NURSE PROGRESS NOTE/TREATMENT SHEET
Employee Name
*
First Name
Last Name
Date of shift
*
-
Month
-
Day
Year
Patients First Name
*
Patient Last Name
*
ID#
*
Patient ID#
On Duty Report from
*
Status
*
Medications on schedule.
Informed of PRNs admin
No issues reported
Issue
General Status/Vital Signs
*
Oriented
Alert/awake
Cooperative
Appropriate affect for pt
Responds to voice/touch
Non-verbal
Verbal
Makes needs known
Signs
Vital Signs
*
specify Apical
Radial
Axillary
Oral
Ear
Other
Vital Signs
*
Was BP taken?
*
Yes
No
BP
*
Pulse OX
Is patient diabetic
*
Yes
No
Requires blood sugar checks?
*
Yes
No
Enter Blood Sugar values
*
Time
Blood Sugar
1
2
3
4
5
Height
Weight
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Gastrointestinal / Nutrition
Nutrition
*
Active bowel sounds
No abdominal distention
Feeds self
Regular diet
Adequate fluid/food intake
G Tube
*
Yes
No
Enteral-tube type/size
*
Was G Tube Changed?
*
Yes
No
Changed at
*
Changed by
*
Date last change
*
-
Month
-
Day
Year
Date
Enteral tube care with soap/H20 at
*
Enteral tube care with/time
*
Site is clear and dry
*
yes
no
Site is
*
Check for
MLS in Balloon
Full rotation of button
yes
no
Oral stimulation with
Bolus feeding?
*
Yes
No
Formula
*
mls
*
Time residual of mls and flush mls H20
*
Continuous Feeding
*
Yes
No
Formula
*
MLS/hr
*
Duration
*
Flush q 4 hrs
*
Yes
No
*
No S/S gastric distress
Pt head elevated during feeding
Vented from/to
NPO
*
Yes
No
Appetite
*
Fluid restricted to
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Musculoskeletal
Musculoskeletal (1)
*
Ambulatory
Bed bound
Ambulatory with assist
Asistive Device
AFO
Bed Bound
*
PROM
Re-positioned q 2 hours
Contractures
Re-positions Independently
Musculoskeletal (2)
Notes
Muscle Tone (UE), (LE)
AROM
Wrist Splint to Right or Left
Activity
Transfers
*
Transfers with mechanical lift only
Pivot Transfer
2 Person Transfer
N/A
Other
In W/C From
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:
Hour
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15
30
45
Minutes
to
until
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01
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:
Hour
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15
30
45
Minutes
With Pressure Relief q
Activity
*
Notes
In bed this shift
Played on floor
Attended school with PT
Therapy this shift
Community Outing
Other
Pain
Pain: Non-Verbal or Verbal
*
No physical or behavior cues of pain
Yes
state intensity (0-5)
*
Location of pain
*
Controlled by
Cardiovascular / Respiratory
Cardiovascular
*
Apical strong/regular
Peripheral pulses present
No pedal edema
Capillary refill < 3 secs
No cyanosis
Pacemaker
Yes
No
Respiratory
*
Lung sounds:
Clear/adequate
No nasal discharge
Resp even
Congestion
Wheezing
Cough
Retractions
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Tracheostomy Care
Tracheostomy
*
Yes
No
Trach type/size
*
If Yes what type and size
Time
*
1
2
3
4
5
6
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Clean with
*
1/2 H202 and H20
Soap and Water
Other
Trach Change
*
Gauze Sponge
Trach Ties Changed
Inner Cannula cleaned
Site Clear/Dry
*
yes
no
Site is
*
Last Change
*
-
Month
-
Day
Year
Date
By
*
Trach cuff deflated q __ hrs for __ mins ( __ mls of air)
*
hrs, mins, mls
Suction with#_ fr catheter
*
q 3-4 hrs
q 1-2 hrs
Other
Lavage with Normal Saline
*
2-3 drops
1 ml
2 ml
Secretions:
*
Thin
Thick
Copious
Small
White
Other
Pass Muir Valve on
*
Yes
No
Chest Physiotherapy performed
*
Yes
No
New HME on
*
Yes
No
BIPAP Settings
*
On
Off
Respiratory Distress
*
Yes
No
Cool mist to trach on from __ to __
Sprinting off vent from __ to __
from , to
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Personal Care/Time
ADLS
*
Bed Bath
Shower/Tub
Shampoo Hair
Shave
Lotion applied to skin
Encouraged to perform self-care
Other
Personal Care/Time
*
Select
Notes
Pericare each diaper change with
Complete bedbath at
Assist with shower at
Tub bath at
Oral hygiene at
Other
Skin/EENT
Skin/EENT
Warm/dry
Intact
Turgor WNL
Eyes clear/no drainage
Ears with no drainage
Any wounds?
*
Yes
No
Wounds
*
Select
Notes
Wound Site
Measures
S/S Infection
Progressive Healing
Wound Care
Change in Skin condition
Psychosocial/Growth & Development
(as appropriate for age of pt)
Choose from the menu below (hold "ctrl" to select multiple)
Head control
Rolls over
Sits alone
Standing
1-2 words
Playing with toys
Reaches for objects
Reads
Using computer
Radio on for auditory stimu1ation
Pt watched age-appropriate 1V
LVN read to pt
Pt sleeping
Assisted with homework
Pt play/interact with siblings/friends
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Bowel Elimination
Choose one
*
Continent
Incontenent (diapered)
Bowel Movment
*
Yes
No
Bowel movement this shift at
*
Color
*
Describe
*
Small
Soft
Medium
Hard
Large
Liquid
Digital stimulation
Enema
Suppository
Bowel Program tolerated without distress
Colostomy
Stoma care with
at
what time
Disimpaction
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Bladder Elimination
Pt diapered
*
Yes
No
Urine clear yellow, no foul odor
*
Yes
No
Catheter
*
Yes
No
Foley Cath #
Suprapubic#
External Cath#
Intermittent Cath
Yes
No
time/amount
*
Bladder Irrigation
Yes
No
Time
Amount
External cath changed/penis cleaned at
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Safety/Emergency Preparedness
Precautions
*
Oxygen
Seizure
Fall
Pediatric
Aspiration
Safety belt when up in w/c to avoid falls
Emergency Prep
Ambu bag
Emergency trach in home
Resucitation device with pt on outings
EpiPen present
VNS magnet with pt at all times
Suction machine, emergency trach, ambu bag w/ patient on outings
Restraints (type, on, off)
What type of restraint - Time on and offf
Infection Control
Infection control
*
Standard
Droplet
Contact
Airborne
Sharps container
Infection control kit present
Equipment
Equipment
Select
Notes
Apnea monior on (duration)
Ventilator on (duration)
Humidifier on (duration)
Supplies adequate
Supplies ordered (when)
Clinical Alarms checked & audible q4 hrs (doc. time)
Select
Notes
Pulse oximeter
Apnea monitor
Enteral pump
Progress towards goals (this shift)
*
No falls or injuries
No seizures
No s/s infection
Weight maintained
Seizures per week
Weight gain (lb/month)
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Intake in mls / Output in mls (enter numerical values only)
*
Response to care this shift: condition
*
Improved
Remain the same
Declined
Narrative Summary
*
Education provided to and on
*
Demonstrates Understanding
*
Yes
No
Needs Review
*
Yes
No
Did you contact MD?
*
Yes
No
Communication
*
New orders given
No new orders
What new orders?
*
Care Endorsed To
*
Status
*
Medications on schedule.
Informed of PRNs admin
No issues reported
Issues/New Medications
Date of shift
*
-
Month
-
Day
Year
Shift Time
*
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Minutes
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AM/PM Option
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until
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Minutes
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AM/PM Option
Employee Name
*
First Name
Last Name
Title
*
Nurses Email (for your submission confirmation)
Employee Signature:
*
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