Nursing leadership and management Delegation

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TODAY DATE: WEDNESDAY 9-23-16 N.A.I.L. © Nursing Unit Report Sheet N.A.I.L. © Geneo Roberts
Rm Patient, Age, Sex Diagnosis IV date Oxygen Tele Diet Activity Lab Flu Vac I/O Notes
Code Status Size Pne Vac Weight
Physician(s) History Location Foley
Admit Date Fluids
101 Ballard, Dee 42 F Vomiting, Epigastric Pain 22-Sep > 94% SR FL AAT Up ad lib CBC, CMP F - @d/c Strict I/O Allergy: Tylenol
**NAME ALERT** UDS (+) Cocaine, Benzo & 22 g Rm Air to Regular P - @ d/c V/S q8h, notify temp >101, pain >8 or uncontrol pain
unknown Cannabinoids Lt hand 9-21 Abd series - no acute findings
Lewis D5NS Smoke Cess Education
Valles Depression, Tobacco use @125 Plan d/c once tolerate po/diet
21-Sep ETOH
102 Kirk, Jackie 77 M COPD Exacerbation 23-Sep > 94% Afib Mech Soft OOB to CBC, CMP F -defer Strict I/O Allergy: Vancomycin, Tetanus, PCN
DNR/DNI UTI/AKI 20 g 2.5L n/c Boost w/ chair w/ P - unknw Daily Wt V/S q4, notify temp>101, pain =/> 8
Smith Bilat venous stasis Lt FA SVN BID each meal meals 9/16 WBC 23-Sep Family Password Horse
Rodriguez New onset Afib SL 12.9 85.7kg Fall Precautions
Madrid SCD 9/20 WBC + 0.3 kg Code Neuro 9/24
16-Sep CHF -EF 55%, COPD 15.1 MRI for possible subdural hematoma
CAD, alcoholic PT/OT Foley Patient & Family refused MRI
dementia, GERD UOM consult - NH Placement
CABG x2 3 more days of antibx then discharge
103 Privacy Patient 38 M Fever, HIV 15-Sep > 94% SR Regular Amb w/ CBC, CMP F- defer Strit I/O Allergy: NKA
NO INFORMATION PT PICC x2 4L n/c Boost Plus assist ANC, Mag, PO4 P - defer V/S q4, notify temp>101/<96, HR >110/<60
Full HIV, hx C-diff Rt Upper Arm each meal Foley RR >24/<14, SBP >160/<100, DBP >90/<70
Lewis SL if < 88% Need pulse ox <90% or Fi02 >35%, AMS, pain >8
Ugalda **REVERSE ISOLATION Site Care due BIPAP PRN Sputum Culture or uncontrolled pain, Uop <20/hr for 2cons hours
Hall 23-Sep 9/15 and 9/20 2units PRBC each day
9-Sep NOTE: Amphotericin is not compatable w/ NS
104 Homer, Kandie 67 F Altered Mental Status 20-Sep Rm Air SR Regular Amb in CBC, CMP F - unknw I/O Allergy: Unknown
Full Insomia 20 g Room P - unknw V/S q4, Neuro q8h
Ugalda Lt Hand 9/20 Trop Pain evaluation referral to pharmacy
Jones, A Hx unable to obtain SL SCD 0.00 Will UOM due homelessness
20-Sep Pt confused 20-Sep need
No family 18 g PT/OT @ d/c
Lt AC ST
NS @ 75
105 Zeal, Matt 68 M Fall, Head trauma, 20-Sep > 94% n/a Mech Soft Up w/ CBC, CMP F -defer Strict I/O Allergy: NKA
DNR 20 g Rm Air assist P -hx V/S q4, notify temp>101, pain =/> 8
Hou Dementia, Seizures, HTN Lt FA 9/21 trop Family Password 1234
20-Sep Hearing loss, Blind Lt eye NS @ 75 PT/ST 1.12 Fall Precautions - UOM Consult -NH Placement
106 Ballard, Henry 82 M Acute Abd pain, Diarrhea 22-Sep > 94% SR Cardiac CBR CBC, CMP F - hx Strict I/O Allergy: PCN
**NAME ALERT** Exacerbation CHF 20 g 4L n/c Boost w/ Mag P - hx Daily Wt V/S q4h, notify if temp >101, pain >8/uncontrolled
DNR Leukocytosis Left FA each meal PT 23-Sep Family Password: redpotatoes
Taylor SL SVN q4h *Need Stool 88.5 kg Fall Precautions
Rodriguez Hard of Hearing, COPD Fluid Restrict Culture -0.2 UOM - consult return to ElderCare for 9-25
20-Sep CHF, Alzheimer, CAD, RA BIPAP 1500/24hr
From ElderCare AAA, prostate CA @ hs Foley
Nursing Facility
107 Crickett, Jannie 25 F Sensation of mites under 21-Sep Rm Air n/a 1800 ADA Up ad lib CBC, CMP F - @ d/c I/O Allergy: NKA
unknown the skin, Right facial and 22 g Carb Count P - defer V/S q4h, notify if temp >101, pain >8/uncontrolled
Sloan Right labial cellulitis Left AC Bedside Gluc 9/22 pemathrine body wash done
Jones, B UDS (+) Cocaine, Benzo & SL ac and hs MHMR consult for discharge care and placement
21-Sep Cannabinoids Diabetic Education
Hx DM
Drug Abuse, MHMR patient
108 Johnson, Neil 53 M New Admit from ER
New Onset Seizures
Lewis
23-Sep
109 LaHook, Cain 44 M Osteomyelitis of left BKA 20-Sep > 94% n/a 1800 ADA CBR CBG ac & hs F- unknw I/O Allergy: NKA
Full stump 20 g Rm Air Cardiac w/ BSC Daily P - unknw V/S q4h, notify temp >101/<96, HR >120/<55
Lewis Left AC CBC, CMP RR >24/<12, SBP >180/<100, DBP >120, pulse
Jones, B DM II, HTN, Hyperlipidemia SL IS q1h PT/OT ox <88%
Lee 6/16 Left BKA, 21-Sep Blood Cultures 9/20 Excision&Debridment Left Stump w/ wound vac
19-Sep PICC - SL pending UOM consult for outpatient antibiotic treatment &
Left Upper Arm LTAC placment - plan discharge for 9/23
110 Mayes, Bonita 30 F Cellulitis LLE 19-Sep >94% SR Regular BR w/BSC CBC, CMP F - defer I/O Allergy: NKA
Full 20 g Rm Air P - defer Daily Wt V/S q8h, notify temp >101, pain >8 or uncontrol pain
Lee No medical hx provided Rt FA PT 9-24 Vanc tr 23-Sep Fall Precautions
18-Sep Tobacco Use SL 89.9 kg Keep Left Leg ELEVATED
From out of town - 0.7 kg 9-19 ID Left Leg - Wound Care
9-20 Debridement w/wound vac applied
WoundCare Team changed drsg/wound vac MWF
CHARGE NURSE
ASSIGNMENTS Patient Room(s) Task for C.N.A./U.A.P.
Staff RN
Staff LVN
N.A.I.L. © 2016 Geneo Roberts

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