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Patient Monitoring Sheet

The document contains monitoring sheets for a 59-year old male patient named Mr. Ms admitted to the hospital on September 14th for acute anterior myocardial infarction. It includes sheets tracking his vital signs, medications, diagnostic tests, treatment plan and fluid intake/output over his hospital stay. His vital signs, medications and treatment plan are documented to be monitored and administered by nurses according to the provided instructions.

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Andrea Sibayan Soriano
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78 views

Patient Monitoring Sheet

The document contains monitoring sheets for a 59-year old male patient named Mr. Ms admitted to the hospital on September 14th for acute anterior myocardial infarction. It includes sheets tracking his vital signs, medications, diagnostic tests, treatment plan and fluid intake/output over his hospital stay. His vital signs, medications and treatment plan are documented to be monitored and administered by nurses according to the provided instructions.

Uploaded by

Andrea Sibayan Soriano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PATIENT MONITORING SHEET

PATIENT NAME: Mr. MS AGE: 59 yrs old


PHYSICIAN: SEX:

DATE/ TIME VITAL SIGNS OTHERS


SHIFT BP CR/PR RR TEMP O2 GCS CBG
SAT
09/14/20 7AM 140/90 mmHg 108 bpm 22 bpm 36°C 92%
09/15/20 7AM 130/80 mmHg 105 bpm 24 bpm 36.8°C 96%
09/16/20 7AM 120/80 mmHg 100 bpm 23 37°C 98%
bpm
KARDEX

PATIENT NAME: Mr. Ms AGE: 59 y/o HOSPITAL NO.:


PHYSICIAN: SEX: M WARD/ROOM:
Date admitted: 09/14/20 Chief Complaint: Chest pain
Diagnosis: Acute Anterior Myocardial Infarction Allergies: No allergies to any food or drug

DIAGNOSTICS DATE ORDERED NURSING ACTION


ECG 09/14/20 Review the patients’
medical record and
plan of care, inspect
the chest of patient for
any breakdown,
position the client,
Expose the chest, do
the ECG & document
data about the patient.
Chest x-ray Assist the patient in
proper position, ask
the patient to wear a
gown but the chest is
09/14/20 exposed.
Troponin test 09/14/20 Monitor vital signs,
inspect for the
breathing pattern of the
patient, document any
findings or result.
MEDICATIONS DATE ORDERED NURSING ACTION
Aspirin 09/14/20 Monitor patient for
signs of bleeding
Simvastin, Enalapril 09/14/20 Monitor pain, muscle
pain, tenderness, or
weakness, especially if
accompanied by fever,
malaise, and dark-
colored urine. Advise
patient that these
symptoms may
represent drug-induced
myopathy and that
myopathy can
progress to severe
muscle damage,
Monitor the client in
any situation that may
lead to a drop in blood
pressure (diarrhea,
sweating, vomiting,
dehydration

IV FLUIDS DATE ORDERED NURSING ACTION


N/A
SPECIAL ENDORSEMENTS DATE ORDERED NURSING ACTION

TREATMENT DATE ORDERED NURSING ACTION


O2 inhalation at 3-4LPM via nasal cannula 09/14/20 Monitor the patients
oxygen if the oxygen is
open or closed to
make sure that we
promote comfort
breathing for the
patient.
PROCEDURES DATE ORDERED NURSING ACTION

DIET DATE ORDERED NURSING ACTION


Low sodium low fat diet 09/14/20 Advise the patient that
he is served low
sodium low fat diet and
instruct to the client
what specific food is he
going to eat or not.
NURSING NEEDS DATE ORDERED NURSING ACTION

MEDICATION SHEET

PATIENT NAME: AGE: HOSPITAL NO.:


PHYSICIAN: SEX: WARD/ROOM:

MEDICATION/DOSAGE/FREQUENCY DATE/ 8/17/20 8/18/20 8/18/20


SHIFT
Aspirin/80mg/OD 7am-3pm 7am 7am 7am

3pm-11pm

11pm-7am

Isosorbide dinitrate/10mg/TID 7am – 3pm 7am 7am 7am


3pm-11pm 3pm 3pm 3pm

11PM-7AM 11am 11am 11am

Simvastatin/20mg/OD 7AM - 3PM

3PM-11PM

11PM-7AM 11am 11am 11am

Enalapril/10mg/OD 7AM - 3PM 7am 7am 7am

3PM-11PM

11PM-7AM

TRANSCRIBE THE DOCTOR’S


ORDERS AND FILL OUT THE
NECESSARY INFO ON THIS
MEDICATION ADMINISTRATION
RECORD
FLUID MONITORING SHEET

PATIENT AGE: HOSPITAL NO.:


NAME:
PHYSICIAN: SEX: WARD/ROOM:

TIME INTAKE (ML) OUTPUT (ML)


MORNING Type of Ora NG URINE NG/ASPIRATE DRAINS STOOLS
SHIFT fluid l
7:00 AM

3:00 PM TOTAL
TOTAL INTAKE
TOTAL OUTPUT
TIME INTAKE (ML) OUTPUT (ML)
AFTERNOON Type of Ora NG URINE NG/ASPIRATE DRAINS STOOLS
SHIFT fluid l
3:00 PM

11:00 PM TOTAL
TOTAL INTAKE
TOTAL OUTPUT
TIME INTAKE (ML) OUTPUT (ML)
NIGHT SHIFT Type of Ora NG URINE NG/ASPIRATE DRAINS STOOLS
11:00 PM fluid l

7:00 AM TOTAL
TOTAL INTAKE
TOTAL OUTPUT
NOTES SHIFT TOTAL (ML) 24 HOUR BALANCE (ML)
MORNING INTAKE 700ml FROM TO
SHIFT
OUTPU DATE DATE
T 650ml
AFTERNOON INTAKE 800ml TIME TIME
SHIFT
OUTPU TOTAL 2,360ml
T 750ml INTAKE
NIGHTSHIFT INTAKE 860ml TOTAL 2,150ml
OUTPUT
OUTPU 750ml DIFFERENCE
T 410ml

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