/A
Anesthesia safety check complete
Yes
Antibiotic prophylaxis given within 60 or 120 minutes before incision Yes; time administered……….... N/A
Surgical team members are introduced and actively participate “Time out” Process Time……………….….
(Time Out) Patient’s name-surname and date of birth Yes
Procedure site and/or side
Yes
Relevant investigation imaging displayed Yes N/A
Yes N/A
Medical device, Implant Yes N/A
Special equipment completely prepared
Confirmed by Scrub nurse and Circulating nurse :
Sterilization indicators have been checked Yes
Confirmed by Scrub nurse and Team :
Procedure room (Sign Out) Procedure name was recorded, Nursing notes completed Yes N/A
Sponge, sharps and instrument was counted and correct Yes N/A
Medical devices / Implant ………………………………………...........................…... N/A
Yes
Specimen(s) was identified and labeled
Yes
Equipment problems to be addressed No
Yes………………………………………………...……..……………………………………….
Scrub nurse’s Signature ……………………………………..……………….….… Employee ID …….……………. Date………… Time…….……
Circulating nurse’s Signature ……………..…….….……………………...……… Employee ID …….………….… Date………… Time…….……
FM-ORD-009-03
Surgery / Special Procedure Date: Time:
Hand off checklist HN:
Name: Room:
Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
Procedure ................................................................................................... Language Barrier: No Yes
Procedure Date ......................................................Time ............................ Interpreter needed No Yes ………………………...…
Patient ID: ID band checked Full name Date of birth
Verbally confirmed by Patient Next of kin Interpreter Disability Deafness Blindness Other........................
Action need to be done Nursing Unit Service Unit
Yes No N/A Comment/Signature Yes No N/A Comment
Inform: Surgeon
Inform: Assistant surgeon
Inform: Anesthesiologist
Get consent: for surgery or special procedure
GPreet-Aconnessethnet:sfioar Pre-Moderate to Deep Sedation and
Assessment: Assessment & History Contrast media
Assessment: History/Physical Examination
Assessment: Pre & Post Anesthesia
Assessment: Pre & Post Conscious Sedation
Aposlsiceyssment: Pre operative assessment (investigations) as
Assessment: Pre operative medical assessment as policy
Operative mark site confirmed
NPO since …………………………………………..……..……....
Skin preparation/Eye preparation
SSE / Fleet enema / NSE
Blood requested ................................................ Unit(s)
Medication...............................brought to procedure unit
Equipment…………….…..…...brought to procedure unit
Pedal pulse marked both sides
Last voiding at ................. Catheterization
Rings Earrings removed
Contact lens removed
Eye glasses Fixed Non Fixed removed
Denture
Teeth mobility detial……………………….
Hearing aid (left/right) Prosthesis removed
Film
Pre operative medication or antibiotic prophylaxis given…….. Nurse’s Signature………………………. Nurse’s Signature…………………….….
……..….…..……..….…..…..……...…………………………….… Employee ID……………………………. Employee ID…………………………..….
IV Cath .................... IV site ..................... Fluid ........................................ Patient was transferred to Department…………………………...…….
Nurse’s note ........................................................................................... By Ambulatory Wheel chair Stretcher Bed
................................................................................................................... Nurse’s note ....................................................................................
................................................................................................................... ...........................................................................................................
................................................................................................................... ...........................................................................................................
.................................................................................................................. ...........................................................................................................
Patient was transferred from Ward/OPD at ...............................................
...........................................................................................................
Hand off communicated to:............................. Employee ID..................... ...........................................................................................................
Nurse’s Signature....................................... Employee ID .................
Nurse’s Signature............................................ Employee ID.....................
FM-ORD-010-00
Post Operative Surgical Nursing Date: Time:
Plan of Care HN:
Name: Room:
Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
1. การประเมนิ ทางการพยาบาล มีโอกาสที่จะเกิดการเปลี่ยนแปลงระบบการไหลเวยี นโลหติ
เป้าหมายทางการพยาบาล ผ้ปู ่ วยมีสญั ญาณชีพปกตคิ งที่
การให้การพยาบาล หลงั ผา่ ตดั ทว่ั ไป วดั สญั ญาณชีพทุกๆ 30 นาที 4 ครงั้ และทกุ ๆ 4 ชว่ั โมง จน stable
2. การประเมนิ ทางการพยาบาล มโี อกาสท่จี ะมีการตดิ เชือ้ แผลผา่ ตดั และทางเดนิ หายใจอดุ ตัน
เป้าหมายทางการพยาบาล ไม่มีไข้ แผลสะอาด ไม่บวมแดง อกั เสบ
การให้การพยาบาล วดั อุณหภูมทิ กุ 4 ช่วั โมง และอาจวดั บ่อยกวา่ นนั้ ถ้าผ้ปู ่ วยมไี ข้ ผู้ป่ วยอาจจะมีสญั ญาณว่ามีไข้
แจ้งแพทยท์ ราบหากมสี ญั ญาณเร่ิมต้นของการเป็นไข้
ทาความสะอาดแผลดูแลแผลให้แห้งและสมั ผัสแผลให้น้อยทสี่ ดุ ให้ยาปฏิชวี นะตามคาสงั่ แพทย์
ชว่ ยเหลอื ให้ผ้ปู ่วยลกุ เดิน หายใจลึกๆ ไออย่างมีประสิทธิภาพ หรือใช้ Triflow ทกุ ๆ 2 ชว่ั โมง
เคาะปอดอยา่ งน้อย เวรละ 1 ครงั้
หากผ้ปู ่ วยมสี ายสวนปัสสาวะไมค่ วรคาสายสวนไว้นานกว่า 24-48 ชว่ั โมง ปรึกษาแพทย์พิจารณา
ถอดสายออก เว้นเสียแต่วา่ การใส่สายสวนนนั้ เก่ยี วข้องกบั การผ่าตดั อยา่ งเช่น Prostatectomy เป็นต้น
3. การประเมินทางการพยาบาล มโี อกาสท่ผี ้ปู ่ วยจะเกดิ ความเจบ็ ปวดจากการผ่าตดั
เป้าหมายทางการพยาบาล ความเจ็บปวดอยูใ่ นระดบั ท่ผี ้ปู ่วยยอมรับได้
การให้การพยาบาล สอบถามผ้ปู ่ วยถึงระดบั ความเจ็บปวด และคอยสนับสนนุ ให้ผ้ปู ่วยรายงานให้ทราบ หากรู้สกึ ปวดแผล
ให้ยาแก้ปวด เปลี่ยนท่านอน และแนะนา เทคนคิ การผ่อนคลายความเจ็บปวดให้แก่ผ้ปู ่วย
4. การประเมินทางการพยาบาล มเี ลือดออกหลงั ผา่ ตัด
เป้าหมายทางการพยาบาล ไม่มีเลือดออกจากแผลผ่าตดั หรือบริเวณอ่นื ๆ
การให้การพยาบาล ตรวจภาวะการมเี ลือดออกทุกครงั้ ท่ีมกี ารวดั สญั ญาณชีพใน 24 ช่วั โมงแรก ต่อไปทกุ 4 ช่วั โมง
3 วนั และ/หรือในช่วงเวลากลางวนั ทุกวนั จนกว่าแผลจะหาย
บนั ทึกการมีเลือดออกทอี่ ื่นๆ อนั เนื่องมาจากการผ่าตดั เช่นการตกเลือดภายในทางเดินอาหาร
การมีภาวะเลอื ดออกสะสมในชัน้ เนือ้ เย่อื กว้างขนึ ้ เป็นต้น แจ้งให้แพทย์ทราบ
5. การประเมินทางการพยาบาล มีโอกาสท่จี ะกลัน้ การขับถา่ ยไมไ่ ด้ หรือไม่สามารถขบั ถ่ายปัสสาวะและอุจจาระได้
เป้าหมายทางการพยาบาล สามารถปัสสาวะหลงั ผ่าตัด 8 ชว่ั โมง และมีการขับถ่ายอจุ จาระได้ตามปกตภิ ายใน 48 ชว่ั โมง
การให้การพยาบาล ขนึ ้ อยกู่ ับความซบั ซ้อนของการผา่ ตัด
ชว่ ยเหลือผ้ปู ่ วยให้ถ่ายปัสสาวะและสามารถไปห้องนา้ ถ้าเป็นไปได้ แจ้งแพทยท์ ราบหากมีปัญหา
ในการถา่ ยปัสสาวะ
บนั ทึกปริมาณนา้ ดืม่ และปัสสาวะเพื่อให้ม่นั ใจว่าผ้ปู ่วยได้สารนา้ เพยี งพอ
ประเมนิ เสียงการเคลือ่ นไหวของลาไส้ หากไม่มีการเคล่อื นไหว ให้สงั เกตอาการและสอบถามผ้ปู ่ วยวา่
มีอาการคล่ืนไส้และปวดท้องหรือไม่ การปวดท้องอาจจะเป็นสญั ญาณเร่ิมต้นของการอุดตนั ในลาไส้
ควรแจ้งแพทยท์ ราบ
ให้ผ้ปู ่วยมกี ารขับถา่ ยให้ได้ภายใน 2 วนั หลงั ผ่าตดั หากไมม่ ีการขบั ถ่าย แจ้งแพทย์หรือ CNC ทราบ
6. การประเมินทางการพยาบาล ได้รับนา้ และสารอาหารเพยี งพอ
เปา้ หมายทางการพยาบาล ผลการตรวจทางห้องปฏิบตั ิการไมม่ ขี ้อบง่ ชีว้ ่ามภี าวะขาดนา้ ไม่มอี าการคล่นื ไส้ อาเจียน
การให้การพยาบาล ผ้ปู ่ วยสามารถรับประทานอาหารและดืม่ นา้ ได้ทางปากตามแพทย์ส่งั
เม่อื สามารถรับประทานอาหารและดื่มนา้ ทางปากได้ ให้บันทึกปริมาณนา้ ดื่มเพื่อให้มนั่ ใจว่าผ้ปู ่ วย
ได้รับนา้ เพยี งพอ และบนั ทึกปริมาณอาหารทรี่ ับประทานได้
7. การประเมินทางการพยาบาล ผ้ปู ่ วยอาจมีภาวะลิม่ เลือดอดุ ตนั อนั เน่ืองมาจากไมไ่ ด้เคล่ือนไหวร่างกาย
เป้าหมายทางการพยาบาล ไม่มีภาวะล่ิมเลอื ดอดุ ตัน
การให้การพยาบาล ให้ผ้ปู ่วยหายใจลึกๆ ไออย่างมีประสทิ ธภิ าพ และเดนิ ออกกาลงั กายเทา่ ที่จะทาได้
ตรวจบริเวณขาของผ้ปู ่ วยเพอื่ ดวู า่ มี 6 Ps ผิดปกติหรือไม่กล่าวคือความเจบ็ ปวด (Pain) คลาชพี จรไมไ่ ด้
(Pulseless)ซดี (Pale) ชา (Paresthesia) มอี าการออ่ นแรง (Paralysis) อวยั วะสว่ นปลายมีอาการเย็น (Polar)
หากมีสิง่ ผิดปกตเิ หล่านเี ้ กดิ ขนึ ้ แจ้งแพทย์ทราบทนั ที และจากดั ไมใ่ ห้ผ้ปู ่วยลกุ จากเตียง
ลายเซ็นพยาบาล ..............................................................................เลขประจาตวั ..........…................... วนั ที.่ ....................... เวลา ......................
FM-ORD-011-03
Perioperative Nursing Record Date ……………………………………..Time ……………………..….
HN. ………………………………………Room: ………………….......
Name: ………………………………...…Gender………..………...…..
Date of Birth: …………………………….Age: ………….……….……
Physician: ………………………………..MD Code…………….….…
Allergies:…………………………….…..…………………………...…..
Pre – Operative Nursing Record
Time of Patient Arrived………………….. By…………………………OR.NO……………..…. Valuable
Yes
General OB-Gyn Neuro Ortho Uro Valuable
N/A No Remove Not Remove
OPT Plastic ENT Breast Chest
Schedule Non Schedule Emergency Denture
Transport by Walk Wheel Chair Stretcher Other………..…..… Eye glasses
Patient Identification Verbally Name band Chart Other………..….…. Contact lens
Consent Form Complete Hearing aid
NPO No Yes time start………………………………………………………… Other……………………
Implant No Yes……………………………………………………………….…….. ………………………….
V/S before procedure : T……...ºC BP……….. /…...……. P…………/min R………../min
Consciousness Alert Sedate Confuse Unconscious
Respiratory status Normal Distress O2…………L/Min Via…………. Tracheostomy Ambu bag Other………………
Strict Precaution
Fall Assessment Standard precaution
Pain Assessment Assessment Tool : < 1 Years (NIPS) > 1-3 Years (FLACC) > 3-8 Years(FACES) > 8 Years (NRS)
Behavior Pain Scale (BPS) Score :…………..(Score > 0 Please fill in location Duration Characteristic Frequency)
Location……………………………………………...Duration……………………………………………………………………………………………..……
Characteristic Prick Sharp Dull Burning colic Throbbing Other…………………..………
Frequency Continuous Intermittent……………………………………………………………………………………………....
Psychological Status Calm / Relaxed Anxiety Depress Frighten
Limitation No Yes Vision Hearing Mobility Speech Other………………………………………….……..
Pre – Medication No Yes History of illness………………………………………………………………..
Medication / Doses Route Time(hr.) Given by Allergies……………………………………………………………………………
Previous Operation……………………………………………………………...
Lab Data No Yes
Supportive systems to Operating room None Blood request No Yes
NG Tube CVP Chest tube IV Infusion Printed Blood Number No Yes
Foley's cath Urine…….….ml. : Color…………….. Arterial line Confirmation Surgical site per Patient/Family Yes
Drain from…….…… ; ………ml : Color……………. Other……………………….. Note :……………………………………………………………………………...
Nursing Diagnosis : Potential for Anxiety Goal : Decreased Anxiety
Plan & Implementation : Give Explanation clearly Listen to concerns Support and reassure
Evaluation : Decreased Anxiety Yes No……………………………………. RN's signature…………….……………….………OR Nurse Time……………
Intra – Operative Nursing Record
Introduce Yourself to the Patient : ……………………………………………….………………………………………………………………………………………………………..
Verify Procedure to be Done : ……………………………………………………………………………………………………………………………………………...……………..
Preoperative diagnosis : ………………………………………………………………………………………………………………………………………………………..………….
Postoperative diagnosis : ……………………………………………………………………………………………………………………………………………………………..…..
Operation : …………………………………………………………………………………………………………………………………………………………………………………..
Time : Patient in………………………. Patient out………………………
Incision…………………………. Closure…………………………..
Note : …………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………
Page 1 / 3 FM-ORD-018-00
Perioperative Nursing Record Date ……………………………………..Time ……………………..….
HN. ………………………………………Room: ………………….......
Name: ………………………………...…Gender………..………...…..
Date of Birth: …………………………….Age: ………….……….……
Physician: ………………………………..MD Code…………….….…
Allergies:…………………………….…..…………………………...…..
Intra – Operative Nursing Record (Cont.)
Surgeon / Assistants ……………………………………………………………………………….. Anesthesiologist ………………………………………………………………..
Scrub nurse ………………………………………………………………………………………… Circulating nurse……………………………………………………………….
Allied health 1. Company………………………………… Observe Scrub nurse 2. Company………………………………… Observe Scrub nurse
Anesthesia : GA EB SB BB NLA TA LA
Start time ………………… hr. Finish time……………….hr.
Anesthesiologist Packed No Yes Type……………………………… Area………………………………………Off by………………………………………...…
Nursing Diagnosis : Potential for injury Goal : Free from injury Plan & Implementation : On step of procedure
1.Surgical position Supine Prone Lithotomy Kidney Jackknife Sitting Lateral Rt Lt Other…………………
Positioning aid. Donut Mayfield Roll sheet Sand bag Safety belt Pillow Arm board Rt Lt Hand table
Stirrups Fx. Table Stryker frame Kidney rest Thermo mattress Other…………………………………………….
Surgical Table Electric table Trans mobile Standard Orthopedic table Other………………………………………………………….
2.Foreign body Swab Instrument Sharp 4.Electric cautery No 5.X-ray No
Counts scrub Circulate Correct Incorrect Monopolar : s/n………………... Flu Portable
Pre-Op Bipolar O - ARM
Secound Argon Plasma coagulation 6.U/S
Closing Laser……………………………. No
other Harmonic Yes……………………………..
Action taken if incorrect : Comply with W/I………………………………………..…… Ligasure 7.Defibrillator
3.Tourniquet No Other……………………………. No
Site Arm Rt Lt Pressure…………. mmHg. Ground pad site No Yes……………………………..
Calf Rt Lt 8.Special Equipment
Leg Rt Lt Pressure…………. mmHg. Thigh Rt Lt No
Time Start 1………………… Finish 1………………… Other……………………………. Yes……………………………..
Start 2………………… Finish 2…………………
Evaluation : Goal Achieve Yes No
Nursing diagnosis : Potential for infection Goal : Free from infection
Plan & Implementation :
Wound classification Clean Clean contaminated Contaminate Dirty
Prep skin by clipper No Yes, Time…………hr.
Surgical site prep No Yes 4% Haxene Scrub Betadine scrub 0.5% Hibitane in water Betadine solution
2% Chlorhexidine in 70% alcohol Other…………………………………………………..………
Urinary Catheterization No Yes Retained from ward Intermittent cath……………..ml.
Inserted in OR Color ……………………..….. Time………….hr. By……………………………….….……..
Implant No Yes …………………………………………………………………………………………………………………………………………………………
Note : …………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………
Evaluation: All necessary precaution taken No Yes
Irrigation No Yes NSS Sterile Water BSS Other………………………………………………………………
In………………ml. Out……………….ml.
Specimens No Yes Routine Frozen section Cytology Other………………………………………………………………
Blood Administered No Yes………………….. ml.
Estimated blood loss……………………..ml.
Page 2 / 3 FM-ORD-018-00
Perioperative Nursing Record Date ……………………………………..Time ……………………..….
HN. ………………………………………Room: ………………….......
Name: ………………………………...…Gender………..………...…..
Date of Birth: …………………………….Age: ………….……….……
Physician: ………………………………..MD Code…………….….…
Allergies:…………………………….…..…………………………...…..
Intra – Operative Nursing Record (Cont.)
Medication No Yes ………………………………………………………………………………………………………………………………….……………
Packing No Yes Type…………………………..……… Area………………………..…………………Off by………………………………….…...…
Culture No Yes Other…………………………………………………………………………………………………………………………………
Skin Condition Un change Remark…………………………………………………………………………………………………………….…….………….
Drain None
Penrose drain Tube drain T-Tube Jacksonpratt Radivac Sump drain Chest tube
Other…………………………………………………………………………………………………………………………………………………………………………
Dressing None
Bactigras Melolin Leukostrip Steristrip Gauze Fixumull Micropore
Other………………………………………………………………………………………………………………………………………………..……………………….
Incision closure No Yes Suture Skin stapler Subcuticular Retention Dermabond
Other……………………………………………………………………………………………………………………
Discharge to PACU Room Ward Critical Care Unit Home
Note :…………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………
RN's signature…………….……………………………………..………OR Nurse Employee ID……………………….. Date………………………….Time……………………
Post – Operative Nursing Record
Nursing diagnosis : Potential for Operative and Anesthetic Complication
Goal : Safety for Operative and Anesthetic Complication
Plan&Implementation : Monitor for Activity,Respiration,Circulations,Consciousness,Color,Nausea/Vomitting,Pain and Bleeding
D/C Evaluation Yes
Health Education Yes (Specify)…………………………………………………………………………………….……………………………………………………..…….
Transport by Walk Wheel Chair Stretcher Other……………………………………………………………………..…..…
Transport from PACU to Ward Critical Care Unit Home
RN's signature…………….……………………………………..………PACU Nurse Employee ID…………………….. Date…………...…………….Time……………………
Page 3 / 3 FM-ORD-018-00
GI ENDOSCOPY NURSING RECORD Date ……………………………………..Time ……………………….
HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
PRE - OPERATIVE NURSING RECORD
OPERATION DATE ……………………………………………………………….
PRE-OPERATIVE DIAGNOSIS: ………………………………….………………POST OPERATIVE DIAGNOSIS: …………………………….......……………….
OPERATION: Gastroscopy Colonoscopy Sigmoidoscopy ERCP PEG Other …….......................................……
With: Biopsy Polypectomy Clip Banding Injection Other …………................................…………..…..…
TYPE OF ANESTHESIA: IV sedation LA GA
ARRIVAL TIME........................................ BY Walk Wheelchair Stretcher Other…….................................................................
PHYSICIAN……………………………..................……….............................…... ANESTHESIOLOGIST……….................................………………………....
SCRUB NURSE………………………………..............................................……. CIRCULATING NURSE………………………………………………………...
PRE- ANESTHETIC ASSESSMENT: No Yes ASA CLASS : 1 2 3 4 5
VITAL SIGN: T ……………˚C PR………/min RR ………/min BP…….....…/…...……mmHg SpO2……..…% BW……...……Kgs
ENDOSCOPY ROOM…………………….
PATIENT IDENTIFICATION: Verbal ID band Date of birth Medication record
CONSENT FORM Complete VALUABLE: No Yes…………………………. NPO AFTER …………………....……………….
UNDERLYING DISEASE………………………………................………...................……. REMOVED: Yes (If have)
IMPLANT: No Yes…………………………………... Denture Eyeglasses/Contact lens
PACEMAKER: No Yes Hearing aid Other……………...………
TOOTH MOBILITY: No Yes ………............................………
BOWEL PREPARATION: Clear N/A ENEMA: No Yes
ANTI PLATLET/ANTI COAGULANT DISCONTINUED …………................…. days before procedure
CONSCIOUSNESS RESPIRATORY STATUS PSYCHOLOGICAL STATUS LIMITATION No Yes
Alert Normal Calm / Relaxed Vision
Sedated Tachypnea Anxious Hearing
Confused Dyspnea Depressed Mobility
O2 …...…L/min Via…....… Frightened Speech……...........……………
Other…..……............…….
MEDICATION TIME GIVEN BY LAB RESULT: Yes
CBC, UA , E’Lyte,
BUN, Creatinine, LFT, Anti HIV
EKG, CT, MRI, U/S, Chest X-Ray
NOTE :…………………………………………..………
……………………………………………….……..……
…………………………………………………….…..…
…………………………………………………….……..
……………………………………………………………
……………………………………………………………
RN’s Signature…………………………..……………Employee No.……………………
Page 1/3
FM-GID-001-00
GI ENDOSCOPY NURSING RECORD Date ……………………………………..Time ……………………….
HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
INTRA - OPERATIVE NURSING RECORD
SIGN IN: Verbally verified by GI endoscopist / anesthesiologist ( if involved) and circulating nurse/RN
TIME: Patient in………................................. ALLERGIES: No
Operating time start………………….. End……......................
Patient out…………………….……….. Yes………………………………………..………
SIGN IN : BLOOD REQUEST: No
Yes OK
INTRODUCE YOURSELF AND TEAM TO THE PATIENT Yes
NOTE : ………………………………………………………………
IDENTIFY CORRECT PATIENT Yes
VERIFY PROCEDURE TO BE DONE Yes
DIFFICULT AIRWAY/OR RESPIRATION RISK CONFIRM BY ANESTHISIOLOGIST: SPECIAL EQUIPMENT No
No
Yes, Equipment/Assistance available Yes, already Provided
MONITOR VITAL SIGNS: Yes N/A NOTE : ……………………………………………………………….
TIME OUT : To be performed before starting GI endoscopy procedure and sedation to ensure the correct patient and correct procedure . Time …………………
NURSING ASSESSMENT: POTENTIAL FOR FLUID VOLUME DEFICIT RELATE TO NPO STATUS
OUTCOMES : NORMAL FLUID VOLUME WILL BE MAINTAINED
PLAN & IMPLEMENTATION :
__________________________________________________________________________________________________________________________________________________
IV STARTED: No Yes…………………………………….
IV SITE APPEARANCE: Redness No Yes Infiltrate/Site Change No Yes
Edema No Yes Secured with tape No Yes
TIME IV FLUID/BLOOD PRODUCT/RATE SIGNATURE
EVALUATION: Patient is free from fluid volume deficit Yes No……………………………………………………………………………………….………………
NURSING ASSESSMENT : POTENTIAL FOR INJURY OUTCOMES : FREE FROM INJURY
PLAN & IMPLEMENTATION :
FALL PREVENTION: Instruct patient cleary Obtain transfer assistance Side rail up Other………………………………………..…………………..
POSITION: Supine Lateral Lt. Rt. Semi-Prone Other………….……………………………….……………………..…………
POSITIONING AID: Safety belt Pillow Rolled sheet Other…………………………………………………………………...………
EVALUATION: NO EVIDENCE OF INJURY
NURSING ASSESSMENT: POTENTIAL FOR BLEEDING /BURNS OUTCOMES : NO/ MINIMAL BLEEDING
PLAN &IMPLEMENTATION: FREE OF BURNS
ELECTROCAUTERY: No Yes GROUND PAD SITE: No Yes
Monopolar Calf Rt. Lt.
Argon Thigh Rt. Lt. Other………………………………..……
Other………..........…………. SKIN: PRE OPERATION Intact Other
POST OPERATION Intact Dry Redness Other…….……….…….
EVALUATION : NO EVIDENCE OF EXCESSIVE BLEEDING /BURNS
Page 2/3
FM-GID-001-00
GI ENDOSCOPY NURSING RECORD Date ……………………………………..Time ……………………….
HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
NURSING ASSESSMENT: POTENTIAL FOR INFECTION OUTCOMES : FREE OF INFECTION
PLAN & IMPLEMENTATION:
SURGICAL SKIN PREP: No Yes Betadine Scrub Solution
Hibitane Scrub Solution
URINARY CATHETERIZATION: No Retained from ward
IRRIGATION: No Yes NSS Water
EVALUATION: NO EVIDENCE OF CONTAMINATION
MEDICATION: No Yes 10% Xylocaine Spray Contrast ……....... ml. Other……………………………............................
SIGN OUT: Confirm operation
IMPLANT No Yes ………………………………………………………………………………………..………………………………………………………
SPECIMEN WAS IDENTIFIED AND LABELED: Yes N/A
Tissue 1…...............................2…………………………….3……………………………...4…………………………….. Total……... Bottle(s)
Clo–test Result Positive Negative
C/S………………………………………………………..…………. Other….......................................................................................................................
INCISION: No Yes /Dressing ESTIMATED BLOOD LOSS: No Yes……………….……………..ml.
BLOOD ADMINISTERED: No Yes ………………………..…..………… TRANSPORT TO: PACU Other………………………………………..……………
RN’s Signature…………………………..……………Employee No.……………………
POST - OPERATIVE NURSING RECORD
NURSING ASSESSMENT: POTENTIAL FOR OPERATIVE AND SEDATIVE / ANESTHETIC COMPLICATION
OUTCOMES: SAFETY FOR OPERATIVE AND SEDATIVE / ANESTHETIC COMPLICATION
PLAN & IMPLEMENTATION: CONTINUOS MONITOR FOR ACTIVITY, RESPIRATION, CIRCULATIONS, CONSCIOUSNESS, COLOR, NAUSEA / VOMITTING,
PAIN AND BLEEDING
DISCHARGE EVALUATION:
VITAL SIGNS : T ……………˚C PR…………/min RR …………/min BP…….....…/…...……mmHg SpO2……..…% BW……...……Kgs
LEVEL OF CONCIOUSNESS Alert Confused Drowsy Stupors Comatose AIR WAY: Clear Other…………………..………
PAIN: Abdominal pain No Yes PAIN SCORE ………………….
FLATULENCE: No Yes ………………….….……....….
NAUSEA/VOMITTING: No Yes ………………………………… MODIFIED ALDRETE SCORE…………………….…………………………………………..
DISCHARE TIME: ………………………………………
COMPLICATION: No Yes ……………………………………………………………………………………………..…………………………………………….....…………
STATUS AT DISCHARGE : Stable Unstable
TO: Home Ward Other……………………………………………………………………………………………………………………
TO HOME:
Patient Education: Food Medication Post-Operative care Urgent signs and symptoms
TO WARD:
Hand off communicate to……………………………………………..……………………..……RN At ward……………………………………………………………..……………
RN’s Signature…………………………..……………Employee No.……………………
Page 3/3
FM-GID-001-00
Code Blue Evaluation Date: Time:
HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
MD Code
Allergies:
Founded by ................………….........…........Assessed by...................................Assessed time.................………..........Location...........…….....................
CPR started time.............………..... Code Blue was activated Yes; time................ No (Silent Code Blue) Discontinued time................
Event prior to arrest............................................................................................................................................................…………………………................
Problem list Electrolyte imbalances CAD CVA Aspiration Multiple Organs failure CA ........................……..
Pre CPR Yes No Remark Post CPR Yes No Remark
Respiration ............................. Respiration .................................
Pulse ............................. Pulse .................................
BP ............................. BP .................................
Conscious ............................. Conscious .................................
EKG Rhythms Yes; VT VF Asytole EKG Rhythms ....................................................................................
Other ............................ Medications Dopamine Adrenaline
No; Specify ............................. Outcome Successful .......................……………..…...….
Conscious
Summary: Respiratory arrest Cardiac arrest Unconscious
CPR Yes No Remark
Unsuccessful
Clear airway .............................
Expired date and time.........................….............…
Ambu with facemask .............................
Intubation ............................. Transfer to ICU……. CCU ……... Ward ...................
Chest compression ............................. Other; Specify……………………………...……...
Medications: Atropine 10% Calcium Gluconate Effects of Code Blue No Yes; …………………………........
Adrenaline Staff injury No Yes; …………………………........
Cordarone Dopamine 50% Glucose Patient injury
NaHCO3
.......................... ........................
Defibrillation: ..................Joules ................Time(s) First physician arrived (name)…………..…….……….... Time……..…..
..................Joules ................Time(s) Patient expired time…………….. Pronounced by………..…….…….....…
Cardioversion ..................Joules ................Time(s) Physician Porter
Time Time
Procedure:
Central line Arterial line Nurse
Transcutaneous pacemaker Time
Others ............................................................................................. Time Record
Time to chest compression…………... min (Time from collapse to initiation of chest compression within ≤ 1 min.)
Time to defibrillation……………..…. min (Time from EKG VF/Pulseless VT to first defibrillation within ≤ 3 mins)
Time to first dose adrenaline……….... min (Time from collapse to first dose of adrenalin within ≤ 5 mins)
Time to team arrival……………….…. min (Time from Code Blue announcement to ICU/CCU nurse or physician arrival within ≤ 4 mins)
Time to finish …………………..….... min (Time from Code Blue announcement to stop CPR)
Comment:
Equipment ............................................................................................................................. ..............................…...………………………….............
Medication ............................................................................................................................. ..........………………………….........................…..........
Practice ........................................................................................................................................…………………………….....................…..............
Time (if recommended time is not met.) ………………………………………………………………..………………….………………….………
Others......………………………………………………………………………..........…………………………………..………………....…...........
.......................................................................................................................................... ...........…………………………............................…...........
Duty Manager’s Signature ....................................………………............ Employee ID……...………..……. Date ……..……....…… Time……...……...
FM-NSO-010-00
Nursing Notes : Code Blue Date: Time:
HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
Allergies: MD Code
Founded by ……..…………... Witness No Yes; Specify …………..... Assessed by ……………….. Assessed time ..................
Location ……………... CPR started time ………………… Code Blue was activated Yes; time ............... No (Silent Code Blue)
Event prior to arrest……………………………………………………………………………………………………………………………………..
Pre CPR
Patient conscious at onset Yes No
EKG Rhythm
P ul se Yes No VT VF Asystole Othe r…… ……… ……… ……… ……… ……… ....
Respiratory Adequate Ina deq uate No
CPR Othe r…… ……… ……… …
BolusVentilation: ET tube time…………..Size………….Mark…………. by whom:………………………..
Time
End-tidal CO2
EKG Rhythm*
Defibrillation* (Joules)
Adrenaline* (amp)
Atropine* (amp)
Ca Gluconate (amp)
Cordarone* (mg)
NaHCO3 (amp)
50% Glucose (amp)
Othe r
Procedure Infusion Adrenaline (mcg/min)
Dobutamine (mcg/kg/min)
Dopamine (mcg/kg/min)
Othe r
Central line
Arterial line
Othe r
Family Informed By phone By verbal Cannot contact : specify ………………………………………………………...…..
Discontinued time ………………………………..
Outcome 1st ROSC Time …………………. Pulse:…….…../min R:…….…../min BP:…….…../mm Hg O2 Sat…….…..%
2nd ROSC Time ………………… Pulse:…….…../min R:…….…../min BP:…….…../mm Hg O2 Sat…….…..%
Consc ious Yes No CCU …… ….. Ward ………… Other …………………………………………………………………...
Transfer to ICU …… …..
Nurse’s Note ……………………………………………………………….…………………………………….……………………………………
…… ……… ……… ……… ……… ……… ……… ……… ….…… ……… ……… ……… ……… .…… ……… ……… ……… ……… ……… ……… ..
…… ……… ……… ……… ……… ……… ……… ……… ….…… ……… ……… ……… ……… .…… ……… ……… ……… ……… ……… ……… ..
…… ……… ……… ……… ……… ……… ……… ……… ….…… ……… ……… ……… ……… .…… ……… ……… ……… ……… ……… ……… ..
…… ……… ……… ……… ……… ……… ……… ……… ….…… ……… ……… ……… ……… .…… ……… ……… ……… ……… ……… ……… ..
…… ……… ……… ……… ……… ……… ……… ……… ….…… ……… ……… ……… ……… .…… ……… ……… ……… ……… ……… ……… ..
Duty Manager’s Signature…………………………….…….. Employee ID…………..….…….Date………..…………..Time……….…..…….
FM-NSO-005-00
Critical Care : 8 hour Flow Sheet Date : ……………………………… Time : ………………………
HN : ……………………………….. Room : …………………….
Time Name : …………………………….. Gender : ………………...
Physician visits Date of Birth : ………………...…… Age : ………………………
Telephone visits Physician : ………………………… MD code : ………………..
Allergies : …………………………………………………………..
Lab order
Temperature
Heart rate
Respiratory rate
Noninvasive blood pressure (NIBP)
Arterial blood pressure (ABP)
Mean arterial blood pressure (MAP)
Central venous pressure (CVP)
Pulmonary artery pressure
Wedge
SpO2 %
ET / Tracheostomy : size / mark / cuff pressure
Spontaneous tidal volume (STV)
EKG rhythm
Pacemaker setting
IABP setting
Ventilation
Blood
Plasma
Platelet
Total volume / hour
Intake
Oral
Tube feeding
Urine / Foley's catheter Total
NG / Emesis Total
Output Stool FM-ICU-001-00
Drainage
Chest tube l
ll
lll
RN’s Signature
/ Initial
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