Task

Prompt: What are abnormal flowsheets that I should pay attention?

Example

Comfort/Sleep,,,,,,
Pain Management Interventions,relaxation techniques promoted;simple massage provided;quiet environment facilitated,,,,,
Fever Reduction/Comfort Measures,lightweight bedding;lightweight clothing,,,,,
Sleep/Rest/Relaxation,no problem identified,,,,,
Pain/Comfort/Sleep Interventions,,,,,,
Sleep/Rest Enhancement,Awakenings minimized;regular sleep/rest pattern promoted;relaxation techniques promoted,,,,,
Coping/Psychosocial,,,,,,
Observed Emotional State,accepting;calm;cooperative,,,,,
Verbalized Emotional State,acceptance,,,,,
Plan of Care Reviewed With,patient,,,,,
Psychosocial Support,,,,,,
Trust Relationship/Rapport,care explained;choices provided;questions answered;questions encouraged;reassurance provided,,,,,
Diversional Activities,television,,,,,
Family/Support System Care,involvement promoted,,,,,
Involvement in Care,,,,,,
Family/Support Persons,patient,,,,,
Involvement in Care,supportive of patient,,,,,
Coping/Psychosocial Interventions,,,,,,
Supportive Measures,active listening utilized;relaxation techniques promoted;self-responsibility promoted;self-care encouraged;self-reflection promoted,,,,,
Assessment/Reassessment,,,,,,
Assessment,Shift Assessment,,,,,
Oral Assessment Tool,,,,,,
Teeth,0--> No Teeth,,,,,
Lips,"2--> Dry, wrinkled, cracked, some reddened areas",,,,,
Tongue,"2--> Dry, slightly reddened areas, prominent papillae at base",,,,,
Oral Mucosa,"1--> Smooth, pink, moist, intact",,,,,
Saliva,"1--> Thin, watery, plentiful",,,,,
Score for Oral Dysfunction,6,,,,,
HEENT,,,,,,
HEENT WDL,ex;eye,,,,,
Left Vision Change,blind,,,,,
Right Vision Change,blind,,,,,
Mouth/Teeth WDL,,,,,,
Mouth/Teeth WDL,ex,,,,,
Teeth Symptoms,teeth absent,,,,,
HEENT Care,,,,,,
Mouth Care,oral rinse provided;lips moistened,,,,,
Dental Appliance Use/Teeth Care,oral rinse provided,,,,,
Oral Care Kit Given?,Yes,,,,,
Cognitive,,,,,,
Cognitive/Neuro/Behavioral WDL,ex;arousability;level of consciousness;orientation;speech,,,,,
Level of Consciousness,alert,,,,,
Arousal Level,arouses to voice,,,,,
Orientation,disoriented to;place,,,,,
Speech,logical;spontaneous;clear,,,,,
Cognitive Interventions,,,,,,
Sensory Stimulation Regulation,auditory stimulation minimized;auditory stimulation provided;care clustered;lighting decreased,,,,,
Pupils,,,,,,
Pupil PERRLA,no,,,,,
Pupil Size Left,3 mm,,,,,
Pupil Shape Left,round,,,,,
Pupil Reaction Left,fixed,,,,,
Pupil Accommodation Left,absent,,,,,
Pupil Size Right,5 mm,,,,,
Pupil Shape Right,round,,,,,
Pupil Reaction Right,fixed,,,,,
Pupil Accommodation Right,absent,,,,,
Glasgow Coma Scale,,,,,,
Best Eye Response,4-->(E4) spontaneous,,,,,
Best Motor Response,6-->(M6) obeys commands,,,,,
Best Verbal Response,4-->(V4) confused,,,,,
Glasgow Coma Scale Score,14,,,,,
Assessment Qualifiers,"Valid GCS - no intubation, not sedated, no eye obstruction",,,,,
Motor Response,,,,,,
Motor Response,general motor response;LUE motor response;LLE motor response;RUE motor response;RLE motor response,,,,,
General Motor Response,purposeful motor response,,,,,
LUE Motor Response,purposeful motor response,,,,,
RUE Motor Response,purposeful motor response,,,,,
LLE Motor Response,purposeful motor response,,,,,
RLE Motor Response,purposeful motor response,,,,,
Hand Grip/Ankle Strength,,,,,,
"Hand Grip, Left",strong,,,,,
"Hand Grip, Right",strong,,,,,
"Dorsiflexion, Left",moderate,,,,,
"Dorsiflexion, Right",moderate,,,,,
"Plantarflexion, Left",moderate,,,,,
"Plantarflexion, Right",moderate,,,,,
Sensory Assessment,,,,,,
LUE Light Touch,WNL,,,,,
RUE Light Touch,WNL,,,,,
LLE Light Touch,WNL,,,,,
RLE Light Touch,WNL,,,,,
Musculoskeletal,,,,,,
Musculoskeletal WDL,ex;mobility,,,,,
General Mobility,generalized weakness;moderately impaired,,,,,
Musculoskeletal Interventions,,,,,,
Activity/Level of Assistance,lying in bed,,,,,
Respiratory,,,,,,
Respiratory WDL,ex;breath sounds,,,,,
"Rhythm/Pattern, Respiratory",tachypneic;labored,,,,,
Expansion/Accessory Muscles/Retractions,accessory muscle use,,,,,
Cough Frequency,frequent,,,,,
Cough And Deep Breathing,done independently per patient,,,,,
Additional Documentation,Sputum Assessment (Group),,,,,
Sputum Assessment,,,,,,
Secretions Amount,moderate,,,,,
Secretions Color,tan,,,,,
Breath Sounds,,,,,,
Breath Sounds,All Fields,,,,,
All Lung Fields Breath Sounds,"Anterior:;Posterior:;crackles, coarse",,,,,
Airway,,,,,,
Airway WDL,WDL,,,,,
Respiratory Interventions,,,,,,
Airway/Ventilation Management,airway patency maintained,,,,,
Breathing Techniques/Airway Clearance,deep/controlled cough encouraged,,,,,
Cardiac,,,,,,
Cardiac WDL,WDL,,,,,
Cardiac Rhythm,,,,,,
Lead Monitored,Lead II,,,,,
Rhythm,sinus arrhythmia,,,,,
Peripheral Neurovascular,,,,,,
Peripheral Neurovascular WDL,WDL;LUE neurovascular assessment;RUE neurovascular assessment;RLE neurovascular assessment;LLE neurovascular assessment;pulse assessment;capillary refill limb specific,,,,,
"Capillary Refill, LUE",less than/equal to 3 secs,,,,,
"Capillary Refill, RUE",less than/equal to 3 secs,,,,,
"Capillary Refill, LLE",less than/equal to 3 secs,,,,,
"Capillary Refill, RLE",less than/equal to 3 secs,,,,,
Pulse Assessment,radial;dorsalis pedis,,,,,
VTE Prevention/Management,bleeding precautions maintained;bleeding risk assessed;ambulation promoted;compression stockings on;sequential compression devices on,,,,,
All Extremities Neurovascular Assessment,,,,,,
General All Extremity Temperature,warm,,,,,
General All Extremity Color,no discoloration,,,,,
General All Extremity Sensation,no numbness;no tingling,,,,,
LUE Neurovascular Assessment,,,,,,
Temperature,warm,,,,,
Color,no discoloration,,,,,
Sensation,no tingling;no numbness,,,,,
RUE Neurovascular Assessment,,,,,,
Temperature,warm,,,,,
Color,no discoloration,,,,,
Sensation,no tingling;no numbness,,,,,
LLE Neurovascular Assessment,,,,,,
Temperature,warm,,,,,
Color,no discoloration,,,,,
Sensation,no tingling;no numbness,,,,,
RLE Neurovascular Assessment,,,,,,
Temperature,warm,,,,,
Color,no discoloration,,,,,
Sensation,no tingling;no numbness,,,,,
Radial Pulse,,,,,,
Left Radial Pulse,2+ (normal),,,,,
Right Radial Pulse,2+ (normal),,,,,
Dorsalis Pedis Pulse,,,,,,
Left Dorsalis Pedis Pulse,1+ (weak),,,,,
Right Dorsalis Pedis Pulse,1+ (weak),,,,,
Nutrition,,,,,,
Diet/Feeding Assistance,other (see comments),,,,,
,(NPO),,,,,
Nutrition Interventions,,,,,,
Glycemic Management,blood glucose monitored,,,,,
Gastrointestinal,,,,,,
GI WDL,ex,,,,,
Abdominal Appearance,rounded;nondistended,,,,,
Bowel Sounds,All Quadrants,,,,,
All Quadrants Bowel Sounds,audible and normoactive;audible and active in all quadrants,,,,,
Genitourinary,,,,,,
Genitourinary WDL,ex;voiding ability/characteristics,,,,,
Voiding Characteristics,patient on hemodialysis,,,,,
Skin,,,,,,
Skin WDL,WDL,,,,,
"Braden Risk Assessment - 8 years and older  (Daily Assessment, Transfer, and Deterioration)",,,,,,
Sensory Perception,3-->slightly limited,,,,,
Moisture,4-->rarely moist,,,,,
Activity,1-->bedfast,,,,,
Mobility,2-->very limited,,,,,
Nutrition,1-->very poor,,,,,
Friction and Shear,1-->problem,,,,,
Braden Score,12,,,,,
Skin Interventions,,,,,,
Pressure Reduction Devices,specialty bed utilized;heel offloading device utilized;positioning supports utilized;pressure-redistributing mattress utilized,,,,,
Pressure Reduction Techniques,Non-skid socks,,,,,
Daily Care,,,,,,
Activity Management,lying in bed,,,,,
"Line [date] Midline Catheter Single brachial vein, left 18 gauge",,,,,,
"Date/Time:   Origin of line: New insertion  Line Type: Midline Catheter  Lumens: Single  Location: brachial vein, left  Size: 18 gauge  Device: placed with ultrasound guidance (UGPIV)  Patient Tolerance: Insertion: tolerated well",,,,,,
Indication/Daily Review of Necessity,"Fluid therapy, intermittent;Medication therapy, intermittent",,,,,
Site WDL,WDL,,,,,
Dressing Status,clean;dry;intact,,,,,
Patency/Maintenance,"alcohol impregnated valve cap applied/changed/in place;flushed without difficulty;blood return, able to obtain",,,,,
Safety,,,,,,
Safety WDL,WDL,,,,,
All Alarms,none present,,,,,
Infection Prevention,cohorting utilized;environmental surveillance performed;equipment surfaces disinfected,,,,,
Medication Review/Management,medications reviewed;high-risk medications identified,,,,,
Environmental Safety Modification,assistive device/personal items within reach;clutter free environment maintained;lighting adjusted,,,,,
Safety Promotion/Fall Prevention,activity supervised;assistive device/personal items within reach;clutter-free environment maintained;fall prevention program maintained,,,,,
Safety Promotion/Elopement (Non-CO-1:1),hospital gown worn;bed alarm,,,,,
Morse Fall Risk,,,,,,
History of Falling,0,,,,,
Secondary Diagnosis,15,,,,,
Ambulatory Aids,0,,,,,
IV Therapy/Heparin/Saline Lock,20,,,,,
Gait/Transferring,10,,,,,
Mental Status,15,,,,,
Score,60,,,,,
Morse Fall Risk,High,,,,,
"ABCS Risk for Injury with Fall (Admission, Fall, and Change in Condition)",,,,,,
Is patient > 85 years of age?,1,,,,,
Bone Fracture Risk or Injury?,1,,,,,
Is patient on an anticoagulant or has a bleeding disorder?,1,,,,,
Has patient had surgery this encounter?,0,,,,,
ABCS Score,3,,,,,
ABCS Fall Injury Risk Interventions,Bed in lowest position  with side rails;Chair /Bed Alarm where appropriate;Identification in Safety Rounds,,,,,