Documentos de Académico
Documentos de Profesional
Documentos de Cultura
FLUID BALANCE
Date: Previous Fluid Balance Total date
(see key below)
Input (mls)
Oral/NG/NJ Fluid Type Fluid Type Volume (mls) Line 1 (I/V) Hourly Total Fluid Type Running Total Line 2 (I/V) Hourly Total Fluid Type Running Total Line 3 (I/V) Hourly Total
Output (mls)
Bowels / Stoma
(from separate drain chart)
Time
2400 0100
Time
2400 0100
L/min %
Blood Pressure
(mmHg)
PLAN
60 50
Heart rate
(beats/min)
140 130 120 110 100 90 80 70 60 50 40 40 39 38 37 36 35 120 80 119 79 Alert Voice Agitation / confusion Pain Unresponsive Pain at rest Pain on movement Respiratory rate Systolic BP Heart rate 4 hour urine output Consciousness TOTAL ewS
1400 1500 8 hr total 1600 1700 1800 1900 2000 2100 2200 2300
90 80 70 60
50 40 40 39 38
Temperature (C)
X
37 36 35
8 hr total 24 hr total
Input
Output Balance
Level of Consciousness
(indicate + or -)
Rest Movement Respiratory rate Systolic BP Heart rate 4 hour urine output Consciousness TOTAL ewS
e A R LY w A R N I N G S C O R e K e Y
3
NOT FOR MeT
Dial 777 and state Medical Emergency Team (MET): STAY WITH THE PATIENT Registrar review within 20 minutes: Inform PAR Nurse (page 6785), House Officer and Nurse in Charge House Officer review within 60 minutes: discuss with Nurse in charge and inform PAR Nurse (page 6785) Manage pain, fever or distress: Consider increasing frequency of vital sign observations and discussion with Nurse in charge/referral for review
MeT
777
Respiratory Rate Systolic BP heart rate 4 hour urine output Level of consciousness
CALL 777 MET FOR ANY PATIENT YOU ARE SERIOUSLY CONCERNED ABOUT REgARDLESS OF VITAL SIgNS/EWS
At the time of referral to a House Officer, Registar or PAR Nurse complete an Activation of EWS sticker and place it in the patient record. If there is no timely response to your request for review to escalate to the next coloured zone.
ZX2309 EXCEL AUG 2011
to to to to to
write the acceptable ranges outside which abnormal vital signs are tolerated for the patients clinical condition - the ewS will be 0
Bicarbonate
EPAP
IPAP
pCO2
pO2
pH
Running Total
Drain(s) Total
Hourly Total
Total Input
Total Output
Balance
Running Total
Urine
NIGhT
Nurse Signature Nurse
AM
Signature Nurse
PM
Signature
A B
AIRwAY
Asymmetrical Symmetrical
NOTeS:
A B
AIRwAY
Asymmetrical Symmetrical
NOTeS:
A B
AIRwAY
Asymmetrical Symmetrical
NOTeS:
INSPIRATORY/eXPIRATORY NOISeS
RIGHT LEFT APEX MIDZONE BASES
INSPIRATORY/eXPIRATORY NOISeS
RIGHT LEFT APEX MIDZONE BASES
INSPIRATORY/eXPIRATORY NOISeS
RIGHT LEFT APEX MIDZONE BASES
AUSCULTATION
AUSCULTATION
AUSCULTATION
wORK OF BReAThING
Cyanosis Accessory Muscle Usage NO/YES NO/YES Diaphragmatic Breathing NO/YES
wORK OF BReAThING
Cyanosis Accessory Muscle Usage NO/YES NO/YES Diaphragmatic Breathing NO/YES
wORK OF BReAThING
Cyanosis Accessory Muscle Usage NO/YES NO/YES Diaphragmatic Breathing NO/YES
CARdIOVASCuLAR
Rhythm NO/YES Present Weak Absent Thready Bounding Full ON/OFF Seconds NO/YES NO/YES NO/YES NO/YES C Suction @
CARdIOVASCuLAR
Rhythm NO/YES Present Weak Absent Thready Bounding Full ON/OFF Seconds NO/YES NO/YES NO/YES NO/YES C Suction @
CARdIOVASCuLAR
Rhythm NO/YES Present Weak Absent Thready Bounding Full ON/OFF Seconds NO/YES NO/YES NO/YES NO/YES C Suction @
TEDS Capillary Refill Time Oedema Obvious Signs of Bleeding Chest Drains Other Drains Temperature
TEDS Capillary Refill Time Oedema Obvious Signs of Bleeding Chest Drains Other Drains Temperature
TEDS Capillary Refill Time Oedema Obvious Signs of Bleeding Chest Drains Other Drains Temperature
NeuROLOGICAL
S 1
NO/YES NO/YES NO/YES
NeuROLOGICAL
S 1
NO/YES NO/YES NO/YES
NeuROLOGICAL
S 1
NO/YES NO/YES NO/YES
Sedation Score
Pain Assessment Made Advanced Analgesia Confused
3
PCA
4
NO/YES NO/YES
Sedation Score
Pain Assessment Made Advanced Analgesia Confused
3
PCA
4
NO/YES NO/YES
Sedation Score
Pain Assessment Made Advanced Analgesia Confused
3
PCA
4
NO/YES NO/YES
Agitated
Agitated
Agitated
GASTROINTeSTINAL
Soft Firm Hard Distended Bowel Sounds Active Hypoactive Absent Free Drainage X-Ray NBM TPN Litmus NO/YES NO/YES NO/YES
GASTROINTeSTINAL
Soft Firm Hard Distended Bowel Sounds Active Hypoactive Absent Free Drainage X-Ray NBM TPN Litmus NO/YES NO/YES NO/YES
GASTROINTeSTINAL
Soft Firm Hard Distended Bowel Sounds Active Hypoactive Absent Free Drainage X-Ray NBM TPN Litmus NO/YES NO/YES NO/YES
Abdomen
Abdomen
Abdomen
Enteric Tube in Place Position Confirmed Feeding Protocol Stoma Present Abdominal Drains
Enteric Tube in Place Position Confirmed Feeding Protocol Stoma Present Abdominal Drains
Enteric Tube in Place Position Confirmed Feeding Protocol Stoma Present Abdominal Drains
Gu I
Skin Temp
GeNITO uRINARY
NO/YES U.O. > 0.5ml / kg / hr NO/YES
PLAN:
Gu I
Skin Temp
GeNITO uRINARY
NO/YES U.O. > 0.5ml / kg / hr NO/YES
PLAN:
Gu I
Skin Temp
GeNITO uRINARY
NO/YES U.O. > 0.5ml / kg / hr NO/YES
PLAN:
Urinary Catheter
Urinary Catheter
Urinary Catheter
INTeGuMeNT
Warm Cool Dry Clammy Diaphoretic Skin Colour Normal Pale Flushed Jaundiced Mottled Mouth Dry Moist Sores Thrush
INTeGuMeNT
Warm Cool Dry Clammy Diaphoretic Skin Colour Normal Pale Flushed Jaundiced Mottled Mouth Dry Moist Sores Thrush
INTeGuMeNT
Warm Cool Dry Clammy Diaphoretic Skin Colour Normal Pale Flushed Jaundiced Mottled Mouth Dry Moist Sores Thrush
wOuNdS / IV ACCeSS
Site
wOuNdS / IV ACCeSS
Site
wOuNdS / IV ACCeSS
Site
Inspected
Inspected
Inspected
SAFeTY
SAFeTY
SAFeTY
O2 Level Correct and Functioning Suction, Connected and Correctly Functioning Emergency Equipment Correct Emergency Trolley and Defib. Checked Monitor Alarms On, Limits Set Intubation Drugs Checked Drug Infusions Checked and Lines Labelled Patient ID In Place Shift Nurse Completing Assessment
O2 Level Correct and Functioning Suction, Connected and Correctly Functioning Emergency Equipment Correct Emergency Trolley and Defib. Checked Monitor Alarms On, Limits Set Intubation Drugs Checked Drug Infusions Checked and Lines Labelled Patient ID In Place Shift Nurse Completing Assessment
O2 Level Correct and Functioning Suction, Connected and Correctly Functioning Emergency Equipment Correct Emergency Trolley and Defib. Checked Monitor Alarms On, Limits Set Intubation Drugs Checked Drug Infusions Checked and Lines Labelled Patient ID In Place Shift Nurse Completing Assessment