Frequency Flutter Valve: Acapella, Aerobika Nebulizer Treatments: Albuterol, Levalbuterol, Acetylcysteine 9. hrs per Res

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Frequency Flutter Valve Acapella Aerobika Nebulizer Treatments Albuterol Levalbuterol Acetylcysteine 9 Hrs Per Res 1 (62.43 KiB) Viewed 27 times

Frequency Flutter Valve Acapella Aerobika Nebulizer Treatments Albuterol Levalbuterol Acetylcysteine 9 Hrs Per Res 2 (65.02 KiB) Viewed 27 times

Frequency Flutter Valve: Acapella, Aerobika Nebulizer Treatments: Albuterol, Levalbuterol, Acetylcysteine 9. hrs per Respiratory Size: Therapy Tracheostomy: Inner Cannula: Yes, No Disposable: Yes, No Suctioned times Quality of mucus: Dressing changed at Tracheostomy stabilizer changed: Trach Care q shift Suction prn = Mucus: Thick, Thin, Clear, White, Yellow, Green, Rust, Blood tinged, Grossly bloody Hemostat & extra tubes(same size & 1 smaller) in room: Yes, No Extra disposable inner cannula at bedside: Yes, No Chest Tube mL Output Previous Shift: Previous Shift Levels: 1 Location: Left, Right Current Shift Levels: 1 Type of Chest Drainage: Heimlich valve, Atrium: Wet Suction, Atrium Dry Suction, Pleurevac: Wet Suction, Pleurevac Dry Suction, Medela. Suction: Yes, No Differences + or -: 1. cm Suction Output Current Shift: Suction Amount: -_ Fluctuation: Yes, No Air leak: Yes, No Crepitation: Yes, No 2 clamps with flat blades & Vaseline gauze in room Cardiovascular Cardiac Assessment Findings: Within defined limits Irregular Rhythm, Irregularly Irregular Rhythm, Extra Heart Sound, Murmur, Carotid Bruit, Aortic Bruit Arterial Assessment Findings: Within defined limits, Pulse Strength Rating: Left, Right, Bilateral, Dorsalis Pedis, Posterior Tibial Color: Pallor, Rubor, Hyperpigmentation, Hypopigmentation 2 2 2 mL
Temperature: Hot, Warm, Cool, Cold: Capillary Refill: <3 seconds, > 3 seconds, Venous Assessment Findings: Within defined limits Edema (bilateral, Left/right leg, Varicosities, Erythema, Warmth, brownish discoloration over shins DVT Prophylaxis: SCD, Foot pumps, TED hose, heparin, enoxaparin Gastrointestinal & Nutrition. GI Assessment Findings Within defined limits Inspection: Flat, Rounded, Distended, Scaphoid Bowel sounds: Absent, Decreased, Active GI Prophylaxis: IV Proton Pump Inhibitor (PPI), Oral PPI, IV H2 blocker, Oral H2 blocker, Sucralfate Enteral Tube Type: Percutaneous Endoscopic Gastrostomy (PEG), Nasogastric (NG) Tube, Nasojejunal (NJ) Tube Placement: Length of tube extending from nose_ cm Residual volume(mL):_ mL Flushes: Volume, Frequency Suction: Intermittent, Continuous Last Dressing Change: Mon Tues Wed Thu Fri Sat Sun Tube Feedings: Solution: @ mL/hr Flush: mL q hrs Tubing change due Last BM: Date Color Consistency Urinary Urinary Assessment Findings: Within defined limits. Abnormal Urinary Assessment findings: Urinary Pattern: Voids, Incontinent, External catheter Foley Catheter (Rationale for continued use) Length of tube extending from nose: cm Residual volume(mL): mL