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Med Surg Report Sheet Night Shift FINAL

John Doe, a 78-year-old male with a history of CAD, MI, CABG, CHF, HTN, HLD, and Afib was admitted from home with chest pain. His vital signs were stable and he was experiencing mild pain managed with dilauded. Labs were unremarkable except for an elevated BNP. He was NPO and receiving IV fluids with a regular diet planned. His plan was for cardiac rehab and home health after discharge.

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Cindy Ann
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170 views2 pages

Med Surg Report Sheet Night Shift FINAL

John Doe, a 78-year-old male with a history of CAD, MI, CABG, CHF, HTN, HLD, and Afib was admitted from home with chest pain. His vital signs were stable and he was experiencing mild pain managed with dilauded. Labs were unremarkable except for an elevated BNP. He was NPO and receiving IV fluids with a regular diet planned. His plan was for cardiac rehab and home health after discharge.

Uploaded by

Cindy Ann
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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MED SURG REPORT SHEET NIGHT SHIFT

Name: Dx:
AGE:

CODE: FULL DNR DNI_________


Allergies: NKDA /_______________________________
HISTORY: CAD / MI / CABG / CHF / HTN / HLD /
AFIB / STENT / PE / COPD / GERD / CKD / DM / CA / VITALS PAIN____ LABS
TOBACCO / ETOH / DRUGS ________________ BP ________
DIL _____mg Glu
HR ________ Q2 4 6 Na Cl BUN
RR ________ Time: ______
Glu
INTEGUMENTARY K CO2 Cr
O2 ________ M/S _____mg
T ________ Q2 4 6
WVAC: __________
Time: ______
Drain #1________ Plt Hct
Drain #2 _______ TELE: Narco: ___mg WBC INR PTT
Q 4 6 8 INR
Wounds: SR AF Time: ______ Hgb Hct
NEURO PT PTT
O2 Y N Tram: PT

A&OX 1 2 3 4 % ________ ___mg Hgb PltWBC


Q 4 6 8
S/S: RA NC NR Ca+______
Perc: ___mg Mg+______
Q 4 6 8 Phos______
NIH / Neuro BiPAP CPAP
Tylenol____

GI/GU Incont Foley IV: R L _____G DIET Fluid Restriction _________


BM_____ Bedpan Dialysis CATH ML PICC REG CL FL 2GNA SOFT CARDIAC NPO
Urinal Anuria AC HAND UA LA
N/V/D BSC Retention BG AC & HS Q6
Bathrm
Activity: PAIN Notes Meds: Is&Os:
adlib / weak
1900
bedrest
assist: x1 x2
2000
Notes
2100

2200

2300

0000

0200

0400

0600
MED SURG REPORT SHEET NIGHT SHIFT
CONSULTS: CV CTVS PULM NEPH PSYCH GI NEURO CAME FROM: ____________________
SURG WOUND POD ONC ID ORTHO PALTV HOSPC PLAN: HOME HH SNF REHAB

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