Admission Doctor : Dr. Robert
Admission Doctor : Dr. Williams
ENCOUTERENTRIES
13/01/2025^11:38:46^Nurse Betty^Critical Care Nurses^08 ICU MSB
Forms
CAUTI Maintenance Bundle Checklist
Bundle Criteria : Morning Shift
Day : D1
Regular documentation for assessment for need of catheter :
YES
The Urinary catheter has been continuously connected :
YES
Date &amp; time meatal hygiene done :
YES
Drainage bag emptied into a clean : YES
Container : YES
Hand hygiene performed for patient contact : YES
Catheter secured : YES
Keep the drianage bag above the floor, but below the bladder
level to prevent reflux / contamination
: YES
Score : 0
Fall Risk Assessment Tool
Categories
Total Fall Risk Score(sum of all points per category)
Age : 70-79 Years 2
Elimination,Bowel and Urine : Incontinence- 2
Medications:
ON 1 HIGH FALL RISK DRUG 3
Patient care Equipment
: One Present- 1
Mobility : Requires assisstance or supervision for
mobility, transfer or ambulation
2
Type of Assessment : Initial Assessment
Score : 0
Pain Assessments
: 10
Date
13/01/2025
Time 11:53
Score
:
2
Type of Assessment
Pain Assessment Scale
:
Initial Assessment
:
Numeric Pain Scale (0-10 Scale)
Numeric Pain Scale
:
2


2/7/25, 6:56 PM
Text
Additional Pain Assessment Details
Type : Not Applicable
Duration : Not Applicable
Continuous : Not Applicable
Time : Not Applicable
NURSING INITIAL ASSESSMENT NEW
Patient Name : John Doe
MRN : ID123456789
Age : 74
Gender : MALE
Patient arrival Date : 13/01/2025
Patient Arrival Time : 11:15
Accompanied by Relative : Yes
Name of Relative :
Jane Doe
Relationship with Patient : SON
Contact Number : 8884697221
Primary Language Spoken : ENGLISH
Interpreter Needed : No
Room Orientation Given : Yes
Patient Identification Band Fixed : Yes
If Yes Type Of Band : GREEN
Height(Cm) : 154
Weight(Kgs) : 78
Chief Complaints : PATIENT PRESENTED WITH C/O ABDOMINAL
PAIN, SUDDEN IN ONSET, DIFFUSE MORE IN UPPER ANDOMEN ASSOCIATED
WITH ONE EPISODE OF VOMITING CONTAINING FOOD PARTICLES ON
10/01/2025. ATTENDER ALSO GIVES H/O ONE EPISODE OF FEVER ON 10TH
WHICH REDUCED WITH MEDICATIONS.
H/O GENERALISED WEAKNESS SINCE LAST 3-4 DAYS ASSOCIATED WITH
REDUCED ORAL INTAKE SINCE PAST 2 DAYS
H/O NOT HAVING PASSED URINE SINCE YESTERDAY AFTERNOON AND LAST
PASSED STOOLS YESTERDAY MORNING
H/O ALTERED SENSORIUM SINCE TODAY MORNING
Past History : : S/P PPI ( 3/5/22 )
BPH
? CIRRHOSIS OF LIVER
CKD on conservative management
hypothyroid on thyronorm 125 mcg
B/L LOWER LIMB CELLULITIS S/P B/L WOUND DEBRIDEMENT ( 17/10/24-
21/10/24)
Vital Assessment


2/7/25, 6:56 PM
Temp(F) : 98.2
Pulse/min : 82
Blood Pressure(mmHg)
: 94/66
Respiration/min : 16
Spo2(%) : 97
GRBS (mg/dl)
:
158
Skin Integrity
Text
:
RDNESS PRESENT ON BOTH LEG DISCOULOURATION
PRESENT, CELLULITIS PRESENT
Other Parameters
Valuable handover checklist completed : Yes
Belongings
Dentures : No
Hearing Aid
:
: No
No
Eye Glasses/Contact Lens : No
Vulnerable : Yes
Restraints :
No
Any Known Allergies
:
NIL
Current Medications
:
TAB THYRONORM 125mcg 1-0-0
TAN DYTOR 10MG 1-0-0
TAB UDILIV 300 1-0-1
TAB FEBUTAZ 40 1-0-0
TAB A TO Z GOLD 1-0-0
TAB ALDACTONE 25MG 1-0-0
TAB ECOSPRIN AV 75/10 0-0-1
TAB NEBICARD 2.5MG 0-0-1
TAB SILODOL D8 0-0-1
TAB LIPAGLYN 4MG 0-0-1
NOVORAPID INSULIN 12-12-10
TUOJEO INSULIN 20UNITS AT NIGHT
Informed the Doctor : Yes
Name of the Doctor : Dr. Brown
Investigations Ordered
Diet : NPO
Collected Old records :
:
NIL
No
Is the patient at risk for any of the following? If Yes,
complete the risk assessment form.
Pressure Score : NO
Fall : NO
DVT
:
NO
Aspiration : NO
Ability to perform activities of daily living
Activity
Bathing : Assisted
Dressing : Assisted
Eating : Assisted
Walking : Assisted


2/7/25, 6:56 PM
Toilet Use : Assisted
Text
Nursing needs(complete Nursing care plan based on the identified
needs)
Actual needs :
SEPSIS
Potential needs : PAIN / FALL
Assessment Done By : Nurse Betty
BMI : 32.89
General Physical Examination:
Pallor :
NO
Icterus : NO
Edema : YES, NO
Clubbing : NO
Cyanosis : NO
Lymphadenopathy : NO
Score :
0
Questionnaires
Date : 13/01/2025
Patient&#39;s Indentification No. :
Sex
: Male
A
Each Risk Factor Represents 1 Point
month), Medical patient currently at bed rest
Total Tickmarks :
2
Total Score A :
2
B Each Risk Factor Represents 2 Point
Total Tickmarks :
1
Total Score B :
2
Total Score (A+B+C+D+E)
=
:
4
Intravascular Access Lines
Status : Entered
Status
:
Entered
Score
:
0
Intravascular Access Type
Central IV TPA Intervention
:
ID123456789
: Sepsis (< 1
: Age 60 74 years
: Peripheral IV Line
Arterial Line Status
Peripheral IV Activity
: Site assessed
Peripheral IV Assessment
Peripheral IV Drainage Present
: No
Peripheral IV Condition : No Phlebitis
CVC Site Assesst


2/7/25, 6:56 PM
Text
Catheter position corrected/withdrawn
empty
Lumen color : PINK
Peripheral IV No Phlebitis Score : 0
ADULT &amp; PAEDIATRIC
CATEGORIES
ASPIRATION RISK ASSEMENT TOOL
TOTAL SCORE
:
4
Score
:
0
Adult Pressure Ulcer Braden Scale
SENSORY PERCEPTION
:
3
3 Slightly Limited :
Y
MOISTURE :
3
3 Occasionaly Moist :
Y
ACTIVITY :
2
2
Chair Bound :
Y
MOBILITY : 3
3 Slightly Limited :
Y
NUTRITION :
3
3 Adequate :
Y
TOTAL SCORE : 14
Forms
Nursing Safety Checks
Status
: Entered
Safety Checks : Alarm limits set,Oxygen,Suction,Air,Ambu-
bag, Resus-bag,Emergency drugs (Expiry), Face mask ? S,M,L, x1 Oxygen
cylinder, Room stocked and cleaned, Add humidifier, Fall
precautions, Infection control
Invasive Lines : Not Applicable
Patient ID : ID Band
Allergies reviewed
: Yes
13/01/2025^11:38:53^Dr. Miller^IP Doctor Initial Assessment ^08
ICU MSB
IP Initial Assessment
Status
: Entered
Patient Arrival Date
:
Patient Arrival Time
:
13/01/2025
11:00
Chief Complaints : c/o pain abdomen x 2 days
c/o fever x 2 days
c/o reduced responsiveness x 1 days
c/o recuced urine output x 1 day


2/7/25, 6:56 PM
Text
History of Presenting illness
: PATIENT PRESENTED WITH C/O
ABDOMINAL PAIN, SUDDEN IN ONSET, DIFFUSE MORE IN UPPER ANDOMEN
ASSOCIATED WITH ONE EPISODE OF VOMITING CONTAINING FOOD PARTICLES
ON 10/01/2025. ATTENDER ALSO GIVES H/O ONE EPISODE OF FEVER ON 10TH
WHICH REDUCED WITH MEDICATIONS.
H/O GENERALISED WEAKNESS SINCE LAST 3-4 DAYS ASSOCIATED WITH
REDUCED ORAL INTAKE SINCE PAST 2 DAYS
H/O NOT HAVING PASSED URINE SINCE YESTERDAY AFTERNOON AND LAST
PASSED STOOLS YESTERDAY MORNING
H/O ALTERED SENSORIUM SINCE TODAY MORNING
Allergy
:
Past Medical History : S/P PPI ( 3/5/22 )
BPH
? CIRRHOSIS OF LIVER
CKD on conservative management
hypothyroid on thyronorm 125 mcg
Past Surgical History
WOUND DEBRIDEMENT ( 17/10/24- 21/10/24 )
: B/L LOWER LIMB CELLULITIS S/P B/L
Family History
:
Social / Personal History
Menstrual History :
:
Previous Pregnancy :
Current medications
TAN DYTOR 10MG 1-0-0
: TAB THYRONORM 125mcg 1-0-0
TAB UDILIV 300 1-0-1
TAB FEBUTAZ 40 1-0-0
TAB A TO Z GOLD 1-0-0
TAB ALDACTONE 25MG 1-0-0
TAB ECOSPRIN AV 75/10 0-0-1
TAB NEBICARD 2.5MG 0-0-1
TAB SILODOL D8 0-0-1
TAB LIPAGLYN 4MG 0-0-1
NOVORAPID INSULIN 12-12-10
TUOJEO INSULIN 20UNITS AT NIGHT
Pulse /min
:
81
Resp Rate/min : 19
Temp F : 98.5
BP mm Hg :
Room Air :
96/40
Y
GRBS mg/dL
:
158
JVP
:
normal
Pallor : NO
Icterus : NO
Edema : YES


2/7/25, 6:56 PM
Clubbing : NO
Cyanosis : NO
Lymphadenopathy : NO
Peripheral Pulse
:
Text
+
Others
:
CVS
:
s1s2+
RS
: b/l aee, NVBS
PA
: SOFT
CNS
:
E3V2M5
Others
: Generalised vitiligo
:
Local Examination : B/L LOWER LIMB CELLULITIS
Provisional Diagnosis
acute on CKD
: urosepsis with septic shock
Care Plan : nephro review
arterial line
Spo2 : 98
Diet Plan :
Status : Entered
Score :
0
13/01/2025^12:21:42^Dr. Brown^IP Doctor Initial Assessment
^08 ICU MSB
Apache II scoring sheet
A.ACUTE PHYSIOLOGY SCORE :
B.Age
:
5
C.CHRONIC HEALTH POINTS
18
:
0
APACHEII SCORE=&quot;A(ACUTE&quot; PHYSIOLOGY SCORE)+B(AGE
POINTS)+C(CHRONIC HEALTH POINTS):
DONE BY : Nurse Joy
: Curative
Care plan and Special Needs
Status : Authorised
Care Plan
Special Needs required at discharge
Care Plan Details : start meropnem
23
: Physiotherapy
urology and nephrology opinion
secure art line and dialysis catheter
Status
: Authorised
Score
:
0
13/01/2025^13:20:07^Dr. Davis^Critical Care Doctors^08 ICU MSB
Procedure Notes
:
LEFT INTERNAL JUGULAR VEIN HD CATHETER


2/7/25, 6:56 PM
Text
The left neck area was painted with Chlorhexidine
Waited for two minutes
LT Internal Jugular vein visualized
with USG
Local Anaesthesia given
USG guided needle
insertion into LT Internal Jugular vein done, guidewire inserted.
The position of guidewire was confirmed with USG.
lumen HD catheter threaded over the guidewire.
Backflow is present in all 3 ports.
removed.
taken.
Dressing done.
Daily Notes
:
C/S/B Dr Brown/ Dr Davis ON 13/01/2025
Diagnosis:
pyeloneohritis
septic shock
acute on CKD
History:
PATIENT PRESENTED WITH C/O
ABDOMINAL PAIN, SUDDEN IN ONSET, DIFFUSE MORE IN UPPER ANDOMEN
ASSOCIATED WITH ONE EPISODE OF VOMITING CONTAINING FOOD PARTICLES
ON 10/01/2025. ATTENDER ALSO GIVES H/O ONE EPISODE OF FEVER ON 10TH
WHICH REDUCED WITH MEDICATIONS.
H/O GENERALISED WEAKNESS SINCE LAST 3-4 DAYS ASSOCIATED WITH
REDUCED ORAL INTAKE SINCE PAST 2 DAYS
H/O NOT HAVING PASSED URINE SINCE YESTERDAY AFTERNOON AND LAST
PASSED STOOLS YESTERDAY MORNING
H/O ALTERED SENSORIUM SINCE TODAY MORNING
BPH
Comorbidities:
S/P PPI ( 3/5/22 )
? CIRRHOSIS OF LIVER
CKD on conservative management
hypothyroid on thyronorm 125 mcg.
Current medications :
TAB THYRONORM 125mcg 1-0-0
TAN DYTOR 10MG 1-0-0
TAB UDILIV 300 1-0-1
TAB FEBUTAZ 40 1-0-0
TAB A TO Z GOLD 1-0-0
TAB ALDACTONE 25MG 1-0-0
TAB ECOSPRIN AV 75/10 0-0-1


2/7/25, 6:56 PM
TAB NEBICARD 2.5MG 0-0-1
TAB SILODOL D8 0-0-1
TAB LIPAGLYN 4MG 0-0-1
NOVORAPID INSULIN 12-12-10
TUOJEO INSULIN 20UNITS AT NIGHT
Text
Issues:
septic shock on noradrenaline
metabolic acidosis
altered sensorium
paroxysmal venticular tachycardia
AOCKD oliguria
ct abdomen- Features are of concern for moderate pyelonephritis
in the left kidney with hydroureteronephrosis. Renal papillary
Possible
necrosis with ureteric obstruction cannot be excluded.
mild pyelonephritis in the right kidney. Features of chronic
liver disease.
Cholelithiasis
O/E:
RR-20/min
Screening USG-
own
B- spo2- 95 on RA
Auscultation- b/l aee, nvbs, s1s2 +
No effusion / consolidation
No B-lines
C- HR-
no
108/min BP-90/60mmHg inj norad 10ml, peripheral pulses+
D-E3V2M5 Pupils 2mm BERL
pedal edema
E-Na 127
creat-5.97
k-
5.6
urea 248
G-GRBS-mg/dl
TLC-4.09
P/A- soft
F- npo
H-Hb
9.2
Plt count - 340
I- afebrile
Mobilisation: no
DVT prophylaxis: mechanical
Bed sore: no
Deescalation: no
Plan:
nephrology opinion
urology opinion
cardiology review
NPO
plan for dj stenting
continue inj noradrenaline
f/u urine and blood culture
inj meropenem 2g iv stat
infusion.
Glycemic control, if GRBS &gt; 180 mg/dl- start insulin
Incentive spirometry, Chest physiotherapy
Forms
Fluid balance-positive


2/7/25, 6:56 PM
CCM HandOver Note
Shift : Morning to Evening
Note
:
septic shock
acute on CKD
Diagnosis:
Text
pyeloneohritis
History:
PATIENT PRESENTED WITH C/O
ABDOMINAL PAIN, SUDDEN IN ONSET, DIFFUSE MORE IN UPPER ANDOMEN
ASSOCIATED WITH ONE EPISODE OF VOMITING CONTAINING FOOD PARTICLES
ON 10/01/2025. ATTENDER ALSO GIVES H/O ONE EPISODE OF FEVER ON 10TH
WHICH REDUCED WITH MEDICATIONS.
H/O GENERALISED WEAKNESS SINCE LAST 3-4 DAYS ASSOCIATED WITH
REDUCED ORAL INTAKE SINCE PAST 2 DAYS
H/O NOT HAVING PASSED URINE SINCE YESTERDAY AFTERNOON AND LAST
PASSED STOOLS YESTERDAY MORNING
H/O ALTERED SENSORIUM SINCE TODAY MORNING
Comorbidities:
S/P PPI ( 3/5/22 )
BPH
? CIRRHOSIS OF LIVER
CKD on conservative management
hypothyroid on thyronorm 125 mcg.
Current medications :
TAB THYRONORM 125mcg 1-0-0
TAN DYTOR 10MG 1-0-0
TAB UDILIV 300 1-0-1
TAB FEBUTAZ 40 1-0-0
TAB A TO Z GOLD 1-0-0
TAB ALDACTONE 25MG 1-0-0
TAB ECOSPRIN AV 75/10 0-0-1
TAB NEBICARD 2.5MG 0-0-1
TAB SILODOL D8 0-0-1
TAB LIPAGLYN 4MG 0-0-1
NOVORAPID INSULIN 12-12-10
TUOJEO INSULIN 20UNITS AT NIGHT
Issues:
septic shock on noradrenaline
metabolic acidosis
altered sensorium


2/7/25, 6:56 PM
Text
paroxysmal venticular tachycardia
AOCKD oliguria
ct abdomen- Features are of concern for moderate pyelonephritis
in the left kidney with hydroureteronephrosis. Renal papillary
Possible
necrosis with ureteric obstruction cannot be excluded.
mild pyelonephritis in the right kidney.
Features of chronic
liver disease.
Cholelithiasis
nephrology
Plan:
opinion
urology opinion
cardiology review
про
plan for dj stenting
continue inj noradrenaline
f/u urine and blood culture
inj meropenem 2g iv stat
Glycemic control, if GRBS &gt; 180 mg/dl- start insulin
infusion.
Incentive spirometry, Chest physiotherapy
Fluid balance-positive
: Dr. Garcia
Handed over to
: Dr. Davis
Hand over by
:
0
Score
Treatment
13/01/2025^14:07:19^DR. RODRIGUEZ^IP Doctor
Sheet CARDIOLOGY MSB
Progress Notes :
THANKS FOR REFERENCE
74 YEAR MALE
S/P PPI- MAY 2022 (BOSTON)
DIABETES MELLITUS ON INSULIN
CKD ON MEDICAL MANAGEMENT
HYPOTHYROID
NO H/O CVA/ IHD
ADMITTED WITH PYELONEPHRITIS, ACUTE ON CKD
PLANNED FOR DJ STENTING
PATIENT IS IN ALTERED SENSORIUM
ECHO- NORMAL CHAMBER DIMENSIONS, CONCENTRIC LVH, MR-MILD, TR-MILD,
PASP-46MMHG, MILD PAH, NO RWMA, ADEQUATE LV SYSTOLIC FUNCTION, LVEF-
50%


2/7/25, 6:56 PM
Text
CREAT- 5.97; HB-9.2
LAST DOSE TAB ECOSPRIN AV ON 11.1.25
RCRI SCORE +2
PATIENT CAN BE TAKEN UP FOR PROPOSED SURGERY UNDER MODERATE TO
HIGH CARDIAC RISK FOR MACE EVENTS
ADVICE
TO CHANGE PACEMAKER MODE TO DOO MODE
COUNSELED FAMILY
13/01/2025^15:11:38^DR. MARTINEZ^IP Doctor Treatment
Sheet NEPHROLOGY MSB
Progress Notes
72M
:
Nephrology follow up
Type AV block- S/P permanent Pacemaker implantation-3.5.22
Diabetes Mellitus
Hypertension
Hypothyroidism
BPH
22 years
NAFLD -Cirrhosis of liver
(B.Cr 0.84 9/2023)
Current medications :
TAB THYRONORM 125mcg 1-0-0
TAN DYTOR 10MG 1-0-0
TAB UDILIV 300 1-0-1
TAB FEBUTAZ 40 1-0-0
TAB A TO Z GOLD 1-0-0
TAB ALDACTONE 25MG 1-0-0
TAB ECOSPRIN AV 75/10 0-0-1
TAB NEBICARD 2.5MG 0-0-1
TAB SILODOL D8 0-0-1
TAB LIPAGLYN 4MG 0-0-1
NOVORAPID INSULIN 12-12-10
TUOJEO INSULIN 20UNITS AT NIGHT
History:
PATIENT PRESENTED WITH C/O ABDOMINAL PAIN, SUDDEN IN ONSET,
DIFFUSE MORE IN UPPER ANDOMEN ASSOCIATED WITH ONE EPISODE OF
VOMITING CONTAINING FOOD PARTICLES ON 10/01/2025. ATTENDER ALSO

Text
2/7/25, 6:56 PM
GIVES H/O ONE EPISODE OF FEVER ON 10TH WHICH REDUCED WITH
MEDICATIONS.
H/O NOT HAVING PASSED URINE SINCE YESTERDAY AFTERNOON AND LAST
PASSED STOOLS YESTERDAY MORNING
H/O ALTERED SENSORIUM SINCE TODAY MORNING
Pt is shifted to OT for emergency DJ stenting
Labs 13/1
Pro 2+ WBC 2861 RBC 81
ALB 2.13
U 246 B 116 Cr 5.97 UA 8.2 Na 127.2 K 5.62
Hb 9.2 TC 40900 Pl 3.4 L
ECHO- NORMAL CHAMBER DIMENSIONS, CONCENTRIC LVH, MR-MILD, TR-MILD,
PASP-46MMHG, MILD PAH, NO RWMA, ADEQUATE LV SYSTOLIC FUNCTION, LVEF-
50%
ct kub
Features are of concern for moderate pyelonephritis in the
left kidney with hydroureteronephrosis. Renal papillary necrosis
with ureteric obstruction cannot be excluded.
Possible mild pyelonephritis in the right kidney.
Features of chronic liver disease.
Cholelithiasis
Diagnosis:
pyelonephritis
septic shock
acute on CKD
Adv
Total fluid intake as per IVC status
Intake output charting
RRT sos
Monitor ABG
Inform sos
To repeat Renal panel 1 tomo morning
13/01/2025^15:12:02^Nurse Betty^Critical Care Nurses^08 ICU
MSB
Forms
CAUTI Maintenance Bundle Checklist
Bundle Criteria : Evening Shift
Day :
D1


2/7/25, 6:56 PM
Text
Regular documentation for assessment for need of catheter :
YES
The Urinary catheter has been continuously connected :
YES
Date &amp; time meatal hygiene done :
YES
Drainage bag emptied into a clean : YES
Container : YES
Hand hygiene performed for patient contact : YES
Catheter secured : YES
Keep the drianage bag above the floor, but below the bladder
level to prevent reflux / contamination
: YES
Score :
0
Fall Risk Assessment Tool
Categories
Total Fall Risk Score(sum of all points per category)
Age : 70-79 Years 2
Patient care Equipment
Mobility : Requires assisstance or supervision for
mobility, transfer or ambulation
Type of Assessment : Shift Assessment
: 3 or more Present
2
Score :
0
Pain Assessments
Date
13/01/2025
Time 15:12
Score
:
2
Type of Assessment
Pain Assessment Scale
: Shift Assessment
:
Numeric Pain Scale (0-10 Scale)
Numeric Pain Scale
:
2
Additional Pain Assessment Details
Central Line Maintenance Bundle Checklist
Bundle Criteria : Evening Shift
Day :
D1
Remarks
: hd catheter
Regular assessment and documentation for Central Line
:
YES
Inspect the insertion site for sign of infection
Bath patients with a 4% chlorhexidine daily :
YES
YES
:
:
:
7
3


2/7/25, 6:56 PM
Text
Perform hand hygiene before handling central line : YES
Scrub the hub using 70% alcohol swab or chlorhexidine. If
multiple hubs are accessed at a time use each hub separate swab :
YES
If alcohol cap is used for closing the hub, while accessing the
lumen scrub the hub is not necessary, but once alcohol cap is
removed replace with new alcohol caps :
YES
Change central line dressing every 7 days if chlorhexidine
impregnated dressing is used
: NO
If gauze or plain transparent dressing is used, change every 48
hours : YES
Change administrations sets for continuous infusions every 4
days (label date and time on the set) : YES
If blood or blood products or fat emulsions are administered
change tubing every 24 hours : NO
If propofol infusion is used change set every 6 hours : NO
Score :
0
Intravascular Access Lines
Status : Entered
Status
:
Entered
Score
:
0
Intravascular Access Type
Central IV TPA Intervention
: Peripheral IV Line
Arterial Line Status
Peripheral IV Activity
: New insertion
Peripheral IV Insertion Date : 13/01/2025
Peripheral IV Insertion Time
:
14:00
Peripheral IV Catheter Type
: IV Cannula
Peripheral IV Location : Right
Peripheral IV Gauge
:
18 Gauge
Peripheral IV Procedure Preparation : Handwashing
observed, Hand hygiene performed,Skin prepared with sterile
solution,Skin prepared with other
Peripheral IV Insertion Indication
: IV hydration/medication
Peripheral IV Number Of Attempts : 1
Peripheral IV Assessment
Need Assessment : Yes
Care : Skin cleansed with chlorhexidine,Secured with steri-
strips
Site Details : No complications
Dressing Type/Appearance :
Peripheral IV Patency :
Dry, Transparent
No complications


2/7/25, 6:56 PM
Text
Peripheral IV Equipment used
:
Manual
Referred To IV Nurse
:
No
Peripheral IV Site
:
Hand
CVC Site Assesst
Catheter position corrected/withdrawn
Peripheral IV Procedure Result :
empty
Successful insertion
Intravascular Access Lines
Status : Entered
Status : Entered
Score :
0
Intravascular Access Type
Central IV TPA Intervention
: Peripheral IV Line
Arterial Line Status
Peripheral IV Activity
Peripheral IV Assessment
: Site assessed
Need Assessment : Yes
Site Details : No complications
Dressing Type/Appearance :
Peripheral IV Patency :
CVC Site Assesst
Dry, Transparent
No complications
Catheter position corrected/withdrawn
empty
Intravascular Access Lines
Status
: Entered
Status
:
Entered
Score :
0
Intravascular Access Type : Arterial Line
Central IV TPA Intervention
Arterial Line Activity : New insertion
Arterial Line Procedure Type :
Elective
Arterial Line Location : Left
Arterial Line Site : Radial artery
Arterial Line Insertion Date : 13/01/2025
Arterial Line Insertion Time : 12:00


2/7/25, 6:56 PM
Arterial Line Patient Identified :
Text
Identification band
Arterial Line Procedure Preparation : Handwashing
observed, Handwashing verbalized, Invasive line cart used, Aseptic
technique used,Skin dry at first puncture,Skin prepared with
chlorhexidine/other
Arterial Line Sterile Field : Maintained
Arterial Line Performing Insertion : Dr. Brown
Arterial Line Assisting In Insertion
: David Clark
Arterial Line Status
: Accurate, optimally damped,Correlates with
Status
manual, Flushes easily,Good blood return
Care/Troubleshoot : Air removed,Aspirated &amp;
flushed, Connections secured, Leveled, zeroed, calibrated
Site Condition : Within normal limits
Dressing Condition : Dry,Intact
Dressing :
Transparent
Arterial Line Procedure Result :
Insertion
successful, Dressing dated, Sterile dressing applied immediately
Peripheral IV Assessment
CVC Site Assesst
Catheter position corrected/withdrawn
empty
Intravascular Access Lines
Status : Entered
Central IV Procedure Type
Central IV Access Type :
Central IV Number Of Lumens
Central IV Location
: Elective
Dialysis catheter
: Left
: Triple lumen
Central IV Site : Internal jugular vein
Central IV Patient Identified :
Date of Insertion :
13/01/2025
Identification band
Status
: Entered
Score :
0
IntraVascular Access Type :
Central Line
Central IV Activity : New insertion
Time of Insertion : 12:00
Central IV Reason For Insertion :
plasmapheresis
CVC Insertion Unit : 08 ICU MSB
Hemodialysis or
Central Guided Ultrasound Used : Yes
Central IV Radiographic Confirmation
: Yes


2/7/25, 6:56 PM
Central IV Performing Provider
:
Dr. Davis
Text
:
Successful insertion
Central IV Number Of Attempts :
1
: Handwashing
Central IV Procedure Preparation
observed, Handwashing verbalized,Invasive line cart used, Hand
hygiene, Maximum Barrier Protection,Skin dry at first puncture,Skin
prepared with chlorhexidine,Skin prepared with other
Central IV Sterile Field
:
Maintained
Central IV MBP Compliance
: Yes
Central IV TPA Intervention
Arterial Line Status
Peripheral IV Assessment
CVC Site Assesst
Is CVC Required : Yes
Line Status : Accurate, optimally damped, Flushes easily, Good
blood return
Site Condition : Within normal limits
Dressing : Dry &amp; intact
Care
: Line flushed with saline
: None
Limb Temperature : Warm
Drainage Description :
Pulse Distal To Insertion Site : Strong
Catheter position corrected/withdrawn
empty
ADULT &amp; PAEDIATRIC - ASPIRATION RISK ASSEMENT TOOL
CATEGORIES
EATING HABILTS : Needs assistance to eat 1
TOTAL SCORE
:
1
Score :
0
Adult Pressure Ulcer Braden Scale
SENSORY PERCEPTION
:
4
4
No Impairment :
Y
MOISTURE
:
3
3
Occasionaly Moist :
Y
ACTIVITY : 1
1 Bed Bound :
Y
MOBILITY : 3
3
Slightly Limited :
Y


2/7/25, 6:56 PM
NUTRITION :
2
Text
2
Probably Inadequate
:
Y
FRICTION AND SHEAR : 2
2 Potiential Problem
TOTAL SCORE : 15
:
Y
Forms
Add Nursing Care Plan
Status
: Authorised
Nursing Care Plan discussed with Patient
Patient Measurable Goal for the day
incidence of fall
:
: Yes
:
Risk for fall
patient wont have
Nursing Diagnosis
:
Education and comments: : teach fall prevention maesures
Nursing Interventions : perform fall risk assessment
put on side rails always
close monitoring of the patient
provide maximum assistance in mobilization
keep all the needed belongings near to the patient
monitor hemodynamics
teach fall prevention maesures
Evaluation : Continue
13/01/2025^15:59:22^Nurse Betty^Critical Care Nurses^08 ICU MSB
13/01/2025^15:59:58^Nurse Joy^Critical Care Nurses^08 ICU MSB
ReAssessment No
:
PATIENT SHIFTED TO ОТ @ 15.50 HANDOVER GIVEN TO OT STAFF
PATIENT IS CONCIOUS AND DROWSY
PATIENT IS ON ROOM AIR SATURATION 97%
GCSE3V5M6
PUPILS R/L 2MM EQUALLY REACTING TO LIGHT
SKIN INTACT LEFT LEG CELLULITIS PRESENT
DIET NPO
LINES AND TUBING
20 G CANNULA PRESENT @ LEFT HAND FROM ER D1
18 G CANNULA @ RIGHT HAND D1 FROM ICU
14 F FOLEYS CATH FROM ER D1
TRIPLE LUMEN HD CATH @ LEFT IJV FROM ICU D1
INFUSION

**MEDICATION ORDERS**

Drug / Generic Item-Frequency-Instructions/Notes-Duration-OrderedBy-OrderedDate
PANTOCID 40 MG/VIAL LYOPHILIZED POWDER FOR INJECTION-Once--2 Day(s)-Dr. Miller-13/01/2025
ECOSPRIN-AV 75 MG CAPSULE, 10 MG - 75 MG-Once--2 Day(s)-Dr. Miller-13/01/2025
NORMAL SALINE (0.9%) solution for infusion [100ml]-4 Hourly ( Q4H)--1 Day(s)-Dr. Miller-13/01/2025
RL 500 ML PVC Bottle solution for infusion, Claris-Every 6 Hrs(6 Hourly (Q6H))--1 Day(s)-Dr. Miller-13/01/2025
NORMAL SALINE 09% W/V AQUA PULSE 500 ML-Every 6 Hrs(6 Hourly (Q6H))--1 Day(s)-Dr. Miller-13/01/2025
REFRESH TEARS 0.5% W/V EYE DROPS 10 ML-Once--1 Day(s)-Dr. Miller-13/01/2025
CANDID 1% W/W DUSTING POWDER 120 GM-Once--1 Day(s)-Dr. Miller-13/01/2025
LOX 2% W/V 30 ML VIAL SOLUTION FOR INJECTION-Once--1 Day(s)-Dr. Miller-13/01/2025
LOX 2% W/V JELLY 30 GM-Once--1 Day(s)-Dr. Miller-13/01/2025
TEGADERM IV DRESSING KIT 6.5 CM X 7 CM, # 1683-Once--1 Day(s)-Nurse Betty-13/01/2025
6.5STERILE GLOVES (SERJUN)-Once--1 Day(s)-Nurse Betty-13/01/2025
ICUBAC-H 1000 MG/VIAL FOR INJECTION-Every 8 Hrs(8 Hourly ( Q8H))--3 Day(s)-Dr. Miller-13/01/2025
NOR 4MG-Once--1 Day(s)-Nurse Joy-13/01/2025
