medical-surgical flowsheet guidelines - Department of Nursing ...

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GuidelineMedical-Surgical/Gero-Psych - Unit Practice Manual Page 2 of 13John Dempsey Hospital - Department of NursingThe University of Connecticut Health CenterGUIDELINES FOR:Medical-Surgical-Oncology, Medicine 4/Medical Stepdown, andGeroPsych Flowsheetsa Y (yes) or N (no) indicating whether or not the patientfinds the pain level acceptable to him/herPCA Document the number of injected doses of medication and thenumber of attempts for patients on a PCA pumpSedation Score,Sensory Check, Enter values using the legend at top of page.Motor CheckEpidural Rate/Site Enter the rate that the epidural is running at. RateCheckchanges are captured here Epidural site check must be performed every 12 hours. Thesite should be assessed for redness, bruising, swelling andleakage. The check mark indicates the check was done, ifany of the above are present (redness, bruising,swelling,leakage), document in the nursing note and notifyanesthesia.Pulses Document strength of blood flow of the RRAD (right radial),LRAD (left radial), RDP (right dorsalis pedis) and LDP(left dorsalis pedis) by indicating if the palpable pulsesor Doppler pulse is 0 (absent), 1 (diminished/weak), 2 (asexpected), 3 (full/increased), or 4 (bounding), or if thedoppler measurement is audible (DA) or inaudible(DI)Comments/Meds Use this column for any medications you want to include onthe Flowsheet (perhaps in response to an elevated VS or FSGor pain) or any other comments that may be helpful. ReferFingerstickglucose (FSG)to MAR for documentation of any medications administeredEnter any decentralized lab testing values and slidingscale insulin coverage if applicable; refer to MAR fordocumentation of all drugs administered in response to thevalue** A significant deterioration in any vital sign or other objective measure ofpatient status indicates the need to report the condition to the LicensedIndependent Practitioner (LIP).PAGE 2: 24 HOUR FLUID INTAKEIV Sites Document the location(s) of each IV site. There is space toinclude 3(three) IV sites as well as 1 (one) central line.Be sure to specify insertion date. If the dressing isintact, changed or the IV is discontinued, check theappropriate box.For Portacaths, identify the date of the needle change, aswell is when the dressing change was done and whether theneedle was discontinues.Infusions A column is provided for up to 5 (Five) separate infusions.Each infusion should have the intravenous fluid (IVF) beingadministered identified along with the corresponding sitenumber (#).Solutions infused must be documented with the correspondingcolumn/IV site, as well as the hourly ratePhlebitis and infiltration scores should be documentedevery 8 hours under the corresponding IV site
GuidelineMedical-Surgical/Gero-Psych - Unit Practice Manual Page 3 of 13John Dempsey Hospital - Department of NursingThe University of Connecticut Health CenterGUIDELINES FOR:Medical-Surgical-Oncology, Medicine 4/Medical Stepdown, andGeroPsych FlowsheetsIV document the volume of intermittent medicationsMedications/Flush administered, when applicableTube Feeds Document the type of tube feeding product being used, aswell as the hourly infusion rateResidual/Placement Document the volume of residual aspirated as well as theplacement of the tube (+ for positive placement – fornegative placement, if placement is negative, nothingshould be placed in the tube, and the LIP contactedPO Fluid All oral fluids must be included in the cumulative 24-hourintake CalculationPO Solid (%)DietDocument the percentage of each meal consumed, especiallyfor patients on calorie counts. Document the patientscurrent diet orderIntake Hourly If needed, this column can be used to keep track of allCumulativeintake on an hourly basis8 Hour Total At eight hour intervals, record the 8-hour intake for eachcolumn24 Hour Total At the bottom of the page, record the 24-hour intake foreach columnPAGE 3: 24 HOUR FLUID OUTPUTTop Left BoxTop Right BoxTubes 1-5CBI: Continuousbladder irrigationCheck the appropriate box to indicate how the patient voids,and if they have a colostomy or ileostomy. If they do have anappliance, indicate when the change was done and the dateHemodialysis- check the box if they are a hemodylasis patientCAPD- check the box if the patient is a CAPD patient- thiswill indicate a separate CAPD flowsheetDue to Void (DTV): check the box and enter the time that thepatient is due to void in this space.EBL: enter the estimated blood loss in this column.Enter type of tube at top of column, and the hourly output,if applicableMake certain that each tube is clearly labeled on theflowsheet and correspond to the same tube on the patient.Enter the type of continuous bladder irrigation fluid beingused.Record amounts for solution hung, amount infused each hour,and amount of output each hour. Then calculate the true urineoutput by subtracting amount infused from the output.Urine OutputEnter volume of output corresponding to the appropriate timeof dayPost Void Residual Enter volume of urine obtained after patient voids(PVR):Stool/Heme LBM = last bowel movement; enter the date of the last bowelmovement Indicate the volume of stool produced, as appropriate. Forhemacult testing use + if positive or – if negativestickermay be used.Emesis Enter amount produced, as appropriate
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