UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
MEDICAL CENTER

GUIDELINE

 GUIDELINE:           KK
EFFECTIVE:       10/96
REVISION:         10/03
APPROVAL:      10/03

Pages 2 and 3 (of 4)

Flowsheet is divided into 24 hour segments.

  1. *Place date on both page2/3.
  2. *Write patient's name.
  3. *Allergies should be listed daily.  "Multiple" is not acceptable.  Enter "NKDA" if no allergies known.
  4. Check for presence of legible ID band.  Replace if illegible.
  5. Check for presence of blue "high risk safety" band on same arm as ID band.
  6. Check for presence of allergy band.
  7. Vital Signs - place value for vital signs including temperature, heart rate, respiratory rate, blood pressure, and pulse ox saturation under the proper time designated.
  8. Initial vital signs column.
  9. Miscellaneous orders.  May be used for lab draws, tests, treatments, etc.  Use arrows for treatment started/completed (­¯).
  10. Respiratory.  IS spirometry expected.
  11. Amount of 02.

PCA/Epidural/Pain pumps

PCA/Epidural/Subcutaneous pain pump.  Refer to protocols for patient receiving PCA/Epidural Analgesia or procedure for sq pain pump.

KEYPOINT:  When a PCA/epidural is started or there is a change in concentration, rate, or any medication is wasted, this is indicated with the initials of 2 professionals.

  1. Drug-record narcotic name
  2. Concentration of drug
  3. Continuous rate, if applicable
  4. Bolus amt/PCA dosage
  5. Lockout
  6. 4 hour dose limit
  7. Level of pain (0-10).
  8. Level of sedation (0-4-see scale on right side of page 3).
  9. Initials of both RNs verifying dosage and settings.

DIABETIC CARE

  1. Glucometer reading.
  2. Blood sugar results from laboratory.
  3. Urine sugar and acetone per dipstick.  (May use for initials of person performing glucose check if different from insulin giver (if applicable)
  4. Insulin type/amt.
  5. Site
  6. Initials of caregiver.

INTAKE

  1. Oral intake-record under appropriate time.
  2. Intake total for D shift.  Also record in eChart.
  3. Intake total for E shift.  Also record in eChart.
  4. Intake total for N shift.  Also record in eChart.
  5. Enteric tube feedings when given.
  6. Enteric tube feeding total per shift.
  7. Blood products are documented in the PRBS column or platelets column.
  8. Blood products totals per shift.
  9. Addition IV fluids are documents - including piggy backs under IV fluids.  May list by number (36).  Totals are entered into eChart by RN.
  10. Number IVs and piggybacks and list by name.
  11. Total intake is entered for 24 hours.  Place this total on new flow sheet under "yesterday's intake" (*).

OUTPUT

  1. Estimate amount of blood loss if applicable.
  2. Measure emesis amount.  Guaiac emesis if applicable (40).

 

  1. Record stool (in ml if liquid).  If ileostomy mark "I", colostomy "C".  Guaiac stool, if applicable (42).

 

  1. Record amount of urine in ml under appropriate time.  Indicate in title box if drainage device is used.  Totals for shift are recorded at 1400, 22-00, 0600.  (44)

 

  1. List and record out[put separately from other sources, e.g. chest tubes, davol or other drains.
  2. Total each area separately for D., E, and N (1400, 220, 0600)  Record in eChart.
  3. Record total output per shift by adding the appropriate columns.
  4. Total output per twenty four hours.  Place this total on new flow sheet under "yesterday's output" (49*).

 

  1. Record the "maximum temperature" for previous day.
  2. Record today's weight.
  3. Record yesterday's weight (from previous flow sheet).
  4. *Attach patient identification label.
  5. Each team member involved in care should legibly place signature, designation and initials (55).

Continued on Page Four

             


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