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Vital Signs Graphic Sheet: Days of The Month No. of Days in Hospital Height/weight Resp Pulse Temp 4

The documents provide medical information for a patient named Consuelo Rivera including vital signs, medications, and nursing notes. The vital signs graphic sheet and monitoring sheet track measurements over time. The medication sheets list intravenous and oral medications ordered with dosages and administration times. The nursing notes from February 4th document the patient's general condition upon receipt, intravenous fluid status and oxygen administration with actions taken and the patient's response.

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Macen Ortega
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© © All Rights Reserved
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Download as DOCX, PDF, TXT or read online on Scribd
144 views

Vital Signs Graphic Sheet: Days of The Month No. of Days in Hospital Height/weight Resp Pulse Temp 4

The documents provide medical information for a patient named Consuelo Rivera including vital signs, medications, and nursing notes. The vital signs graphic sheet and monitoring sheet track measurements over time. The medication sheets list intravenous and oral medications ordered with dosages and administration times. The nursing notes from February 4th document the patient's general condition upon receipt, intravenous fluid status and oxygen administration with actions taken and the patient's response.

Uploaded by

Macen Ortega
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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VITAL SIGNS GRAPHIC SHEET

SURNAME: _________________AGE: _______ SEX: ______ HOSP. NO: ___________

GIVEN NAME: ______________ MI:______________ WARD: ____________________

Days of the Month


No. of Days in Hospital
Height/weight
RESP PULSE TEMP 8 12 4

42
41
180 40
39
160 38
37
140 36
35
120

100
60
50 80
40
30 60
20
10

SHIFT BP U S BP U S BP U S BP U S
7-3
3-11
11-7
MEDICATION SHEET - IV

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: _______ WARD: ___________

Date/Time Medication Dosage Route Freq Date


Ordered
Shift Time Sig Time Sig Time Sig
02-04-21 Reteplase IV   7-3 8 MCO
8am 3-11
11-7

02-04-21 Nitroglycerin IV 7-3 8 MCO


8am 3-11
11-7
morphine  4 mg IV q5min prn 7-3 8 MCO
02-04-21 3-11
8am 11-7

Weight-based heparin IV   7-3 8 MCO


02-04-21 3-11
8am 11-7

Metoprolol ) 5 mg IV q5min 7-3 8 MCO


02-04-21 3-11
8am 11-7

7-3
3-11
11-7
7-3
3-11
Treatment 11-7
7-3
3-11
11-7
Breakfast DAT
Diet Lunch DAT
Dinner
MEDICATION SHEET-ORAL

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: _______ WARD: ___________

Date/Time Medication Dosage Route Freq Date


Ordered
Shift Time Sig Time Sig Time Sig
Aspirin 325 mg/ PO/ 7-3 8 MCO
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
Treatment 11-7
7-3
3-11
11-7
Breakfast DAT
Diet Lunch
Dinner
VITAL SIGNS MONITORING SHEET

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: ______ WARD: ____________

DATE/SHIFT/TIM BP PR RR CR T
E
02-04-21 150/70 110 28 110 37.5
02-04-21 150/70 110 38 110 37.5
150/70 110 38 110 37.5

NURSE’S PROGRESS NOTES


SURNAME: Rivera_______ AGE: 51___ HOSP.NO.: ______________________

GIVEN: Consuelo_______ MI: ______________ SEX: M____ WARD: ____________

DATE/TIM FOCUS DATA ACTION RESPONSE


E
02-4-21 General - Received pt. lying - v/s taken & recorded
8am Disposition on bed - morning care
- weak in appearance rendered - Rapport established
- bedside care done

IVF - c IVF of D5LRS 1L - checked for patency - patent and intact


X 12hrs and intactness

O2 - O2 inhalation - checked for patency - patent and intact


administered via and intactness
nasal cannula @
2-3 LPM

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