This log is also available as text (107cc.txt) and as a (binary) annotation file (107cc.log).
Generated: Thursday, 23-Apr-2009 00:34:50 EDT
(All dates below are surrogates.)
id: Service Type t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 u1: BPM st: NotStopd id: Heart Rhythm t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg v2: 65 n2: 65 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 79 n1: 79 u1: mmHg st: NotStopd id: Precautions t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: SpO2 t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [13:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [13:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: TPN 1000.0ml t0: [13:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [13:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 12 vu: ml id: Urine Out Foley t0: [13:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml id: .9% Normal Saline 50.0ml + 50mghr Midazolam t0: [13:00:00 25/02/2016] el: 1 ai: 274 cg: RN cu: CSRU vo: 3 vu: ml
id: Fentanyl t0: [13:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 120 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip id: Midazolam t0: [13:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 3 du: mghr so: .9% Normal Saline sv: 50 su: ml rt: IV Drip
pi: 4532685 hi: 27155 t0: [15:00:00 25/02/2016] tf: [17:00:00 22/03/2016] mn: Chlorhexidine Gluconate pt: Unit Dose st: Discontinued rt: PO fr: TID:PRN di: Ongoing xv: 36 xu: Hours
id: Service Type t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: HOB t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 88 n1: 88 u1: BPM st: NotStopd id: Heart Rhythm t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: AntiEmbDevice/Status t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 109 n1: 109 u1: mmHg v2: 66 n2: 66 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: mmHg st: NotStopd id: Position t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Assistance Device t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Skin Care t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Sputum Color/Consist t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: White v2: Thick st: NotStopd id: Sputum Source/Amt t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Suctioned v2: Moderate st: NotStopd id: Therapeutic Bed t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Back Care t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [14:00:00 25/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [14:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: TPN 1000.0ml t0: [14:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [14:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 12 vu: ml id: Urine Out Foley t0: [14:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml id: .9% Normal Saline 50.0ml + 50mghr Midazolam t0: [14:00:00 25/02/2016] el: 1 ai: 274 cg: RN cu: CSRU vo: 3 vu: ml st: Stopped
id: Fentanyl t0: [14:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 80 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip id: Midazolam t0: [14:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 3 du: mghr so: .9% Normal Saline sv: 50 su: ml rt: IV Drip st: Stopped
id: Service Type t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: ETT Mark/Location t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 21cm v2: Lip st: NotStopd id: Ectopy Frequency t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 111 n1: 111 u1: BPM st: NotStopd id: Heart Rhythm t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Airway Size t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 7.5 mm st: NotStopd id: Airway Type t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Endotracheal st: NotStopd id: Intubation Date t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: Arterial BP t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 139 n1: 139 u1: mmHg v2: 86 n2: 86 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 u1: mmHg st: NotStopd id: Precautions t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 23 n1: 23 u1: BPM st: NotStopd id: SpO2 t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Sputum Color/Consist t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: White v2: Frothy st: NotStopd id: Sputum Source/Amt t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Suctioned v2: Moderate st: NotStopd id: Ventilator Type t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Drager st: NotStopd id: calprevflg t0: [15:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [15:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: TPN 1000.0ml t0: [15:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [15:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 8 vu: ml id: Urine Out Foley t0: [15:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: Fentanyl t0: [15:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 80 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
pi: 4532954 hi: 27155 t0: [16:00:00 25/02/2016] tf: [10:00:00 03/03/2016] mn: Sulfameth/Trimethoprim pt: IV Piggyback st: Discontinued rt: IV fr: Q12H ds: 16, 4 dn: 2 di: Ongoing xu: Enter on Label pi: 4532956 hi: 27155 t0: [16:00:00 25/02/2016] tf: [18:00:00 02/03/2016] mn: Midazolam pt: Unit Dose st: Discontinued rt: IV fr: Q2H:PRN di: Ongoing xv: 36 xu: Hours pi: 4532957 hi: 27155 t0: [16:00:00 25/02/2016] tf: [18:00:00 02/03/2016] mn: Midazolam pt: Unit Dose st: Discontinued rt: IV fr: Q2H:PRN di: Ongoing xv: 36 xu: Hours pi: 4532958 hi: 27155 t0: [16:00:00 25/02/2016] tf: [16:00:00 25/02/2016] mn: Fentanyl Citrate pt: Unit Dose st: Discontinued rt: IV fr: Q4H:PRN di: Ongoing xv: 36 xu: Hours pi: 4532959 hi: 27155 t0: [16:00:00 25/02/2016] tf: [16:00:00 25/02/2016] mn: Midazolam pt: Unit Dose st: Discontinued rt: IV fr: Q4H:PRN di: Ongoing xv: 36 xu: Hours
id: Extubation Date t0: [15:10:00 25/02/2016] el: 0 cg: RT cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: FiO2 Set t0: [15:10:00 25/02/2016] el: 0 cg: RT cu: CSRU v1: 0.5 n1: 0.5 u1: torr st: NotStopd id: Intubation Date t0: [15:10:00 25/02/2016] el: 0 cg: RT cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: O2 Delivery Device t0: [15:10:00 25/02/2016] el: 0 cg: RT cu: CSRU v1: Aerosol-Cool st: NotStopd
id: Stool Out Stool t0: [15:30:00 25/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Large id: Drain Out #1 Jackson Pratt t0: [08:30:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 5 vu: ml
pi: 4533183 hi: 27155 t0: [17:00:00 25/02/2016] tf: [18:00:00 28/02/2016] mn: Fentanyl Patch pt: Unit Dose st: Inactive (Due to a change order) rt: TP fr: Q72H dn: 0 di: Ongoing xv: 36 xu: Hours pi: 4533350 hi: 27155 t0: [17:00:00 25/02/2016] tf: [19:00:00 27/02/2016] mn: Lorazepam pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q4H:PRN di: Ongoing xv: 36 xu: Hours
id: Service Type t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Risk for Falls t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: BPM st: NotStopd id: Heart Rhythm t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 130 n1: 130 u1: mmHg v2: 77 n2: 77 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: mmHg st: NotStopd id: Precautions t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: SpO2 t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: Fentanyl t0: [16:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 80 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Less Restrict Meas. t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Less Restrict Meas. t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: PainLevel Acceptable t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Service Type t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Daily Wake Up t0: [16:00:00 25/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Education Barrier t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Education Handout t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Not Given st: NotStopd id: Education Learner t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: GI#1 Intub Site t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Salem Sump v2: Right Nare st: NotStopd id: Education Readiness t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Understands st: NotStopd id: Education Topic #1 t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #1 t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #2 t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Plan of Care st: NotStopd id: Eye Opening t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Family Communication t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Family Called st: NotStopd id: Follows Commands t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: points st: NotStopd id: GI Intub #1/Site t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Salem Sump v2: Right Nare st: NotStopd id: GI#1 Tube PlaceCheck t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: GI#1 Tube Stat/Drain t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Clamped st: NotStopd id: HOB t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#2 Type/Site t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: INV Line#2InsertDate t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: INV#2 WaveformAppear t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sharp st: NotStopd id: IV #1 Insert Date t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: Activity t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #1 t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Impaired Skin Site#1 t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#1 t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Incision/Wound #1 t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Incision/Wound #1 t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: LLL Lung Sounds t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: LUL Lung Sounds t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Oral Cavity t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 3 st: NotStopd id: AntiEmbDevice/Status t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 142 n1: 142 u1: mmHg v2: 86 n2: 86 u2: mmHg st: NotStopd id: Pain Location t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Type t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Arterial BP Mean t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg st: NotStopd id: Position t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: RLL Lung Sounds t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 11 n1: 11 u1: BPM st: NotStopd id: Responds to Stimuli t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Spontaneous Movement t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Support Systems t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#2 Tubing Change t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Cap Change t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Axillary st: NotStopd id: Temperature C (calc) t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 36.3333 n1: 36.3333 u1: Deg. C st: NotStopd id: Temperature F t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 97.4 n1: 97.4 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Oriented st: NotStopd id: Back Care t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [17:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd id: Pt./Family Informed t0: [14:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: Braden Activity t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd id: Braden Moisture t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Adequate st: NotStopd id: Braden Score t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: number st: NotStopd id: Braden SensoryPercep t0: [16:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [17:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [17:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 150 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [17:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 16 vu: ml id: Urine Out Foley t0: [17:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 220 vu: ml
id: Fentanyl t0: [17:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 80 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Stool Out Stool t0: [14:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Large
id: Service Type t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 138 n1: 138 u1: mmHg v2: 81 n2: 81 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: mmHg st: NotStopd id: Precautions t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Radiologic Study t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Chest Xray st: NotStopd id: Respiratory Rate t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: SpO2 t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Fingerstick Glucose t0: [18:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 rs: Manual st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [18:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: TPN 1000.0ml t0: [18:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [18:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 8 vu: ml
id: Fentanyl t0: [18:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 80 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: D5W 100.0ml t0: [18:00:00 25/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: Urine Out Foley t0: [18:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 65 vu: ml
pi: 4534067 hi: 27155 t0: [20:00:00 25/02/2016] tf: [12:00:00 01/03/2016] mn: Haloperidol pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q4H:PRN di: Ongoing xv: 36 xu: Hours
id: Service Type t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: HOB t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: AntiEmbDevice/Status t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 146 n1: 146 u1: mmHg v2: 84 n2: 84 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg st: NotStopd id: Position t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Skin Care t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Therapeutic Bed t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Back Care t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [19:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [19:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: TPN 1000.0ml t0: [19:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [19:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 8 vu: ml id: Stool Out Stool t0: [19:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Large id: Urine Out Foley t0: [19:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 220 vu: ml id: Drain Out #1 Jackson Pratt t0: [16:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 10 vu: ml
id: Fentanyl t0: [19:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 80 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Less Restrict Meas. t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [20:00:00 25/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Barrier t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Education Handout t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Not Given st: NotStopd id: Education Learner t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: GI#1 Intub Site t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Salem Sump v2: Right Nare st: NotStopd id: Education Readiness t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Reinforced st: NotStopd id: Education Topic #1 t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Extubation Date t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Eye Opening t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: FiO2 Set t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 0.5 n1: 0.5 u1: torr st: NotStopd id: Follows Commands t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: points st: NotStopd id: GI Intub #1/Site t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Salem Sump v2: Right Nare st: NotStopd id: GI#1 Tube PlaceCheck t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: GI#1 Tube Stat/Drain t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Clamped st: NotStopd id: HOB t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: BPM st: NotStopd id: Heart Rhythm t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#2 Type/Site t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: INV Line#2InsertDate t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: INV#2 WaveformAppear t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sharp st: NotStopd id: IV #1 Insert Date t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: Activity t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #1 t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: ImpSkin Treatment #1 t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Duoderm st: NotStopd id: Impaired Skin Site#1 t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Inc Dsg/Status #1 t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg st: NotStopd id: Incision/Wound #1 t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Intubation Date t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: LL Strength/Movement t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: LLL Lung Sounds t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: LUL Lung Sounds t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: O2 Delivery Device t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: Oral Cavity t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 136 n1: 136 u1: mmHg v2: 80 n2: 80 u2: mmHg st: NotStopd id: Pain Management t0: [20:00:00 25/02/2016] el: 1 cg: RN cu: CSRU v1: IV Gtt st: NotStopd id: Pain Type t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Aching st: NotStopd id: Arterial BP Mean t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: mmHg st: NotStopd id: Position t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: RLL Lung Sounds t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: Responds to Stimuli t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: % st: NotStopd id: Spontaneous Movement t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#2 Tubing Change t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Cap Change t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 36.2222 n1: 36.2222 u1: Deg. C st: NotStopd id: Temperature F t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 97.2 n1: 97.2 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Ventilator Type t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Drager st: NotStopd id: Verbal Response t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Oriented st: NotStopd id: calprevflg t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Pt./Family Informed t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: Braden Activity t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd id: Braden Moisture t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Adequate st: NotStopd id: Braden Score t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: number st: NotStopd id: Braden SensoryPercep t0: [20:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [20:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: TPN 1000.0ml t0: [20:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [20:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 8 vu: ml id: Urine Out Foley t0: [20:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 225 vu: ml
id: Fentanyl t0: [20:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 80 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
pi: 4534398 hi: 27155 t0: [22:00:00 25/02/2016] tf: [21:00:00 26/02/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 250 ml NS Bolus 250 ml Over 30 mins it: B dt: 1 di: Doses xu: Enter on Label
id: Service Type t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Risk for Falls t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: FiO2 Set t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 0.5 n1: 0.5 u1: torr st: NotStopd id: HOB t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 u1: BPM st: NotStopd id: Heart Rhythm t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Activity t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: NBP t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: mmHg v2: 62 n2: 62 u2: mmHg st: NotStopd id: NBP Mean t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 70 n1: 70 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: AntiEmbDevice/Status t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 106 n1: 106 u1: mmHg v2: 69 n2: 69 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 82 n1: 82 u1: mmHg st: NotStopd id: Position t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Skin Care t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: Therapeutic Bed t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Back Care t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [21:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd
id: D5W 100.0ml t0: [20:00:00 25/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: D5W 100.0ml t0: [21:00:00 25/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 150 vu: ml id: .9% Normal Saline 1000.0ml t0: [21:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: TPN 1000.0ml t0: [21:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [21:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 8 vu: ml id: Stool Out Stool t0: [21:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Large id: Urine Out Foley t0: [21:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 325 vu: ml
id: Fentanyl t0: [21:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 70 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Stool Out Total t0: [23:00:00 25/02/2016] el: 3 cg: RN cu: CSRU cv: 0 ac: 24 ap: carryForward re: 0
id: Service Type t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: BPM st: NotStopd id: Heart Rate t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 114 n1: 114 u1: BPM st: NotStopd id: Heart Rhythm t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Heart Rhythm t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Level of Conscious t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd id: Arterial BP t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: mmHg v2: 65 n2: 65 u2: mmHg st: NotStopd id: Arterial BP t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: mmHg v2: 62 n2: 62 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 76 n1: 76 u1: mmHg st: NotStopd id: Arterial BP Mean t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 73 n1: 73 u1: mmHg st: NotStopd id: Precautions t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: ABP Alarm (Lo/Hi) t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Respiratory Rate t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: SpO2 t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: SpO2 t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: calprevflg t0: [21:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [22:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 250 vu: ml id: TPN 1000.0ml t0: [22:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [22:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 7 vu: ml id: Urine Out Foley t0: [22:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml
id: Fentanyl t0: [21:30:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 70 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 113 n1: 113 u1: BPM st: NotStopd id: Heart Rhythm t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Arterial BP t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 91 n1: 91 u1: mmHg v2: 56 n2: 56 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 68 n1: 68 u1: mmHg st: NotStopd id: Precautions t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: SpO2 t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Temp. Site t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Axillary st: NotStopd id: Temperature C (calc) t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 37.1111 n1: 37.1111 u1: Deg. C st: NotStopd id: Temperature F t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 98.8 n1: 98.8 u1: Deg. F st: NotStopd id: calprevflg t0: [22:30:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: Gastric Meds t0: [20:00:00 25/02/2016] el: 2 ai: 155 cg: RN cu: CSRU vo: 100 vu: ml id: Gastric Meds t0: [22:00:00 25/02/2016] el: 2 ai: 155 cg: RN cu: CSRU vo: 30 vu: ml id: GT Flush t0: [20:00:00 25/02/2016] el: 1 ai: 338 cg: RN cu: CSRU vo: 30 vu: ml id: GT Flush t0: [22:00:00 25/02/2016] el: 1 ai: 338 cg: RN cu: CSRU vo: 30 vu: ml
id: Fentanyl t0: [22:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 50 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip id: Fentanyl t0: [22:30:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 50 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip st: Stopped
pi: 4534567 hi: 27155 t0: [00:00:00 26/02/2016] tf: [23:00:00 26/02/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 500 ml NS Bolus 500 ml Over 30 mins it: B dt: 1 di: Doses xu: Enter on Label pi: 4534587 hi: 27155 t0: [00:00:00 26/02/2016] tf: [23:00:00 26/02/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 500 ml NS Bolus 500 ml Over 30 mins it: B dt: 1 di: Doses xu: Enter on Label
id: Less Restrict Meas. t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Range of Motion t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sedated st: NotStopd id: Risk for Falls t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: FiO2 Set t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 0.5 n1: 0.5 u1: torr st: NotStopd id: Heart Rate t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 103 n1: 103 u1: BPM st: NotStopd id: Heart Rhythm t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: O2 Delivery Device t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: Arterial BP t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: mmHg v2: 55 n2: 55 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 67 n1: 67 u1: mmHg st: NotStopd id: Position Change t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Restraint Location t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [22:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Fingerstick Glucose t0: [23:00:00 25/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 rs: Manual st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [23:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 500 vu: ml id: TPN 1000.0ml t0: [23:00:00 25/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [23:00:00 25/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: Urine Out Foley t0: [23:00:00 25/02/2016] el: 1 cg: RN cu: CSRU vo: 480 vu: ml
id: Art.pH t0: [23:26:00 25/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.4 n1: 7.4 rs: Final st: NotStopd id: Lactic Acid t0: [23:26:00 25/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1 n1: 1 rs: Final st: NotStopd id: Arterial Base Excess t0: [23:26:00 25/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3 n1: 3 rs: Final st: NotStopd id: Arterial CO2(Calc) t0: [23:26:00 25/02/2016] el: 0 cg: 3161 cu: CSRU v1: 30 n1: 30 rs: Final st: NotStopd id: Arterial PaCO2 t0: [23:26:00 25/02/2016] el: 0 cg: 3161 cu: CSRU v1: 47 n1: 47 u1: mmHg rs: Final st: NotStopd id: Arterial PaO2 t0: [23:26:00 25/02/2016] el: 0 cg: 3161 cu: CSRU v1: 179 n1: 179 u1: mmHg rs: Final st: NotStopd id: Arterial pH t0: [23:26:00 25/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.4 n1: 7.4 rs: Final st: NotStopd id: Lactic Acid(0.5-2.0) t0: [23:26:00 25/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1 n1: 1 rs: Final st: NotStopd
id: Levophed-k io: D5W 250.0ml + 8mcgkgmin Levophed-k el: 200 cg: RN cu: CSRU am: 8 du: mcgkgmin rt: IV Drip
io: D5W 250.0ml + 8mcgkgmin Levophed-k el: 2 cg: RN cu: CSRU ra: 4.21875 ru: ml/hr
id: Less Restrict Meas. t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Range of Motion t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sedated st: NotStopd id: Risk for Falls t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: GI#1 Intub Site t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Salem Sump v2: Right Nare st: NotStopd id: Health Care Proxy t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Care t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Eye Opening t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 3 To speech st: NotStopd id: FiO2 Set t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 0.5 n1: 0.5 u1: torr st: NotStopd id: Follows Commands t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 10 n1: 10 u1: points st: NotStopd id: GI Intub #1/Site t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Salem Sump v2: Right Nare st: NotStopd id: GI#1 Tube PlaceCheck t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: GI#1 Tube Stat/Drain t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Clamped st: NotStopd id: HOB t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#2 Type/Site t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: INV Line#2InsertDate t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: INV#2 WaveformAppear t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sharp st: NotStopd id: IV #1 Insert Date t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: Activity t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #1 t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: ImpSkin Treatment #1 t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Duoderm st: NotStopd id: Impaired Skin Site#1 t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Inc Dsg/Status #1 t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg st: NotStopd id: Incision/Wound #1 t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: LLL Lung Sounds t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: No Movement st: NotStopd id: LUL Lung Sounds t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Arouse to Stimul st: NotStopd id: Motor Response t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Localizes Pain st: NotStopd id: NBP t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: mmHg v2: 51 n2: 51 u2: mmHg st: NotStopd id: NBP Mean t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: Oral Care t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Oral Cavity t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Disoriented st: NotStopd id: AntiEmbDevice/Status t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 u1: mmHg v2: 53 n2: 53 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 66 n1: 66 u1: mmHg st: NotStopd id: Position t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Pupil Response R/L t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 mm v2: 4 mm st: NotStopd id: RL Strength/Movement t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: No Movement st: NotStopd id: RLL Lung Sounds t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: No Movement st: NotStopd id: RUL Lung Sounds t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: Responds to Stimuli t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Significant Events t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Fluid Bolus st: NotStopd id: Skin Care t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Skin Color t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Pale st: NotStopd id: Skin Integrity t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: Spontaneous Movement t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Support Systems t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#2 Tubing Change t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Cap Change t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Axillary st: NotStopd id: Temperature C (calc) t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 36.7222 n1: 36.7222 u1: Deg. C st: NotStopd id: Temperature F t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 98.1 n1: 98.1 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Light Yellow v2: Clear st: NotStopd id: Urine Source t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Incomp sounds st: NotStopd id: Back Care t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sedated st: NotStopd id: Pt./Family Informed t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: Braden Activity t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd id: Braden Moisture t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Adequate st: NotStopd id: Braden Score t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: number st: NotStopd id: Braden SensoryPercep t0: [00:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [00:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 500 vu: ml id: TPN 1000.0ml t0: [00:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: Urine Out Foley t0: [00:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 300 vu: ml
id: Service Type t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: FiO2 Set t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 0.5 n1: 0.5 u1: torr st: NotStopd id: Heart Rate t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 84 n1: 84 u1: BPM st: NotStopd id: Heart Rhythm t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: O2 Delivery Device t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: Arterial BP t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: mmHg v2: 55 n2: 55 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 69 n1: 69 u1: mmHg st: NotStopd id: Precautions t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: SpO2 t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [01:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [22:00:00 25/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml id: .9% Normal Saline 1000.0ml t0: [01:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: TPN 1000.0ml t0: [01:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml
id: Less Restrict Meas. t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: bath t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done id: Pain Assess Method t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Non-verbal cues st: NotStopd id: Service Type t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [02:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Care t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: FiO2 Set t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 0.5 n1: 0.5 u1: torr st: NotStopd id: HOB t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: BPM st: NotStopd id: Heart Rhythm t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Activity t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: O2 Delivery Device t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: Oral Care t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: AntiEmbDevice/Status t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: mmHg v2: 65 n2: 65 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 80 n1: 80 u1: mmHg st: NotStopd id: Position t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Position Change t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: Restraint Location t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: Therapeutic Bed t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Back Care t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [02:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: D5W 100.0ml t0: [01:00:00 26/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 150 vu: ml id: D5W 100.0ml t0: [02:00:00 26/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [02:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: TPN 1000.0ml t0: [02:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: Stool Out Stool t0: [01:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Large id: Urine Out Foley t0: [01:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 900 vu: ml
id: Service Type t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Risk for Falls t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 79 n1: 79 u1: BPM st: NotStopd id: Heart Rhythm t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 130 n1: 130 u1: mmHg v2: 78 n2: 78 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: mmHg st: NotStopd id: Precautions t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: calprevflg t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1000.0ml t0: [03:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [00:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml st: Stopped id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [01:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [02:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml id: Urine Out Foley t0: [03:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 380 vu: ml
id: Less Restrict Meas. t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [04:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: FiO2 Set t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 0.4 n1: 0.4 u1: torr st: NotStopd id: FiO2 Set t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 0.4 n1: 0.4 u1: torr st: NotStopd id: Follows Commands t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Heart Rate t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: BPM st: NotStopd id: Heart Rhythm t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#2 Type/Site t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: INV Line#2InsertDate t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: INV#2 WaveformAppear t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sharp st: NotStopd id: IV #1 Insert Date t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: IV Site Appear #1 t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: ImpSkin Treatment #1 t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Duoderm st: NotStopd id: Impaired Skin Site#1 t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Inc Dsg/Status #1 t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg st: NotStopd id: Incision/Wound #1 t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: LLL Lung Sounds t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: LUL Lung Sounds t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: O2 Delivery Device t0: [03:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: O2 Delivery Device t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: Oral Cavity t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: Arterial BP t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: mmHg v2: 67 n2: 67 u2: mmHg st: NotStopd id: Pain Location t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Pain Management t0: [04:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: IV Gtt st: NotStopd id: Pain Type t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aching st: NotStopd id: Arterial BP Mean t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: mmHg st: NotStopd id: Position Change t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Pupil Response R/L t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 mm v2: 4 mm st: NotStopd id: RL Strength/Movement t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RLL Lung Sounds t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Responds to Stimuli t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Spontaneous Movement t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#2 Tubing Change t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Cap Change t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Axillary st: NotStopd id: Temperature C (calc) t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 37.0556 n1: 37.0556 u1: Deg. C st: NotStopd id: Temperature F t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 98.7 n1: 98.7 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Pt./Family Informed t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: Braden Activity t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd id: Braden Moisture t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Prob. Inadequate st: NotStopd id: Braden Score t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: number st: NotStopd id: Braden SensoryPercep t0: [04:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd
id: TPN 1000.0ml t0: [04:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: Urine Out Foley t0: [04:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: Fentanyl t0: [04:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: WBC (4-11,000) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 5.6 n1: 5.6 rs: Final st: NotStopd id: WBC t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 5.6 n1: 5.6 rs: Final st: NotStopd id: Hematocrit t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 32.9 n1: 32.9 u1: % rs: Final st: NotStopd id: Hemoglobin t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 11 n1: 11 u1: gm/dl rs: Final st: NotStopd id: Platelets t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 202 n1: 202 rs: Final st: NotStopd id: RBC t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.55 n1: 3.55 u1: /mic l rs: Final st: NotStopd id: WBC (4-11,000) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 5.6 n1: 5.6 rs: Final st: NotStopd
id: BUN t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 13 n1: 13 rs: Final st: NotStopd id: Calcium t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 8.4 n1: 8.4 u1: mg/dl rs: Final st: NotStopd id: Chloride t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 100 n1: 100 rs: Final st: NotStopd id: Creatinine t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.3 n1: 0.3 rs: Final st: NotStopd id: Glucose t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 97 n1: 97 rs: Final st: NotStopd id: Magnesium t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.9 n1: 1.9 rs: Final st: NotStopd id: Phosphorous t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4.7 n1: 4.7 u1: mEq/L rs: Final st: NotStopd id: Potassium t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.4 n1: 3.4 rs: Final st: NotStopd id: Sodium t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 134 n1: 134 rs: Final st: NotStopd id: BUN (6-20) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 13 n1: 13 rs: Final st: NotStopd id: Calcium (8.4-10.2) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 8.4 n1: 8.4 u1: mg/dl rs: Final st: NotStopd id: Carbon Dioxide t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 28 n1: 28 rs: Final st: NotStopd id: Chloride (100-112) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 100 n1: 100 rs: Final st: NotStopd id: Creatinine (0-1.3) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.3 n1: 0.3 rs: Final st: NotStopd id: Glucose (70-105) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 97 n1: 97 rs: Final st: NotStopd id: Magnesium (1.6-2.6) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.9 n1: 1.9 rs: Final st: NotStopd id: Phosphorous(2.7-4.5) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4.7 n1: 4.7 u1: mEq/L rs: Final st: NotStopd id: Potassium (3.5-5.3) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.4 n1: 3.4 rs: Final st: NotStopd id: Sodium (135-148) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 134 n1: 134 rs: Final st: NotStopd
id: PT t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 13.6 n1: 13.6 rs: Final st: NotStopd id: INR t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.2 n1: 1.2 rs: Final st: NotStopd id: PTT t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 34.2 n1: 34.2 rs: Final st: NotStopd id: INR (2-4 ref. range) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.2 n1: 1.2 rs: Final st: NotStopd id: PT(11-13.5) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 13.6 n1: 13.6 rs: Final st: NotStopd id: PTT(22-35) t0: [04:05:00 26/02/2016] el: 0 cg: 3161 cu: CSRU v1: 34.2 n1: 34.2 rs: Final st: NotStopd
id: Fingerstick Glucose t0: [06:00:00 26/02/2016] el: 0 cg: CoWker cu: CSRU v1: 104 n1: 104 rs: Manual st: NotStopd
id: Less Restrict Meas. t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Range of Motion t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sedated st: NotStopd id: Risk for Falls t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Care t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: FiO2 Set t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 0.4 n1: 0.4 u1: torr st: NotStopd id: HOB t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 87 n1: 87 u1: BPM st: NotStopd id: Heart Rate t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: BPM st: NotStopd id: Heart Rhythm t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: O2 Delivery Device t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aerosol-Cool st: NotStopd id: O2 Delivery Device t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) #2 t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 n1: 4 u1: lpm st: NotStopd id: Oral Care t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: AntiEmbDevice/Status t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 116 n1: 116 u1: mmHg v2: 63 n2: 63 u2: mmHg st: NotStopd id: Arterial BP t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: mmHg v2: 60 n2: 60 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 78 n1: 78 u1: mmHg st: NotStopd id: Arterial BP Mean t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 74 n1: 74 u1: mmHg st: NotStopd id: Position t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: ABP Alarm (Lo/Hi) t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Respiratory Rate t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: Restraint Location t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: SpO2 t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Therapeutic Bed t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: calprevflg t0: [05:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [06:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: D5W 100.0ml t0: [06:00:00 26/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [03:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: .9% Normal Saline 1000.0ml t0: [04:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: .9% Normal Saline 1000.0ml t0: [05:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: .9% Normal Saline 1000.0ml t0: [06:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [05:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: TPN 1000.0ml t0: [06:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [04:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [05:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [06:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Stool Out Stool t0: [05:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Large id: Urine Out Foley t0: [05:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 210 vu: ml id: Urine Out Foley t0: [06:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml
id: Fentanyl t0: [05:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip id: Fentanyl t0: [06:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Stool Out Total t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU cv: 0 ac: 24 ap: carryForward re: 0
id: Service Type t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: BPM st: NotStopd id: Heart Rhythm t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: O2 Delivery Device t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) #2 t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 3 n1: 3 u1: lpm st: NotStopd id: Arterial BP t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 116 n1: 116 u1: mmHg v2: 64 n2: 64 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 79 n1: 79 u1: mmHg st: NotStopd id: Precautions t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: SpO2 t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [07:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [07:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [07:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [07:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [07:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 180 vu: ml
id: Fentanyl t0: [07:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: GI#1 Intub Site t0: [08:00:00 26/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: GI Intub #1/Site t0: [08:00:00 26/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: GI#1 Tube PlaceCheck t0: [08:00:00 26/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: GI#1 Tube Stat/Drain t0: [08:00:00 26/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd
id: Less Restrict Meas. t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [08:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Learner t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Health Care Proxy t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #2 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Plan of Care st: NotStopd id: Extubation Date t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Eye Opening t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 107 n1: 107 u1: BPM st: NotStopd id: Heart Rhythm t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#2 Type/Site t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: INV Line#2InsertDate t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: INV#2 WaveformAppear t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sharp st: NotStopd id: IV #1 Insert Date t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: Activity t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #1 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: ImpSkin Treatment #1 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Duoderm st: NotStopd id: Impaired Skin Site#1 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Inc Dsg/Status #1 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg st: NotStopd id: Incision/Wound #1 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Intubation Date t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: LL Strength/Movement t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: LLL Lung Sounds t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: LUL Lung Sounds t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 123 n1: 123 u1: mmHg v2: 90 n2: 90 u2: mmHg st: NotStopd id: NBP Mean t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) #2 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 3 n1: 3 u1: lpm st: NotStopd id: Oral Care t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Oral Cavity t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: AntiEmbDevice/Status t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 113 n1: 113 u1: mmHg v2: 86 n2: 86 u2: mmHg st: NotStopd id: Pain Management t0: [08:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: IV Gtt st: NotStopd id: Pain Type t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aching st: NotStopd id: Arterial BP Mean t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: mmHg st: NotStopd id: Position t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Position Change t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Pupil Response R/L t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 mm v2: 4 mm st: NotStopd id: RL Strength/Movement t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RLL Lung Sounds t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: Responds to Stimuli t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Spontaneous Movement t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Stool Guaiac t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Not Applicable st: NotStopd id: Support Systems t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#2 Tubing Change t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Cap Change t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 36.7222 n1: 36.7222 u1: Deg. C st: NotStopd id: Temperature F t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 98.1 n1: 98.1 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Pt./Family Informed t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [08:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: intact
id: D5W 100.0ml t0: [08:00:00 26/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml id: .9% Normal Saline 1000.0ml t0: [08:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [08:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: Urine Out Foley t0: [08:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 220 vu: ml
id: Fentanyl t0: [08:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 50 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 102 n1: 102 u1: BPM st: NotStopd id: Heart Rhythm t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Arterial BP t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 113 n1: 113 u1: mmHg v2: 70 n2: 70 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 84 n1: 84 u1: mmHg st: NotStopd id: Precautions t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: SpO2 t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [09:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1000.0ml t0: [08:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: TPN 1000.0ml t0: [09:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [09:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml
id: Fentanyl t0: [09:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 50 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
pi: 4535332 hi: 27155 t0: [10:00:00 26/02/2016] pt: TPN st: Expired
id: Less Restrict Meas. t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Range of Motion t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 107 n1: 107 u1: mmHg v2: 62 n2: 62 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 76 n1: 76 u1: mmHg st: NotStopd id: Position Change t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Restraint Location t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: SpO2 t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: D5W 100.0ml t0: [10:00:00 26/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [09:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [10:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [10:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [10:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: Urine Out Foley t0: [09:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml id: Urine Out Foley t0: [10:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml
id: Fentanyl t0: [10:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 50 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: HOB t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: BPM st: NotStopd id: Heart Rhythm t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: AntiEmbDevice/Status t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 110 n1: 110 u1: mmHg v2: 63 n2: 63 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 77 n1: 77 u1: mmHg st: NotStopd id: Position t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Assistance Device t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: SpO2 t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Therapeutic Bed t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: calprevflg t0: [11:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [11:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [11:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [11:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml
id: Fentanyl t0: [11:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 50 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
pi: 4536070 hi: 27155 t0: [13:00:00 26/02/2016] tf: [12:00:00 27/02/2016] mn: Potassium Chloride pt: IV Piggyback st: Expired rt: IV fr: ONCE ds: 13 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
id: Less Restrict Meas. t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Range of Motion t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Risk for Falls t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Extubation Date t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Heart Rate t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#2 Type/Site t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: INV Line#2InsertDate t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: INV#2 WaveformAppear t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sharp st: NotStopd id: IV #1 Insert Date t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: IV Site Appear #1 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: ImpSkin Treatment #1 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Duoderm st: NotStopd id: Impaired Skin Site#1 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Inc Dsg/Status #1 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg st: NotStopd id: Incision/Wound #1 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Intubation Date t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: O2 Delivery Device t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) #2 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Arterial BP t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 111 n1: 111 u1: mmHg v2: 63 n2: 63 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 78 n1: 78 u1: mmHg st: NotStopd id: Position Change t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: Restraint Location t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [10:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Support Systems t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#2 Tubing Change t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Cap Change t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: calprevflg t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd id: Pt./Family Informed t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [12:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [12:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [12:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml
id: Fentanyl t0: [12:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Radiologic Study t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Chest Xray st: NotStopd
id: Pain Present t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Daily Wake Up t0: [12:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Eye Opening t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Abdominal Assessment t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: LL Strength/Movement t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: LLL Lung Sounds t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: LUL Lung Sounds t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Oral Cavity t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: Pain Location t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Pain Management t0: [12:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: IV Gtt st: NotStopd id: Pain Type t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aching st: NotStopd id: PostTib. Pulses R/L t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Pupil Response R/L t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 3 mm v2: 3 mm st: NotStopd id: RL Strength/Movement t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RLL Lung Sounds t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Respiratory Pattern t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Responds to Stimuli t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Spontaneous Movement t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Stool Guaiac t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Not Applicable st: NotStopd id: Temp. Site t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 36.4444 n1: 36.4444 u1: Deg. C st: NotStopd id: Temperature F t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97.6 n1: 97.6 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Bowel Sounds t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: intact
id: Urine Out Foley t0: [11:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml id: Urine Out Foley t0: [12:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 140 vu: ml
id: Total Hourly Output t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: 260 cv: 260 ac: 1 ap: none re: 0 id: Urine Out Total t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: 260 cv: 5260 ac: 24 ap: none re: 0 id: 24h Total Out t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: 260 cv: 5275 ac: 24 ap: carryForward re: 0
id: Fingerstick Glucose t0: [12:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 111 n1: 111 rs: Manual st: NotStopd
id: Service Type t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 106 n1: 106 u1: mmHg v2: 61 n2: 61 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 75 n1: 75 u1: mmHg st: NotStopd id: Precautions t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: SpO2 t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [13:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [13:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [13:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [13:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml
id: Fentanyl t0: [13:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Care t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: HOB t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: BPM st: NotStopd id: Heart Rhythm t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Activity t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Oral Care t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: AntiEmbDevice/Status t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 118 n1: 118 u1: mmHg v2: 63 n2: 63 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 80 n1: 80 u1: mmHg st: NotStopd id: Position t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Assistance Device t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: Skin Care t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: INV#4 Tubing Change t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: Therapeutic Bed t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Back Care t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [14:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [15:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [14:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: TPN 1000.0ml t0: [15:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [14:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [15:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Stool Out Stool t0: [15:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Medium id: Urine Out Foley t0: [13:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 150 vu: ml id: Urine Out Foley t0: [14:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml id: Urine Out Foley t0: [15:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml id: Drain Out #1 Jackson Pratt t0: [08:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 15 vu: ml
id: Fentanyl t0: [14:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 118 n1: 118 u1: mmHg v2: 63 n2: 63 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: mmHg st: NotStopd id: Precautions t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: SpO2 t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: % st: NotStopd id: calprevflg t0: [15:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: Fentanyl t0: [15:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Less Restrict Meas. t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Less Restrict Meas. t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [16:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Learner t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Health Care Proxy t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #2 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Plan of Care st: NotStopd id: Extubation Date t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Eye Opening t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: BPM st: NotStopd id: Heart Rhythm t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#2 Type/Site t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: INV Line#2InsertDate t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: INV#2 WaveformAppear t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sharp st: NotStopd id: IV #1 Insert Date t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: Activity t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #4 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: ImpSkin Treatment #1 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Duoderm st: NotStopd id: Impaired Skin Site#1 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Inc Dsg/Status #1 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg st: NotStopd id: Incision/Wound #1 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Intubation Date t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: LL Strength/Movement t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: O2 Delivery Device t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) #2 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Cavity t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 102 n1: 102 u1: mmHg v2: 56 n2: 56 u2: mmHg st: NotStopd id: Pain Location t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Pain Management t0: [16:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: IV Gtt st: NotStopd id: Pain Type t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Aching st: NotStopd id: Arterial BP Mean t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 71 n1: 71 u1: mmHg st: NotStopd id: Position t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Pupil Response R/L t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 mm v2: 4 mm st: NotStopd id: RL Strength/Movement t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: Responds to Stimuli t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Skin Color t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Spontaneous Movement t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#2 Tubing Change t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#4 Cap Change t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 36.8333 n1: 36.8333 u1: Deg. C st: NotStopd id: Temperature F t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 98.3 n1: 98.3 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Back Care t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Pt./Family Informed t0: [14:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [16:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: INTACT
id: .9% Normal Saline 1000.0ml t0: [16:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [17:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [16:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: TPN 1000.0ml t0: [17:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [16:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [17:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Stool Out Stool t0: [17:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Medium id: Urine Out Foley t0: [16:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 150 vu: ml id: Urine Out Foley t0: [17:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 150 vu: ml
id: Fentanyl t0: [16:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: PO/Gastric In Total t0: [23:00:00 26/02/2016] el: 3 cg: RN cu: CSRU cv: 0 ac: 24 ap: none re: 0
id: Service Type t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 120 n1: 120 u1: mmHg v2: 69 n2: 69 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 68 n1: 68 u1: mmHg st: NotStopd id: Precautions t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: SpO2 t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: % st: NotStopd id: calprevflg t0: [17:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [18:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [18:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [18:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [18:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 140 vu: ml
id: Fentanyl t0: [17:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
pi: 4537204 hi: 27155 t0: [19:00:00 26/02/2016] tf: [12:00:00 01/03/2016] mn: Fentanyl Citrate pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q2H:PRN di: Ongoing xv: 36 xu: Hours
id: Service Type t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: BPM st: NotStopd id: Heart Rhythm t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Arterial BP t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: mmHg v2: 72 n2: 72 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 84 n1: 84 u1: mmHg st: NotStopd id: Precautions t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 10 n1: 10 u1: BPM st: NotStopd id: SpO2 t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: % st: NotStopd id: calprevflg t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Fingerstick Glucose t0: [18:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 117 n1: 117 rs: Manual st: NotStopd
id: Fentanyl t0: [18:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: HOB t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: AntiEmbDevice/Status t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 126 n1: 126 u1: mmHg v2: 77 n2: 77 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 84 n1: 84 u1: mmHg st: NotStopd id: Position t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: SpO2 t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 u1: % st: NotStopd id: Therapeutic Bed t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: calprevflg t0: [19:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [19:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [19:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml nb: 1 id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [19:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [19:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: Fentanyl t0: [19:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Less Restrict Meas. t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sedated st: NotStopd id: Daily Wake Up t0: [20:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Weak Palpable v2: Weak Palpable st: NotStopd id: Ectopy Frequency t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Barrier t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Given st: NotStopd id: Education Learner t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Understands st: NotStopd id: Education Topic #1 t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #2 t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Invasive Lines st: NotStopd id: Extubation Date t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Eye Opening t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: points st: NotStopd id: Heart Rate t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: BPM st: NotStopd id: Heart Rhythm t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#2 Type/Site t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: INV Line#2InsertDate t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: INV#2 WaveformAppear t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Dampened st: NotStopd id: IV #1 Insert Date t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: IV Site Appear #1 t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Impaired Skin Site#1 t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Incision/Wound #1 t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Intubation Date t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: LL Strength/Movement t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Lethargic st: NotStopd id: Motor Response t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Localizes Pain st: NotStopd id: O2 Delivery Device t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) #2 t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Cavity t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: Arterial BP t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg v2: 69 n2: 69 u2: mmHg st: NotStopd id: Pain Location t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Management t0: [20:00:00 26/02/2016] el: 1 cg: RN cu: CSRU v1: IV Gtt st: NotStopd id: Arterial BP Mean t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: mmHg st: NotStopd id: Position Change t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Precautions t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Pupil Response R/L t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 3 mm v2: 3 mm st: NotStopd id: RL Strength/Movement t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: Responds to Stimuli t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal for Race st: NotStopd id: Skin Integrity t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: % st: NotStopd id: Spontaneous Movement t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#2 Tubing Change t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#4 Cap Change t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 37.6667 n1: 37.6667 u1: Deg. C st: NotStopd id: Temperature F t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 99.8 n1: 99.8 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd id: Pt./Family Informed t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [20:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: intact
id: D5W 100.0ml t0: [19:30:00 26/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml id: .9% Normal Saline 1000.0ml t0: [20:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [20:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [20:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [20:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 220 vu: ml
id: Fentanyl t0: [20:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Risk for Falls t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: BPM st: NotStopd id: Heart Rhythm t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Arterial BP t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 128 n1: 128 u1: mmHg v2: 71 n2: 71 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 89 n1: 89 u1: mmHg st: NotStopd id: Precautions t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: SpO2 t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: % st: NotStopd id: calprevflg t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [21:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [21:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [21:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [21:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [21:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 160 vu: ml
id: Fentanyl t0: [21:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: HOB t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: BPM st: NotStopd id: Heart Rhythm t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: AntiEmbDevice/Status t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 109 n1: 109 u1: mmHg v2: 73 n2: 73 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 87 n1: 87 u1: mmHg st: NotStopd id: Position t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Assistance Device t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 11 n1: 11 u1: BPM st: NotStopd id: SpO2 t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: % st: NotStopd id: Therapeutic Bed t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: calprevflg t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [21:00:00 26/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 150 vu: ml id: .9% Normal Saline 1000.0ml t0: [22:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [22:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [22:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [22:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 150 vu: ml
id: Fentanyl t0: [22:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 102 n1: 102 u1: BPM st: NotStopd id: Heart Rhythm t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Arterial BP t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 114 n1: 114 u1: mmHg v2: 73 n2: 73 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 88 n1: 88 u1: mmHg st: NotStopd id: Precautions t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: SpO2 t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: % st: NotStopd id: calprevflg t0: [23:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [22:00:00 26/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [23:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [23:00:00 26/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [23:00:00 26/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [23:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 260 vu: ml
id: Fentanyl t0: [23:00:00 26/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Less Restrict Meas. t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Less Restrict Meas. t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [00:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Weak Palpable v2: Weak Palpable st: NotStopd id: Ectopy Frequency t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Barrier t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Not Given st: NotStopd id: Education Learner t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Understands st: NotStopd id: Education Topic #1 t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #2 t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Medications st: NotStopd id: Extubation Date t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Eye Care t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Eye Opening t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: BPM st: NotStopd id: Heart Rhythm t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#2 Type/Site t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2InsertDate t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: IV #1 Insert Date t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: Activity t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #1 t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Impaired Skin Site#1 t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Incision/Wound #1 t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Intubation Date t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: LL Strength/Movement t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: O2 Delivery Device t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) #2 t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Cavity t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: AntiEmbDevice/Status t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 121 n1: 121 u1: mmHg v2: 74 n2: 74 u2: mmHg st: NotStopd id: Pain Location t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Type t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Arterial BP Mean t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg st: NotStopd id: Position t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 Person Assist st: NotStopd id: Precautions t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Pupil Response R/L t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 3 mm v2: 3 mm st: NotStopd id: RL Strength/Movement t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: Responds to Stimuli t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Spontaneous Movement t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#2 Tubing Change t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#4 Cap Change t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 37.0556 n1: 37.0556 u1: Deg. C st: NotStopd id: Temperature F t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 98.7 n1: 98.7 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Urine Color/Appear t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [22:00:00 26/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Fingerstick Glucose t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 123 n1: 123 rs: Manual st: NotStopd id: Bowel Sounds t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [00:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: intact
id: .9% Normal Saline 1000.0ml t0: [00:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [00:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [00:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [00:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml
id: Fentanyl t0: [00:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 91 n1: 91 u1: mmHg v2: 62 n2: 62 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 74 n1: 74 u1: mmHg st: NotStopd id: Precautions t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: SpO2 t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: Fentanyl t0: [01:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: BPM st: NotStopd id: Heart Rhythm t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: mmHg v2: 61 n2: 61 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 75 n1: 75 u1: mmHg st: NotStopd id: Precautions t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: calprevflg t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [00:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 150 vu: ml id: .9% Normal Saline 1000.0ml t0: [01:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [02:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [01:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: TPN 1000.0ml t0: [02:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [01:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [02:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml
id: Fentanyl t0: [02:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Less Restrict Meas. t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Range of Motion t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Not Done st: NotStopd id: Circulation/SkinInt t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Level of Conscious t0: [01:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd id: Level of Conscious t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd id: Position Change t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Reason For Restraint t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Not Done st: NotStopd id: Restraint Location t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Pt./Family Informed t0: [02:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: D5W 100.0ml t0: [02:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 50 vu: ml id: Urine Out Foley t0: [01:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml id: Urine Out Foley t0: [02:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml
id: Service Type t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: BPM st: NotStopd id: Heart Rhythm t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: mmHg v2: 62 n2: 62 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 75 n1: 75 u1: mmHg st: NotStopd id: Precautions t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: SpO2 t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [03:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [03:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [03:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml
id: Fentanyl t0: [03:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Less Restrict Meas. t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [04:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Weak Palpable v2: Weak Palpable st: NotStopd id: Ectopy Frequency t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Education Barrier t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Not Given st: NotStopd id: Education Learner t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Understands st: NotStopd id: Education Topic #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #2 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Medications st: NotStopd id: Extubation Date t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Eye Opening t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Heart Rate t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: BPM st: NotStopd id: Heart Rhythm t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#2 Type/Site t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2InsertDate t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: IV #1 Insert Date t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: IV Site Appear #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Impaired Skin Site#1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Incision/Wound #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Intubation Date t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: LL Strength/Movement t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: O2 Delivery Device t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) #2 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Cavity t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: Arterial BP t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 112 n1: 112 u1: mmHg v2: 69 n2: 69 u2: mmHg st: NotStopd id: Pain Location t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Type t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Arterial BP Mean t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 84 n1: 84 u1: mmHg st: NotStopd id: Position Change t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Weak Palpable v2: Weak Palpable st: NotStopd id: Precautions t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Pupil Response R/L t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 3 mm v2: 3 mm st: NotStopd id: RL Strength/Movement t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: Responds to Stimuli t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Spontaneous Movement t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#2 Tubing Change t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#4 Cap Change t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 36.5 n1: 36.5 u1: Deg. C st: NotStopd id: Temperature F t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 97.7 n1: 97.7 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: intact
id: D5W 100.0ml t0: [04:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [04:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [04:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [04:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [03:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml id: Urine Out Foley t0: [04:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 160 vu: ml
id: Fentanyl t0: [04:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: WBC (4-11,000) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 5.8 n1: 5.8 rs: Final st: NotStopd id: WBC t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 5.8 n1: 5.8 rs: Final st: NotStopd id: Hematocrit t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 30.7 n1: 30.7 u1: % rs: Final st: NotStopd id: Hemoglobin t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 10.8 n1: 10.8 u1: gm/dl rs: Final st: NotStopd id: Platelets t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 171 n1: 171 rs: Final st: NotStopd id: RBC t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.35 n1: 3.35 u1: /mic l rs: Final st: NotStopd id: WBC (4-11,000) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 5.8 n1: 5.8 rs: Final st: NotStopd
id: IV Infusion In Total t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: 12.5 cv: 2050.76 ac: 24 ap: none re: 0 id: IV Nutrition Total t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: 75 cv: 1800 ac: 24 ap: none re: 0 id: 24h Total In t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: 87.5 cv: 3850.76 ac: 24 ap: none re: 0 id: 24h Net Body Balance t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: -172.5 cv: -1424.24 ac: 24 ap: carryForward re: 0 id: LOS Net Body Balance t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: -172.5 cv: 4881.6 ac: multiple days ap: carryForward re: 0 id: Net Hourly Balance t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU pv: -172.5 cv: -172.5 ac: 1 ap: none re: 0 id: Drain #1 Total Out t0: [23:00:00 26/02/2016] el: 3 cg: 3161 cu: CSRU cv: 15 ac: 24 ap: none re: 0
id: Service Type t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: BPM st: NotStopd id: Heart Rhythm t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Arterial BP t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 119 n1: 119 u1: mmHg v2: 68 n2: 68 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg st: NotStopd id: Precautions t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: SpO2 t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [05:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [05:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [05:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [05:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 230 vu: ml
id: Fentanyl t0: [05:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: HOB t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: HOB t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Activity t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Activity Tolerance t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: AntiEmbDevice/Status t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: AntiEmbDevice/Status t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Position t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Assistance Device t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Assistance Device t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Skin Care t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Therapeutic Bed t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Therapeutic Bed t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Logroll st: NotStopd id: Turn t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Back Care t0: [03:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd
pi: 4538597 hi: 27155 t0: [06:00:00 27/02/2016] tf: [05:00:00 28/02/2016] mn: Calcium Gluconate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 6 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours pi: 4538598 hi: 27155 t0: [06:00:00 27/02/2016] tf: [05:00:00 28/02/2016] mn: Potassium Chloride pt: IV Piggyback st: Expired rt: IV fr: ONCE ds: 6 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
id: Chloride t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 116 n1: 116 rs: Final st: NotStopd id: Sodium t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 141 n1: 141 rs: Final st: NotStopd id: Chloride (100-112) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 116 n1: 116 rs: Final st: NotStopd id: Sodium (135-148) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 141 n1: 141 rs: Final st: NotStopd
id: Imp Skin Cleanse #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soap & H20 st: NotStopd id: ImpSkin Character #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Drain/Amt#1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Serosanguinous v2: Scant st: NotStopd id: ImpSkin Treatment #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: ImpSkin Wound Base#1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: Skin Color t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd
id: Less Restrict Meas. t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Range of Motion t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: BPM st: NotStopd id: Heart Rhythm t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Oral Care t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Arterial BP t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 u1: mmHg v2: 68 n2: 68 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: mmHg st: NotStopd id: Position Change t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Restraint Location t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: % st: NotStopd id: calprevflg t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [06:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: D5W 100.0ml t0: [06:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [06:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [06:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [06:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [06:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 160 vu: ml
id: Fentanyl t0: [06:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: BUN t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 13 n1: 13 rs: Final st: NotStopd id: Calcium t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 8.6 n1: 8.6 u1: mg/dl rs: Final st: NotStopd id: Chloride t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 100 n1: 100 rs: Final st: NotStopd id: Creatinine t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.3 n1: 0.3 rs: Final st: NotStopd id: Glucose t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 116 n1: 116 rs: Final st: NotStopd id: Magnesium t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.8 n1: 1.8 rs: Final st: NotStopd id: Phosphorous t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4.6 n1: 4.6 u1: mEq/L rs: Final st: NotStopd id: Potassium t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4 n1: 4 rs: Final st: NotStopd id: Sodium t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 133 n1: 133 rs: Final st: NotStopd id: BUN (6-20) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 13 n1: 13 rs: Final st: NotStopd id: Calcium (8.4-10.2) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 8.6 n1: 8.6 u1: mg/dl rs: Final st: NotStopd id: Carbon Dioxide t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 25 n1: 25 rs: Final st: NotStopd id: Chloride (100-112) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 100 n1: 100 rs: Final st: NotStopd id: Creatinine (0-1.3) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.3 n1: 0.3 rs: Final st: NotStopd id: Glucose (70-105) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 116 n1: 116 rs: Final st: NotStopd id: Magnesium (1.6-2.6) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.8 n1: 1.8 rs: Final st: NotStopd id: Phosphorous(2.7-4.5) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4.6 n1: 4.6 u1: mEq/L rs: Final st: NotStopd id: Potassium (3.5-5.3) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4 n1: 4 rs: Final st: NotStopd id: Sodium (135-148) t0: [05:18:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 133 n1: 133 rs: Final st: NotStopd
id: Inc Cleansing #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Saline st: NotStopd id: Inc Drainage/Amt #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Purulent v2: Scant st: NotStopd id: Inc Dsg/Status #1 t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Changed st: NotStopd id: Braden Activity t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd id: Braden Moisture t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Prob. Inadequate st: NotStopd id: Braden Score t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: number st: NotStopd id: Braden SensoryPercep t0: [04:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd
id: Glucose t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 76 n1: 76 rs: Final st: NotStopd id: Glucose (70-105) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 76 n1: 76 rs: Final st: NotStopd
id: D5W 100.0ml t0: [06:30:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 50 vu: ml
id: Service Type t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 102 n1: 102 u1: mmHg v2: 58 n2: 58 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 72 n1: 72 u1: mmHg st: NotStopd id: Precautions t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: SpO2 t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [05:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Behavior t0: [07:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [07:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [07:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [07:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml
id: Fentanyl t0: [07:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Urine Out Foley t0: [07:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: BUN t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 9 n1: 9 rs: Final st: NotStopd id: Creatinine t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.1 n1: 0.1 rs: Final st: NotStopd id: Magnesium t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.2 n1: 1.2 rs: Final st: NotStopd id: Phosphorous t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 2.9 n1: 2.9 u1: mEq/L rs: Final st: NotStopd id: BUN (6-20) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 9 n1: 9 rs: Final st: NotStopd id: Carbon Dioxide t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 17 n1: 17 rs: Final st: NotStopd id: Creatinine (0-1.3) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.1 n1: 0.1 rs: Final st: NotStopd id: Magnesium (1.6-2.6) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.2 n1: 1.2 rs: Final st: NotStopd id: Phosphorous(2.7-4.5) t0: [03:34:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 2.9 n1: 2.9 u1: mEq/L rs: Final st: NotStopd
id: Art.pH t0: [07:55:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.47 n1: 7.47 rs: Final st: NotStopd id: Arterial Base Excess t0: [07:55:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: no data rs: Final st: NotStopd id: Arterial CO2(Calc) t0: [07:55:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: no data rs: Final st: NotStopd id: Arterial PaCO2 t0: [07:55:00 27/02/2016] el: 0 cg: 3161 cu: CSRU u1: mmHg rs: Final st: NotStopd id: Arterial PaO2 t0: [07:55:00 27/02/2016] el: 0 cg: 3161 cu: CSRU u1: mmHg rs: Final st: NotStopd id: Arterial pH t0: [07:55:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.47 n1: 7.47 rs: Final st: NotStopd id: Ionized Calcium t0: [07:55:00 27/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.19 n1: 1.19 rs: Final st: NotStopd
id: Pain Present t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Pain Assess Method t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Non-verbal cues st: NotStopd id: Service Type t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [08:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 107 n1: 107 u1: BPM st: NotStopd id: Heart Rhythm t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#2 Type/Site t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2 Zero/Cal t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: INV Line#2InsertDate t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#2SiteAppear t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4 Type/Site t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: Abdominal Assessment t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: INV#2 WaveformAppear t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sharp st: NotStopd id: IV #1 Insert Date t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: Activity t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #1 t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Impaired Skin Site#1 t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Incision/Wound #1 t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: LU Strength/Movement t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Oral Cavity t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 130 n1: 130 u1: mmHg v2: 77 n2: 77 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: mmHg st: NotStopd id: Position t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: PostTib. Pulses R/L t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 Person Assist st: NotStopd id: Precautions t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Pupil Response R/L t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Brisk v2: Brisk st: NotStopd id: Pupil Size R/L t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 3 mm v2: 3 mm st: NotStopd id: RL Strength/Movement t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: RU Strength/Movement t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Respiratory Pattern t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: Responds to Stimuli t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Side Rails t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Integrity t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: SpO2 t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Spontaneous Movement t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#2 Tubing Change t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#4 Cap Change t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Axillary st: NotStopd id: Temperature C (calc) t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 36.7778 n1: 36.7778 u1: Deg. C st: NotStopd id: Temperature F t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 98.2 n1: 98.2 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Airbed/Kinair st: NotStopd id: Turn t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Urine Color/Appear t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd id: Bowel Sounds t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [08:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [08:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [08:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 2.5 vu: ml id: Urine Out Foley t0: [08:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: Fentanyl t0: [08:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip
id: Service Type t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: BPM st: NotStopd id: Heart Rate t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: BPM st: NotStopd id: Heart Rhythm t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 114 n1: 114 u1: mmHg v2: 63 n2: 63 u2: mmHg st: NotStopd id: Arterial BP t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 112 n1: 112 u1: mmHg v2: 63 n2: 63 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 78 n1: 78 u1: mmHg st: NotStopd id: Arterial BP Mean t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 77 n1: 77 u1: mmHg st: NotStopd id: Precautions t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: ABP Alarm (Lo/Hi) t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Respiratory Rate t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: SpO2 t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: SpO2 t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [09:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [10:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: TPN 1000.0ml t0: [10:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 150 vu: ml id: Urine Out Foley t0: [10:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 300 vu: ml
id: Fentanyl t0: [09:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip id: Fentanyl t0: [10:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 0 do: 25 du: mcghr so: .9% Normal Saline sv: 250 su: ml rt: IV Drip st: Stopped
id: Fingerstick Glucose t0: [12:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: 135 n1: 135 rs: Manual st: NotStopd
id: Less Restrict Meas. t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Range of Motion t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Ectopy Frequency t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #1 t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #1 t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Heart Rate t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 102 n1: 102 u1: BPM st: NotStopd id: Heart Rate t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: BPM st: NotStopd id: Heart Rhythm t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Heart Rhythm t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Abdominal Assessment t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Chair st: NotStopd id: Impaired Skin Site#1 t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#1 t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#1 t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Incision/Wound #1 t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Incision/Wound #1 t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Incision/Wound #1 t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: LU Strength/Movement t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Oral Cavity t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: Arterial BP t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 110 n1: 110 u1: mmHg v2: 64 n2: 64 u2: mmHg st: NotStopd id: Arterial BP t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: mmHg v2: 70 n2: 70 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: mmHg st: NotStopd id: Position Change t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: ABP Alarm (Lo/Hi) t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RLL Lung Sounds t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: RUL Lung Sounds t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Reason For Restraint t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: Respiratory Rate t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Responds to Stimuli t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Restraints Evaluated t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Restraints Evaluated t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Spontaneous Movement t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Support Systems t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Support Systems t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Therapeutic Bed t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Airbed/Kinair st: NotStopd id: Urine Color/Appear t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd id: Pt./Family Informed t0: [08:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [10:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [11:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: D5W 100.0ml t0: [10:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml id: D5W 100.0ml t0: [11:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [12:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: TPN 1000.0ml t0: [12:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 150 vu: ml id: Urine Out Foley t0: [12:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 250 vu: ml
id: IV Infusion In Total t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: 110 cv: 1662.5 ac: 24 ap: none re: 0 id: IV Nutrition Total t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: 42 cv: 1701 ac: 24 ap: none re: 0 id: 24h Total In t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: 152 cv: 3363.5 ac: 24 ap: none re: 0 id: Total Hourly Output t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: 300 cv: 300 ac: 1 ap: none re: 0 id: Urine Out Total t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: 300 cv: 4460 ac: 24 ap: none re: 0 id: 24h Net Body Balance t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: -148 cv: -1116.5 ac: 24 ap: carryForward re: 0 id: LOS Net Body Balance t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: -148 cv: 3765.1 ac: multiple days ap: carryForward re: 0 id: Net Hourly Balance t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: -148 cv: -148 ac: 1 ap: none re: 0 id: 24h Total Out t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU pv: 300 cv: 4480 ac: 24 ap: carryForward re: 0
id: Pain Level/Response t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2-Mild st: NotStopd id: Pain Level/Response t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2-Mild st: NotStopd id: Pain Present t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Present t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Non-verbal cues st: NotStopd id: Pain Assess Method t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: PainLevel Acceptable t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: PainLevel Acceptable t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Service Type t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Riker-SAS Scale t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [12:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Daily Wake Up t0: [14:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rate t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 130 n1: 130 u1: mmHg v2: 83 n2: 83 u2: mmHg st: NotStopd id: Arterial BP t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 127 n1: 127 u1: mmHg v2: 77 n2: 77 u2: mmHg st: NotStopd id: Pain Management t0: [12:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: IV Push v2: IV Push st: NotStopd id: Pain Management t0: [14:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: IV Push v2: IV Push st: NotStopd id: Arterial BP Mean t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: mmHg st: NotStopd id: Precautions t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: ABP Alarm (Lo/Hi) t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: SpO2 t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: SpO2 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: calprevflg t0: [13:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [14:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: TPN 1000.0ml t0: [14:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 150 vu: ml id: Urine Out Foley t0: [14:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 240 vu: ml
id: Urine Out Foley t0: [15:00:00 27/02/2016] el: 1 cg: CoWker cu: CSRU vo: 360 vu: ml
id: Service Type t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: points st: NotStopd id: HOB t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: BPM st: NotStopd id: Heart Rate t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: BPM st: NotStopd id: Heart Rhythm t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Heart Rhythm t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Abdominal Assessment t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Imp Skin Cleanse #1 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Wound Cleanser st: NotStopd id: Imp Skin Cleanse #3 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Saline st: NotStopd id: ImpSkin Character #1 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Character #3 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Laceration st: NotStopd id: ImpSkin Drain/Amt #3 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sanguinous v2: Small st: NotStopd id: ImpSkin Drain/Amt#1 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: ImpSkin Treatment #3 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Wet to Dry st: NotStopd id: ImpSkin Wound Base#1 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: ImpSkin Wound Base#3 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: ImpSkin Wth/Lth #3 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 0.5 cm v2: 0.5 cm st: NotStopd id: Impaired Skin Site#1 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Impaired Skin Site#4 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Foot, Right st: NotStopd id: Inc Dsg/Status #1 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Intact st: NotStopd id: Incision/Wound #1 t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: LU Strength/Movement t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Oral Cavity t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Arterial BP t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 134 n1: 134 u1: mmHg v2: 81 n2: 81 u2: mmHg st: NotStopd id: Arterial BP t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 125 n1: 125 u1: mmHg v2: 82 n2: 82 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: mmHg st: NotStopd id: Arterial BP Mean t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: mmHg st: NotStopd id: Position t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: PostTib. Pulses R/L t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: ABP Alarm (Lo/Hi) t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: RL Strength/Movement t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: RLL Lung Sounds t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: RUL Lung Sounds t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Respiratory Pattern t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: Respiratory Rate t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Responds to Stimuli t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Side Rails t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 84 n1: 84 u1: % st: NotStopd id: SpO2 t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Spontaneous Movement t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Therapeutic Bed t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Airbed/Kinair st: NotStopd id: Turn t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Urine Color/Appear t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Oriented st: NotStopd id: Back Care t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [15:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Anxious st: NotStopd id: Bowel Sounds t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: Braden Activity t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd id: Braden Moisture t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Adequate st: NotStopd id: Braden Score t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: number st: NotStopd id: Braden SensoryPercep t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [16:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: TPN 1000.0ml t0: [16:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 150 vu: ml id: Urine Out Foley t0: [16:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 340 vu: ml
id: D5W 100.0ml t0: [14:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml
id: Service Type t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Arterial BP t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 120 n1: 120 u1: mmHg v2: 76 n2: 76 u2: mmHg st: NotStopd id: Arterial BP Mean t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg st: NotStopd id: Precautions t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: SpO2 t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [17:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [17:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [17:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: Urine Out Foley t0: [17:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 240 vu: ml
pi: 4540072 hi: 27155 t0: [19:00:00 27/02/2016] tf: [18:00:00 28/02/2016] pt: IV Large Volume st: Expired rt: IV fr: ONCE ds: 19 iv: Amino Acid 4.25% with Electrolytes in 5% Dextrose 1000 ml dn: 1 dt: 1 di: Doses xu: Enter on Label
id: Less Restrict Meas. t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Level/Response t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1-None to Mild st: NotStopd id: Pain Present t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Non-verbal cues st: NotStopd id: PainLevel Acceptable t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Service Type t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [18:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #1 t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Heart Rate t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: BPM st: NotStopd id: Heart Rhythm t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#2 D/C Date t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 17 n2: 17 st: NotStopd id: INV Line#2 Type/Site t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2InsertDate t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#4 Type/Site t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV #1 Insert Date t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: IV Site Appear #1 t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Impaired Skin Site#1 t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#1 t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Impaired Skin Site#3 t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Incision/Wound #1 t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: NBP t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 110 n1: 110 u1: mmHg v2: 74 n2: 74 u2: mmHg st: NotStopd id: NBP Mean t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 82 n1: 82 u1: mmHg st: NotStopd id: Pain Location t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Management t0: [18:00:00 27/02/2016] el: 1 cg: RN cu: CSRU v1: IV Push v2: IV Push st: NotStopd id: Position Change t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RU Strength/Movement t0: [12:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RU Strength/Movement t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: Reason For Restraint t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Restraint Location t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Restraint Type t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Restraints Evaluated t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Support Systems t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Support Systems t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#2 Tubing Change t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#4 Cap Change t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temperature C (calc) t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 36.6667 n1: 36.6667 u1: Deg. C st: NotStopd id: Temperature F t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: Deg. F st: NotStopd id: calprevflg t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Anxious st: NotStopd id: Pt./Family Informed t0: [14:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [16:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Fingerstick Glucose t0: [18:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 145 n1: 145 rs: Manual st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [18:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [18:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: Urine Out Foley t0: [18:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 240 vu: ml
id: Service Type t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 109 n1: 109 u1: BPM st: NotStopd id: Heart Rhythm t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: NBP t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 112 n1: 112 u1: mmHg v2: 72 n2: 72 u2: mmHg st: NotStopd id: Precautions t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: SpO2 t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [19:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [19:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: Urine Out Foley t0: [19:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml
id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [10:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml st: Stopped id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [12:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [14:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [16:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [17:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [18:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [19:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vu: ml
pi: 4540174 hi: 27155 t0: [20:00:00 27/02/2016] tf: [07:00:00 04/03/2016] mn: Lorazepam pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours
id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl t0: [19:01:00 27/02/2016] el: 1 ai: 107 cg: -1 cu: CSRU vo: 0 st: D/C'd
id: Stool Out Stool t0: [19:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Medium id: Drain Out #1 Jackson Pratt t0: [19:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 20 vu: ml
id: Drain #1 Total Out t0: [23:00:00 27/02/2016] el: 3 cg: RN cu: CSRU cv: 20 ac: 24 ap: none re: 0
id: INV Line#2 D/C Date t0: [20:00:00 27/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: INV Line#2 Zero/Cal t0: [20:00:00 27/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: INV Line#2SiteAppear t0: [20:00:00 27/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: INV#2 WaveformAppear t0: [20:00:00 27/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd
id: Service Type t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: points st: NotStopd id: Heart Rate t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 u1: BPM st: NotStopd id: Heart Rhythm t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#2 Type/Site t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: A-Line v2: Right Radial st: NotStopd id: INV Line#2InsertDate t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 11 n2: 11 st: NotStopd id: INV Line#4 Type/Site t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Abdominal Assessment t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: IV #1 Insert Date t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: IV Site Appear #1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Impaired Skin Site#1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 119 n1: 119 u1: mmHg v2: 79 n2: 79 u2: mmHg st: NotStopd id: NBP Mean t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 89 n1: 89 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Cavity t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 3 st: NotStopd id: PostTib. Pulses R/L t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Precautions t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#2 Dsg Change t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Dsg Change t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: RLL Lung Sounds t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Respiratory Pattern t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: Responds to Stimuli t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Side Rails t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Spontaneous Movement t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#2 Cap Change t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#2 Tubing Change t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 16 n2: 16 st: NotStopd id: INV#4 Cap Change t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: INV#4 Tubing Change t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 15 n2: 15 st: NotStopd id: Temp. Site t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 36.1111 n1: 36.1111 u1: Deg. C st: NotStopd id: Temperature F t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Oriented st: NotStopd id: calprevflg t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: intact id: Braden Activity t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd id: Braden Moisture t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Prob. Inadequate st: NotStopd id: Braden Score t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: number st: NotStopd id: Braden SensoryPercep t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd
id: D5W 100.0ml t0: [20:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 150 vu: ml id: .9% Normal Saline 1000.0ml t0: [20:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [20:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 75 vu: ml id: Urine Out Foley t0: [20:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: bath t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: Done id: HOB t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: 30 degrees st: NotStopd id: Activity t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: Tolerated Well st: NotStopd id: AntiEmbDevice/Status t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Assistance Device t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: 2 Person Assist st: NotStopd id: Skin Care t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: Done st: NotStopd id: Therapeutic Bed t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: Airbed/Kinair st: NotStopd id: Back Care t0: [20:00:00 27/02/2016] el: 0 cg: CoWker cu: CSRU v1: Done st: NotStopd
id: Stool Out Stool t0: [20:00:00 27/02/2016] el: 1 cg: CoWker cu: CSRU vu: ml es: Large
id: Stool Out Total t0: [23:00:00 27/02/2016] el: 3 cg: CoWker cu: CSRU cv: 0 ac: 24 ap: carryForward re: 0
id: Pain Present t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: PainLevel Acceptable t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Service Type t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 110 n1: 110 u1: BPM st: NotStopd id: Heart Rhythm t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Activity t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: NBP t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 110 n1: 110 u1: mmHg v2: 63 n2: 63 u2: mmHg st: NotStopd id: Oral Care t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Location t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Position t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Precautions t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: SpO2 t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Therapeutic Bed t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Airbed/Kinair st: NotStopd id: Turn t0: [19:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Turns by self st: NotStopd id: Turn t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: calprevflg t0: [21:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [21:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [21:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [21:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: D5W 100.0ml t0: [21:00:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml
id: Service Type t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Risk for Falls t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 u1: BPM st: NotStopd id: Heart Rhythm t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: NBP t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 117 n1: 117 u1: mmHg v2: 79 n2: 79 u2: mmHg st: NotStopd id: Precautions t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: SpO2 t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [22:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [22:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [22:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml
id: D5W 100.0ml t0: [22:30:00 27/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml
id: Fingerstick Glucose t0: [00:00:00 28/02/2016] el: 0 cg: CoWker cu: CSRU v1: 108 n1: 108 rs: Manual st: NotStopd
id: Service Type t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: points st: NotStopd id: HOB t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: BPM st: NotStopd id: Heart Rate t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 115 n1: 115 u1: BPM st: NotStopd id: Heart Rhythm t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: Abdominal Assessment t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: IV #1 Insert Date t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV #4 Insert Date t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 13 n2: 13 st: NotStopd id: IV #4 Site/Size t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: LL Post Forearm v2: 20 gauge st: NotStopd id: Activity t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #1 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV Site Appear #4 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Imp Skin Cleanse #1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soap & H20 st: NotStopd id: Imp Skin Cleanse #3 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Saline st: NotStopd id: ImpSkin Character #1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Character #3 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Laceration st: NotStopd id: ImpSkin Drain/Amt #3 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Sanguinous v2: Scant st: NotStopd id: ImpSkin Drain/Amt#1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: ImpSkin Treatment #1 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Open to Air st: NotStopd id: ImpSkin Treatment #1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Open to Air st: NotStopd id: ImpSkin Treatment #3 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Wet to Dry st: NotStopd id: ImpSkin Wound Base#1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: ImpSkin Wound Base#3 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: ImpSkin Wth/Lth #3 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 0.5 cm v2: 0.5 cm st: NotStopd id: Impaired Skin Site#1 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Inc Dsg/Status #1 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Intact st: NotStopd id: Inc Dsg/Status #1 t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Intact st: NotStopd id: Incision/Wound #1 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Localizes Pain st: NotStopd id: NBP t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 114 n1: 114 u1: mmHg v2: 75 n2: 75 u2: mmHg st: NotStopd id: NBP t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 u1: mmHg v2: 76 n2: 76 u2: mmHg st: NotStopd id: NBP Mean t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Care t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Oral Cavity t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: PostTib. Pulses R/L t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: ABP Alarm (Lo/Hi) t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Moves on Bed st: NotStopd id: RLL Lung Sounds t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Respiratory Pattern t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Respiratory Rate t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Responds to Stimuli t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Side Rails t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Skin Integrity t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: SpO2 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: SpO2 t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Spontaneous Movement t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 36 n1: 36 u1: Deg. C st: NotStopd id: Temperature F t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 96.8 n1: 96.8 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Airbed/Kinair st: NotStopd id: Turn t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Urine Color/Appear t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Back Care t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [23:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [00:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [23:00:00 27/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [00:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: TPN 1000.0ml t0: [23:00:00 27/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Stool Out Stool t0: [00:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Large id: Urine Out Foley t0: [00:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml id: Urine Out Foley t0: [23:00:00 27/02/2016] el: 1 cg: RN cu: CSRU vo: 300 vu: ml
id: Pain Present t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 112 n1: 112 u1: BPM st: NotStopd id: Heart Rhythm t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: NBP t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 107 n1: 107 u1: mmHg v2: 64 n2: 64 u2: mmHg st: NotStopd id: Pain Cause t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: At Rest st: NotStopd id: Precautions t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: SpO2 t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [01:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [01:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 150 vu: ml id: .9% Normal Saline 1000.0ml t0: [01:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [01:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [01:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml
id: Service Type t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: BPM st: NotStopd id: Heart Rhythm t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: mmHg v2: 64 n2: 64 u2: mmHg st: NotStopd id: NBP Mean t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 72 n1: 72 u1: mmHg st: NotStopd id: Precautions t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: SpO2 t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [02:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 50 vu: ml id: .9% Normal Saline 1000.0ml t0: [02:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [02:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [02:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: Service Type t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: BPM st: NotStopd id: Heart Rhythm t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: mmHg v2: 51 n2: 51 u2: mmHg st: NotStopd id: Precautions t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: SpO2 t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [03:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [03:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [03:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [03:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 400 vu: ml
id: WBC (4-11,000) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.3 n1: 7.3 rs: Final st: NotStopd id: WBC t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.3 n1: 7.3 rs: Final st: NotStopd id: Hematocrit t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 30.9 n1: 30.9 u1: % rs: Final st: NotStopd id: Hemoglobin t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 10.8 n1: 10.8 u1: gm/dl rs: Final st: NotStopd id: Platelets t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 177 n1: 177 rs: Final st: NotStopd id: RBC t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.32 n1: 3.32 u1: /mic l rs: Final st: NotStopd id: WBC (4-11,000) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.3 n1: 7.3 rs: Final st: NotStopd
id: Service Type t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Follows Commands t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: Heart Rate t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 89 n1: 89 u1: BPM st: NotStopd id: Heart Rhythm t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#4 Type/Site t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Abdominal Assessment t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: IV #1 Insert Date t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 14 n2: 14 st: NotStopd id: IV #1 Site/Size t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV Site Appear #1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Impaired Skin Site#1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: NBP t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: mmHg v2: 59 n2: 59 u2: mmHg st: NotStopd id: O2 Delivery Device t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Cavity t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: PostTib. Pulses R/L t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Precautions t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RLL Lung Sounds t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Respiratory Pattern t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Responds to Stimuli t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Side Rails t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: Spontaneous Movement t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Urine Color/Appear t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: calprevflg t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: D5W 100.0ml t0: [04:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [04:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [04:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [04:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: IV #4 Insert Date t0: [04:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: IV #4 Site/Size t0: [04:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: IV Site Appear #4 t0: [04:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd
id: BUN t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 11 n1: 11 rs: Final st: NotStopd id: Calcium t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 8.8 n1: 8.8 u1: mg/dl rs: Final st: NotStopd id: Chloride t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 102 n1: 102 rs: Final st: NotStopd id: Creatinine t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.3 n1: 0.3 rs: Final st: NotStopd id: Glucose t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 99 n1: 99 rs: Final st: NotStopd id: Magnesium t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.9 n1: 1.9 rs: Final st: NotStopd id: Phosphorous t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4.4 n1: 4.4 u1: mEq/L rs: Final st: NotStopd id: Potassium t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4.2 n1: 4.2 rs: Final st: NotStopd id: Sodium t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 135 n1: 135 rs: Final st: NotStopd id: BUN (6-20) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 11 n1: 11 rs: Final st: NotStopd id: Calcium (8.4-10.2) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 8.8 n1: 8.8 u1: mg/dl rs: Final st: NotStopd id: Carbon Dioxide t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 26 n1: 26 rs: Final st: NotStopd id: Chloride (100-112) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 102 n1: 102 rs: Final st: NotStopd id: Creatinine (0-1.3) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.3 n1: 0.3 rs: Final st: NotStopd id: Glucose (70-105) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 99 n1: 99 rs: Final st: NotStopd id: Magnesium (1.6-2.6) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.9 n1: 1.9 rs: Final st: NotStopd id: Phosphorous(2.7-4.5) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4.4 n1: 4.4 u1: mEq/L rs: Final st: NotStopd id: Potassium (3.5-5.3) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 4.2 n1: 4.2 rs: Final st: NotStopd id: Sodium (135-148) t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 135 n1: 135 rs: Final st: NotStopd
id: Less Restrict Meas. t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Less Restrict Meas. t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Less Restrict Meas. t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Less Restrict Meas. t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Pain Present t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: IV #4 Reason DC'D t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Routine Change st: NotStopd id: Risk for Falls t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Education Topic #1 t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: GCS Total t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 103 n1: 103 u1: BPM st: NotStopd id: Heart Rhythm t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Imp Skin Cleanse #1 t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soap & H20 st: NotStopd id: Imp Skin Cleanse #1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soap & H20 st: NotStopd id: ImpSkin Character #1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Treatment #1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Open to Air st: NotStopd id: ImpSkin Wound Base#1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: Impaired Skin Site#1 t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#1 t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Impaired Skin Site#3 t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Inc Dsg/Status #1 t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Intact st: NotStopd id: Incision/Wound #1 t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Incision/Wound #1 t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Level of Conscious t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 111 n1: 111 u1: mmHg v2: 78 n2: 78 u2: mmHg st: NotStopd id: NBP Mean t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 86 n1: 86 u1: mmHg st: NotStopd id: Oral Care t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Orientation t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: AntiEmbDevice/Status t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Cause t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: At Rest st: NotStopd id: Pain Location t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Position t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Position Change t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Independent st: NotStopd id: Precautions t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Restraint Location t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [00:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [20:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Support Systems t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Support Systems t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Temp. Site t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 36.1111 n1: 36.1111 u1: Deg. C st: NotStopd id: Temperature F t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Verbal Response t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Back Care t0: [04:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [05:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [02:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [22:00:00 27/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [05:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [05:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [05:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 240 vu: ml
id: Drain Out #1 Jackson Pratt t0: [05:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 5 vu: ml
id: Drain #1 Total Out t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU cv: 5 ac: 24 ap: none re: 0
id: Differential-Bands t0: [03:00:00 28/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1 n1: 1 rs: Final st: NotStopd
id: Fingerstick Glucose t0: [06:00:00 28/02/2016] el: 0 cg: CoWker cu: CSRU v1: 141 n1: 141 rs: Manual st: NotStopd
id: Service Type t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: BPM st: NotStopd id: Heart Rate t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: BPM st: NotStopd id: Heart Rhythm t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Activity t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: NBP t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 117 n1: 117 u1: mmHg v2: 77 n2: 77 u2: mmHg st: NotStopd id: NBP t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 103 n1: 103 u1: mmHg v2: 66 n2: 66 u2: mmHg st: NotStopd id: NBP Mean t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg st: NotStopd id: NBP Mean t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 73 n1: 73 u1: mmHg st: NotStopd id: AntiEmbDevice/Status t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: ABP Alarm (Lo/Hi) t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Respiratory Rate t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: SpO2 t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: SpO2 t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Therapeutic Bed t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: calprevflg t0: [05:30:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [06:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [06:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [06:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [06:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 140 vu: ml
id: Less Restrict Meas. t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Range of Motion t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 103 n1: 103 u1: BPM st: NotStopd id: Heart Rhythm t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: NBP t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 91 n1: 91 u1: mmHg v2: 50 n2: 50 u2: mmHg st: NotStopd id: NBP Mean t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: mmHg st: NotStopd id: Position Change t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: ABP Alarm (Lo/Hi) t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 50 n1: 50 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: Restraint Location t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [07:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [06:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [07:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [07:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml
id: Arterial BP t0: [08:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: Arterial BP Mean t0: [08:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: Temperature C t0: [08:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd
id: Less Restrict Meas. t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Risk for Falls t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Ectopy Frequency t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Barrier t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Given st: NotStopd id: Education Learner t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Reinforced st: NotStopd id: Education Topic #1 t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: Education Topic #2 t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Plan of Care st: NotStopd id: Eye Opening t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: GCS Total t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 115 n1: 115 u1: BPM st: NotStopd id: Heart Rhythm t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV #1 Insert Date t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 17 n2: 17 st: NotStopd id: IV #1 Site/Size t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: Activity t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: IV Site Appear #1 t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Activity Tolerance t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Good st: NotStopd id: Impaired Skin Site#1 t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Level of Conscious t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Confused st: NotStopd id: Motor Response t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 107 n1: 107 u1: mmHg v2: 75 n2: 75 u2: mmHg st: NotStopd id: NBP Mean t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Cavity t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: AntiEmbDevice/Status t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Position Change t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: ABP Alarm (Lo/Hi) t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: HR Alarm (Lo/Hi) t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: Restraint Location t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Skin Integrity t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: % st: NotStopd id: Support Systems t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 35.3333 n1: 35.3333 u1: Deg. C st: NotStopd id: Temperature F t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 95.6 n1: 95.6 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Back Care t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Anxious st: NotStopd id: Pt./Family Informed t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [08:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [08:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [08:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 240 vu: ml
id: Less Restrict Meas. t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [08:15:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [08:15:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Risk for Falls t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Follows Commands t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: Heart Rate t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: BPM st: NotStopd id: Heart Rate t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: BPM st: NotStopd id: Heart Rhythm t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Abdominal Assessment t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Impaired Skin Site#1 t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd id: NBP t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: mmHg v2: 67 n2: 67 u2: mmHg st: NotStopd id: NBP t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 55 n2: 55 u2: mmHg st: NotStopd id: NBP Mean t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 73 n1: 73 u1: mmHg st: NotStopd id: NBP Mean t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 63 n1: 63 u1: mmHg st: NotStopd id: Oral Cavity t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Pain Management t0: [08:15:00 28/02/2016] el: 1 cg: RN cu: CSRU v1: IV Push st: NotStopd id: Position Change t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: NBP Alarm (Lo/Hi) t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RLL Lung Sounds t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Reason For Restraint t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: Respiratory Rate t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Responds to Stimuli t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Integrity t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: SpO2 t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: SpO2 t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Spontaneous Movement t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Urine Color/Appear t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: calprevflg t0: [09:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd id: Pt./Family Informed t0: [10:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [08:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: D5W 100.0ml t0: [08:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml id: D5W 100.0ml t0: [10:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: .9% Normal Saline 1000.0ml t0: [09:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [10:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [09:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: TPN 1000.0ml t0: [10:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Urine Out Foley t0: [10:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 155 vu: ml
id: Pain Present t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Care t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Eye Opening t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: points st: NotStopd id: Heart Rate t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 103 n1: 103 u1: BPM st: NotStopd id: Heart Rhythm t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Activity t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Chair st: NotStopd id: Activity Tolerance t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Fair st: NotStopd id: Level of Conscious t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Confused st: NotStopd id: Motor Response t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 113 n1: 113 u1: mmHg v2: 78 n2: 78 u2: mmHg st: NotStopd id: NBP Mean t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 86 n1: 86 u1: mmHg st: NotStopd id: Oral Care t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Orientation t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: Pain Management t0: [11:00:00 28/02/2016] el: 1 cg: RN cu: CSRU v1: IV Push st: NotStopd id: Assistance Device t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Pattern t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Responds to Stimuli t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Skin Care t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Spontaneous Movement t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Verbal Response t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Oriented st: NotStopd id: Back Care t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [11:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Anxious st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [11:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [11:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml id: Stool Out Stool t0: [08:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Small id: Urine Out Foley t0: [11:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 155 vu: ml
id: Service Type t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Risk for Falls t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: BPM st: NotStopd id: Heart Rhythm t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV #1 Insert Date t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 17 n2: 17 st: NotStopd id: IV #1 Site/Size t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: Activity t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Chair st: NotStopd id: IV Site Appear #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: NBP t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 115 n1: 115 u1: mmHg v2: 75 n2: 75 u2: mmHg st: NotStopd id: NBP Mean t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Precautions t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: SpO2 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: INV#4 Cap Change t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: calprevflg t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [12:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: TPN 1000.0ml t0: [12:00:00 28/02/2016] el: 1 ai: 304 cg: RN cu: CSRU vo: 42 vu: ml
id: IV Infusion In Total t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: 10 cv: 1590 ac: 24 ap: none re: 0 id: IV Nutrition Total t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: 75 cv: 1239 ac: 24 ap: none re: 0
pi: 4541984 hi: 27155 t0: [13:00:00 28/02/2016] pt: TPN st: Expired
id: Less Restrict Meas. t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Range of Motion t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Circulation/SkinInt t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Diet Type t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Education Barrier t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Given st: NotStopd id: Education Learner t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Reinforced st: NotStopd id: Education Topic #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: Education Topic #2 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Impaired Skin Site#1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Level of Conscious t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Confused st: NotStopd id: Motor Response t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Oral Cavity t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: Position Change t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Reason For Restraint t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Responds to Stimuli t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: Spontaneous Movement t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Temperature C (calc) t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 36.8889 n1: 36.8889 u1: Deg. C st: NotStopd id: Temperature F t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98.4 n1: 98.4 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Behavior t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Anxious st: NotStopd id: Pt./Family Informed t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: Urine Out Foley t0: [12:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 65 vu: ml
id: Urine Out Total t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: 120 cv: 3125 ac: 24 ap: none re: 0
id: Dorsal PedPulse R/L t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Weak Palpable v2: Weak Palpable st: NotStopd id: Abdominal Assessment t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: LLL Lung Sounds t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LUL Lung Sounds t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: RLL Lung Sounds t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RUL Lung Sounds t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Bowel Sounds t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: Pain Present t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Imp Skin Cleanse #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soap & H20 st: NotStopd id: Imp Skin Cleanse #3 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Saline st: NotStopd id: ImpSkin Character #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Character #3 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Drain/Amt #3 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: ImpSkin Treatment #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Open to Air st: NotStopd id: ImpSkin Treatment #3 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg st: NotStopd id: ImpSkin Wound Base#1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: ImpSkin Wound Base#3 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pink st: NotStopd id: ImpSkin Wth/Lth #3 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 cm v2: 1 cm st: NotStopd id: Inc Cleansing #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Saline st: NotStopd id: Inc Drainage/Amt #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Green v2: Scant st: NotStopd id: Inc Dsg/Status #1 t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Changed st: NotStopd id: Pain Management t0: [12:00:00 28/02/2016] el: 1 cg: RN cu: CSRU v1: IV Push st: NotStopd id: Fingerstick Glucose t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 116 n1: 116 rs: Manual st: NotStopd id: Braden Activity t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Chairfast st: NotStopd id: Braden Frict/Shear t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd id: Braden Moisture t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Prob. Inadequate st: NotStopd id: Braden Score t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: number st: NotStopd id: Braden SensoryPercep t0: [12:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd
id: Gastric Meds t0: [08:00:00 28/02/2016] el: 2 ai: 155 cg: RN cu: CSRU vo: 60 vu: ml id: Stool Out Stool t0: [12:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Medium
id: 24h Total In t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: 85 cv: 2889 ac: 24 ap: none re: 0 id: PO/Gastric In Total t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU cv: 60 ac: 24 ap: none re: 0 id: Stool Out Total t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU cv: 0 ac: 24 ap: carryForward re: 0 id: Total Hourly Output t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: 120 cv: 120 ac: 1 ap: none re: 0 id: 24h Net Body Balance t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: -35 cv: -241 ac: 24 ap: carryForward re: 0 id: LOS Net Body Balance t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: -35 cv: 3524.1 ac: multiple days ap: carryForward re: 0 id: Net Hourly Balance t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: -35 cv: -35 ac: 1 ap: none re: 0 id: 24h Total Out t0: [23:00:00 28/02/2016] el: 3 cg: RN cu: CSRU pv: 120 cv: 3130 ac: 24 ap: carryForward re: 0
id: D5W 250.0ml + 8mcgkgmin Levophed-k t0: [14:00:00 28/02/2016] el: 2 ai: 210 cg: -1 cu: CSRU vo: 0 st: D/C'd id: .9% Normal Saline 50.0ml + 50mghr Midazolam t0: [14:00:00 28/02/2016] el: 1 ai: 274 cg: -1 cu: CSRU vo: 0 st: D/C'd
id: Less Restrict Meas. t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Range of Motion t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Risk for Falls t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Education Barrier t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Education Handout t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Given st: NotStopd id: Education Learner t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sig Othr/Family st: NotStopd id: Education Method t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Understands st: NotStopd id: Education Topic #1 t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #2 t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Family Communication t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Family Called st: NotStopd id: HOB t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 91 n1: 91 u1: BPM st: NotStopd id: Heart Rate t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 89 n1: 89 u1: BPM st: NotStopd id: Heart Rhythm t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Fair st: NotStopd id: Impaired Skin Site#1 t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Level of Conscious t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd id: NBP t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 62 n2: 62 u2: mmHg st: NotStopd id: NBP t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: mmHg v2: 64 n2: 64 u2: mmHg st: NotStopd id: NBP Mean t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 68 n1: 68 u1: mmHg st: NotStopd id: NBP Mean t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 73 n1: 73 u1: mmHg st: NotStopd id: AntiEmbDevice/Status t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Position Change t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: NBP Alarm (Lo/Hi) t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 22 n1: 22 u1: BPM st: NotStopd id: Respiratory Rate t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Restraint Location t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Skin Color t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: SpO2 t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Therapeutic Bed t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Back Care t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [13:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd id: Pt./Family Informed t0: [14:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: TPN 1800.0ml t0: [13:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 42 vu: ml id: TPN 1800.0ml t0: [14:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 42 vu: ml id: .9% Normal Saline 1000.0ml t0: [13:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [14:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: Urine Out Foley t0: [15:00:00 28/02/2016] el: 1 cg: CoWker cu: CSRU vo: 340 vu: ml
id: Service Type t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Ectopy Frequency t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Opening t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: BPM st: NotStopd id: Heart Rhythm t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Abdominal Assessment t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Fair st: NotStopd id: Level of Conscious t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Confused st: NotStopd id: Motor Response t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: mmHg v2: 66 n2: 66 u2: mmHg st: NotStopd id: NBP Mean t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 74 n1: 74 u1: mmHg st: NotStopd id: Oral Cavity t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: AntiEmbDevice/Status t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Pattern t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Responds to Stimuli t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Skin Care t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Spontaneous Movement t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Temp. Site t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 37.1667 n1: 37.1667 u1: Deg. C st: NotStopd id: Temperature F t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98.9 n1: 98.9 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Back Care t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Anxious st: NotStopd id: Bowel Sounds t0: [15:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: TPN 1800.0ml t0: [15:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 42 vu: ml id: .9% Normal Saline 1000.0ml t0: [15:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Stool Out Stool t0: [15:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Small
id: INV#4Chg o/Wire Date t0: [15:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: INV Line#4 Site Date t0: [15:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd
id: Less Restrict Meas. t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Incr Visibility st: NotStopd id: Pain Present t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Risk for Falls t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Education Barrier t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Given st: NotStopd id: Education Learner t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Reinforced st: NotStopd id: Education Topic #1 t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: Family Communication t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Family Called st: NotStopd id: Heart Rate t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: BPM st: NotStopd id: Heart Rhythm t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: IV #1 Insert Date t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 17 n2: 17 st: NotStopd id: IV #1 Site/Size t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Hand v2: 20 gauge st: NotStopd id: IV Site Appear #1 t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Impaired Skin Site#1 t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Level of Conscious t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Confused st: NotStopd id: NBP t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: mmHg v2: 69 n2: 69 u2: mmHg st: NotStopd id: NBP Mean t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 76 n1: 76 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Pain Management t0: [16:00:00 28/02/2016] el: 1 cg: RN cu: CSRU v1: IV Push st: NotStopd id: Position Change t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: Restraint Location t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Support Systems t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: calprevflg t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Anxious st: NotStopd id: Pt./Family Informed t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: D5W 100.0ml t0: [16:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [16:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 42 vu: ml id: .9% Normal Saline 1000.0ml t0: [16:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [16:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 110 vu: ml
id: Dorsal PedPulse R/L t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Weak Palpable v2: Weak Palpable st: NotStopd id: LLL Lung Sounds t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LUL Lung Sounds t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: RLL Lung Sounds t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RUL Lung Sounds t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd
id: Service Type t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 106 n1: 106 u1: BPM st: NotStopd id: Heart Rhythm t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: NBP t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 91 n1: 91 u1: mmHg v2: 57 n2: 57 u2: mmHg st: NotStopd id: NBP Mean t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 65 n1: 65 u1: mmHg st: NotStopd id: Precautions t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: SpO2 t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: calprevflg t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: .9% Normal Saline 1000.0ml t0: [17:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: IV #1 Reason DC'D t0: [17:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: IV #1 D/C Date t0: [17:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: IV #1 Insert Date t0: [17:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: IV #1 Site/Size t0: [17:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd id: IV Site Appear #1 t0: [17:00:00 28/02/2016] el: 0 cg: -1 cu: CSRU st: D/C'd
io: TPN 1800.0ml el: 1 cg: RN cu: CSRU lo: Left Subclavian ra: 75 ru: ml/hr
id: HOB t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Activity t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Good st: NotStopd id: AntiEmbDevice/Status t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Assistance Device t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Skin Care t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Therapeutic Bed t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Back Care t0: [17:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd
id: TPN 1800.0ml t0: [17:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml nb: 1 id: Stool Out Stool t0: [17:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Small id: Urine Out Foley t0: [17:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: IV #1 Reason DC'D t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: IV #1 D/C Date t0: [16:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd
id: Less Restrict Meas. t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Range of Motion t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Risk for Falls t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Opening t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: GCS Total t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Heart Rate t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: BPM st: NotStopd id: Heart Rhythm t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Level of Conscious t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Confused st: NotStopd id: Motor Response t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: mmHg v2: 64 n2: 64 u2: mmHg st: NotStopd id: NBP Mean t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 73 n1: 73 u1: mmHg st: NotStopd id: Orientation t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: Position Change t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Removed x 5 Mins t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: Restraint Location t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Behavior Conts st: NotStopd id: Side Rails t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Support Systems t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Verbal Response t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Anxious st: NotStopd id: Pt./Family Informed t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: TPN 1800.0ml t0: [18:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [18:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
pi: 4542873 hi: 27155 t0: [19:00:00 28/02/2016] tf: [18:00:00 29/02/2016] pt: IV Large Volume st: Expired rt: IV fr: ONCE ds: 20 iv: Amino Acid 4.25% with Electrolytes in 5% Dextrose 1000 ml dn: 1 dt: 1 di: Doses xu: Enter on Label pi: 4542874 hi: 27155 t0: [19:00:00 28/02/2016] tf: [12:00:00 01/03/2016] mn: Fentanyl Patch pt: Unit Dose st: Inactive (Due to a change order) rt: TP fr: Q72H dn: 0 di: Ongoing xv: 36 xu: Hours
id: Fingerstick Glucose t0: [18:00:00 28/02/2016] el: 0 cg: CoWker cu: CSRU v1: 165 n1: 165 rs: Manual st: NotStopd
id: Urine Out Foley t0: [18:00:00 28/02/2016] el: 1 cg: CoWker cu: CSRU vo: 100 vu: ml
id: Service Type t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Follows Commands t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: Heart Rate t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Level of Conscious t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd id: NBP t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 56 n2: 56 u2: mmHg st: NotStopd id: NBP Mean t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 64 n1: 64 u1: mmHg st: NotStopd id: Precautions t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Pattern t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: Responds to Stimuli t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: SpO2 t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: Spontaneous Movement t0: [18:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: calprevflg t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [19:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd
id: TPN 1800.0ml t0: [19:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [19:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: Less Restrict Meas. t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Risk for Falls t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: Eye Opening t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: BPM st: NotStopd id: Heart Rhythm t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#4 Type/Site t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Abdominal Assessment t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Impaired Skin Site#1 t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg v2: 67 n2: 67 u2: mmHg st: NotStopd id: O2 Delivery Device t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Care t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Oral Cavity t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Location t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Position t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 Person Assist st: NotStopd id: Precautions t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RLL Lung Sounds t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Reason For Restraint t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 20 n1: 20 u1: BPM st: NotStopd id: Responds to Stimuli t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Spontaneous Movement t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 36.6667 n1: 36.6667 u1: Deg. C st: NotStopd id: Temperature F t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Urine Color/Appear t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: Braden Activity t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd id: Braden Moisture t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Adequate st: NotStopd id: Braden Score t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: number st: NotStopd id: Braden SensoryPercep t0: [20:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Very Limited st: NotStopd
id: D5W 100.0ml t0: [20:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml id: TPN 1800.0ml t0: [20:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [20:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [20:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 240 vu: ml
id: Service Type t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: BPM st: NotStopd id: Heart Rhythm t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 102 n1: 102 u1: mmHg v2: 72 n2: 72 u2: mmHg st: NotStopd id: NBP Mean t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 80 n1: 80 u1: mmHg st: NotStopd id: Precautions t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 21 n1: 21 u1: BPM st: NotStopd id: SpO2 t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [21:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [21:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 150 vu: ml id: TPN 1800.0ml t0: [21:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [21:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Stool Out Stool t0: [21:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Medium id: Urine Out Foley t0: [21:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: Less Restrict Meas. t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Range of Motion t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: bath t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: done id: Service Type t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: HOB t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: BPM st: NotStopd id: Heart Rhythm t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Activity t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Imp Skin Cleanse #1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soap & H20 st: NotStopd id: Imp Skin Cleanse #3 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Saline st: NotStopd id: ImpSkin Character #1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Character #3 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Drain/Amt #3 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: ImpSkin Drain/Amt#1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: ImpSkin Wound Base#1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: ImpSkin Wound Base#3 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Pink st: NotStopd id: Impaired Skin Site#1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Inc Closure/Appear#1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks v2: Pink st: NotStopd id: Inc Drainage/Amt #1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Green v2: Scant st: NotStopd id: Inc Dsg/Status #1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Changed st: NotStopd id: Incision/Wound #1 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: NBP t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg v2: 69 n2: 69 u2: mmHg st: NotStopd id: NBP Mean t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 78 n1: 78 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: AntiEmbDevice/Status t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Position Change t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 21 n1: 21 u1: BPM st: NotStopd id: Restraint Location t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Skin Integrity t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Support Systems t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Therapeutic Bed t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Back Care t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: D5W 100.0ml t0: [22:00:00 28/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [22:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [22:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [22:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 60 vu: ml
id: Service Type t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: BPM st: NotStopd id: Heart Rhythm t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: NBP t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 122 n1: 122 u1: mmHg v2: 79 n2: 79 u2: mmHg st: NotStopd id: Precautions t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 23 n1: 23 u1: BPM st: NotStopd id: SpO2 t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: calprevflg t0: [23:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [23:00:00 28/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [23:00:00 28/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [23:00:00 28/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: Fingerstick Glucose t0: [00:00:00 29/02/2016] el: 0 cg: CoWker cu: CSRU v1: 117 n1: 117 rs: Manual st: NotStopd
id: Pain Present t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Risk for Falls t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: Eye Opening t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: points st: NotStopd id: HOB t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 118 n1: 118 u1: BPM st: NotStopd id: Heart Rhythm t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Abdominal Assessment t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: ImpSkin Treatment #1 t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Open to Air st: NotStopd id: Impaired Skin Site#1 t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Inc Dsg/Status #1 t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg st: NotStopd id: Incision/Wound #1 t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Confused st: NotStopd id: Motor Response t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Localizes Pain st: NotStopd id: NBP t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 11 n1: 11 u1: mmHg v2: 80 n2: 80 u2: mmHg st: NotStopd id: Oral Care t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Oral Cavity t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: AntiEmbDevice/Status t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Location t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Position t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Respiratory Pattern t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 21 n1: 21 u1: BPM st: NotStopd id: Responds to Stimuli t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Side Rails t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Color t0: [22:00:00 28/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Integrity t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Spontaneous Movement t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 37 n1: 37 u1: Deg. C st: NotStopd id: Temperature F t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98.6 n1: 98.6 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Urine Color/Appear t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: TPN 1800.0ml t0: [00:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [00:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: Urine Out Foley t0: [00:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml
id: Service Type t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: BPM st: NotStopd id: Heart Rhythm t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 115 n1: 115 u1: mmHg v2: 73 n2: 73 u2: mmHg st: NotStopd id: NBP Mean t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: mmHg st: NotStopd id: Precautions t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: SpO2 t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [01:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [01:00:00 29/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 150 vu: ml id: TPN 1800.0ml t0: [01:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [01:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [01:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: Less Restrict Meas. t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: Heart Rate t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: BPM st: NotStopd id: Heart Rhythm t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Impaired Skin Site#1 t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: NBP t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: mmHg v2: 58 n2: 58 u2: mmHg st: NotStopd id: Pain Location t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Position Change t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: Restraint Location t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Support Systems t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: calprevflg t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: TPN 1800.0ml t0: [02:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [02:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [02:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 45 vu: ml
id: Service Type t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 89 n1: 89 u1: BPM st: NotStopd id: Heart Rhythm t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: mmHg v2: 61 n2: 61 u2: mmHg st: NotStopd id: NBP Mean t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 70 n1: 70 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Precautions t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: SpO2 t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [03:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [02:00:00 29/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 50 vu: ml id: TPN 1800.0ml t0: [03:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [03:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [03:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 400 vu: ml
id: WBC (4-11,000) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.1 n1: 7.1 rs: Final st: NotStopd id: WBC t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.1 n1: 7.1 rs: Final st: NotStopd id: Hematocrit t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 30.8 n1: 30.8 u1: % rs: Final st: NotStopd id: Hemoglobin t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 10.7 n1: 10.7 u1: gm/dl rs: Final st: NotStopd id: Platelets t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 196 n1: 196 rs: Final st: NotStopd id: RBC t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.28 n1: 3.28 u1: /mic l rs: Final st: NotStopd id: WBC (4-11,000) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 7.1 n1: 7.1 rs: Final st: NotStopd
id: Service Type t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: BPM st: NotStopd id: Heart Rhythm t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Precautions t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 22 n1: 22 u1: BPM st: NotStopd id: SpO2 t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: % st: NotStopd id: calprevflg t0: [03:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: Service Type t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: Eye Opening t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: points st: NotStopd id: Heart Rate t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: BPM st: NotStopd id: Heart Rhythm t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Abdominal Assessment t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: ImpSkin Treatment #1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Open to Air st: NotStopd id: Impaired Skin Site#1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Inc Dsg/Status #1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Intact st: NotStopd id: Incision/Wound #1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Confused st: NotStopd id: Motor Response t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Localizes Pain st: NotStopd id: NBP t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 106 n1: 106 u1: mmHg v2: 72 n2: 72 u2: mmHg st: NotStopd id: O2 Delivery Device t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Oral Care t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Oral Cavity t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 1 st: NotStopd id: PostTib. Pulses R/L t0: [00:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: PostTib. Pulses R/L t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Precautions t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Lifts and Holds st: NotStopd id: RUL Lung Sounds t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Respiratory Pattern t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: Responds to Stimuli t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Side Rails t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: % st: NotStopd id: Spontaneous Movement t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Sputum Color/Consist t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: White v2: Thick st: NotStopd id: Sputum Source/Amt t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Expectorated v2: Small st: NotStopd id: Support Systems t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 36.5556 n1: 36.5556 u1: Deg. C st: NotStopd id: Temperature F t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97.8 n1: 97.8 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: D5W 100.0ml t0: [04:00:00 29/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [04:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [04:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [04:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: Drain Out #1 Jackson Pratt t0: [04:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 20 vu: ml
id: Drain #1 Total Out t0: [23:00:00 29/02/2016] el: 3 cg: RN cu: CSRU cv: 35 ac: 24 ap: none re: 0
id: BUN t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 11 n1: 11 rs: Final st: NotStopd id: Calcium t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 8.7 n1: 8.7 u1: mg/dl rs: Final st: NotStopd id: Chloride t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 99 n1: 99 rs: Final st: NotStopd id: Creatinine t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.4 n1: 0.4 rs: Final st: NotStopd id: Glucose t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 133 n1: 133 rs: Final st: NotStopd id: Magnesium t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 2 n1: 2 rs: Final st: NotStopd id: Phosphorous t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.8 n1: 3.8 u1: mEq/L rs: Final st: NotStopd id: Potassium t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.6 n1: 3.6 rs: Final st: NotStopd id: Sodium t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 131 n1: 131 rs: Final st: NotStopd id: BUN (6-20) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 11 n1: 11 rs: Final st: NotStopd id: Calcium (8.4-10.2) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 8.7 n1: 8.7 u1: mg/dl rs: Final st: NotStopd id: Carbon Dioxide t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 23 n1: 23 rs: Final st: NotStopd id: Chloride (100-112) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 99 n1: 99 rs: Final st: NotStopd id: Creatinine (0-1.3) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 0.4 n1: 0.4 rs: Final st: NotStopd id: Glucose (70-105) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 133 n1: 133 rs: Final st: NotStopd id: Magnesium (1.6-2.6) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 2 n1: 2 rs: Final st: NotStopd id: Phosphorous(2.7-4.5) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.8 n1: 3.8 u1: mEq/L rs: Final st: NotStopd id: Potassium (3.5-5.3) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 3.6 n1: 3.6 rs: Final st: NotStopd id: Sodium (135-148) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 131 n1: 131 rs: Final st: NotStopd
id: PT t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 15.4 n1: 15.4 rs: Final st: NotStopd id: INR t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.4 n1: 1.4 rs: Final st: NotStopd id: PTT t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 36.3 n1: 36.3 rs: Final st: NotStopd id: INR (2-4 ref. range) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 1.4 n1: 1.4 rs: Final st: NotStopd id: PT(11-13.5) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 15.4 n1: 15.4 rs: Final st: NotStopd id: PTT(22-35) t0: [02:51:00 29/02/2016] el: 0 cg: 3161 cu: CSRU v1: 36.3 n1: 36.3 rs: Final st: NotStopd
id: Radiologic Study t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Chest Xray st: NotStopd
id: Stool Out Stool t0: [04:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Medium
id: Pain Present t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: HOB t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: HOB t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: BPM st: NotStopd id: Heart Rhythm t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Activity t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Activity Tolerance t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Imp Skin Cleanse #1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soap & H20 st: NotStopd id: ImpSkin Character #1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Drain/Amt#1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: ImpSkin Wound Base#1 t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: NBP t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: mmHg v2: 55 n2: 55 u2: mmHg st: NotStopd id: AntiEmbDevice/Status t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: AntiEmbDevice/Status t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Location t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Position t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 Person Assist st: NotStopd id: Assistance Device t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 23 n1: 23 u1: BPM st: NotStopd id: Skin Care t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Therapeutic Bed t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Therapeutic Bed t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [02:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Turn t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Back Care t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [05:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [05:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [05:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [05:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 140 vu: ml
id: Fingerstick Glucose t0: [06:00:00 29/02/2016] el: 0 cg: CoWker cu: CSRU v1: 139 n1: 139 rs: Manual st: NotStopd
id: Less Restrict Meas. t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Less Restrict Meas. t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Medicated st: NotStopd id: Range of Motion t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Service Type t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coping st: NotStopd id: Heart Rate t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 91 n1: 91 u1: BPM st: NotStopd id: Heart Rhythm t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Impaired Skin Site#1 t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: NBP t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: mmHg v2: 59 n2: 59 u2: mmHg st: NotStopd id: NBP Mean t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 68 n1: 68 u1: mmHg st: NotStopd id: Position Change t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Precautions t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 20 n1: 20 u1: BPM st: NotStopd id: Restraint Location t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [04:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Support Systems t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: calprevflg t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [06:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: D5W 100.0ml t0: [06:00:00 29/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [06:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [06:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [06:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: Service Type t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg v2: 64 n2: 64 u2: mmHg st: NotStopd id: NBP Mean t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 82 n1: 82 u1: mmHg st: NotStopd id: Precautions t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 20 n1: 20 u1: BPM st: NotStopd id: SpO2 t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [07:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [07:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [07:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [07:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: Less Restrict Meas. t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Incr Visibility st: NotStopd id: Pain Present t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Range of Motion t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [07:30:00 29/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Barrier t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Not Given st: NotStopd id: Education Learner t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Understands st: NotStopd id: Education Topic #1 t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #2 t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: BPM st: NotStopd id: Heart Rhythm t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: Abdominal Assessment t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Impaired Skin Site#1 t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 114 n1: 114 u1: mmHg v2: 82 n2: 82 u2: mmHg st: NotStopd id: NBP Mean t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 88 n1: 88 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Oral Cavity t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 3 st: NotStopd id: AntiEmbDevice/Status t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Location t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Position t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Clear st: NotStopd id: Reason For Restraint t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 24 n1: 24 u1: BPM st: NotStopd id: Responds to Stimuli t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Flushed st: NotStopd id: Skin Temp/Condition t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: % st: NotStopd id: Spontaneous Movement t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 35.6111 n1: 35.6111 u1: Deg. C st: NotStopd id: Temperature F t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 96.1 n1: 96.1 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: TPN 1800.0ml t0: [07:30:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 37.5 vu: ml id: .9% Normal Saline 1000.0ml t0: [07:30:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: Urine Out Foley t0: [07:30:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 160 vu: ml
id: Pain Level t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 6-Mod to Severe st: NotStopd id: Pain Present t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [09:00:00 29/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: BPM st: NotStopd id: Heart Rate t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: BPM st: NotStopd id: Heart Rhythm t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: Heart Rhythm t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 107 n1: 107 u1: mmHg v2: 76 n2: 76 u2: mmHg st: NotStopd id: NBP t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg v2: 74 n2: 74 u2: mmHg st: NotStopd id: NBP Mean t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: mmHg st: NotStopd id: NBP Mean t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: mmHg st: NotStopd id: Pain Cause t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: At Rest st: NotStopd id: Pain Level (Rest) t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 6-Mod to Severe st: NotStopd id: Pain Location t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Pain Type t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Aching st: NotStopd id: Precautions t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: NBP Alarm (Lo/Hi) t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 22 n1: 22 u1: BPM st: NotStopd id: Respiratory Rate t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 25 n1: 25 u1: BPM st: NotStopd id: SpO2 t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: SpO2 t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [08:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [08:00:00 29/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml id: TPN 1800.0ml t0: [08:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 37.5 vu: ml id: TPN 1800.0ml t0: [09:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [08:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 5 vu: ml id: .9% Normal Saline 1000.0ml t0: [09:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [09:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 180 vu: ml
id: HOB t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Activity t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Oral Care t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: AntiEmbDevice/Status t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Assistance Device t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Therapeutic Bed t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [09:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd
id: Po Intake t0: [09:00:00 29/02/2016] el: 2 ai: 155 cg: RN cu: CSRU vo: 60 vu: ml
id: PO/Gastric In Total t0: [23:00:00 29/02/2016] el: 3 cg: RN cu: CSRU cv: 60 ac: 24 ap: none re: 0
id: Service Type t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 102 n1: 102 u1: BPM st: NotStopd id: Heart Rhythm t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: NBP t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 108 n1: 108 u1: mmHg v2: 75 n2: 75 u2: mmHg st: NotStopd id: NBP Mean t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: mmHg st: NotStopd id: Precautions t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 21 n1: 21 u1: BPM st: NotStopd id: SpO2 t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [10:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [10:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: D5W 100.0ml t0: [10:00:00 29/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: Urine Out Foley t0: [10:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml
id: Service Type t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 u1: BPM st: NotStopd id: Heart Rhythm t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: NBP t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 u1: mmHg v2: 72 n2: 72 u2: mmHg st: NotStopd id: NBP Mean t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 79 n1: 79 u1: mmHg st: NotStopd id: Precautions t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 21 n1: 21 u1: BPM st: NotStopd id: SpO2 t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: calprevflg t0: [10:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: Urine Out Foley t0: [10:30:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml
id: Service Type t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 u1: BPM st: NotStopd id: Heart Rhythm t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 102 n1: 102 u1: mmHg v2: 78 n2: 78 u2: mmHg st: NotStopd id: NBP Mean t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: mmHg st: NotStopd id: Precautions t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: SpO2 t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [11:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sleeping st: NotStopd
id: TPN 1800.0ml t0: [11:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [11:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: Less Restrict Meas. t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [12:00:00 29/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Eye Opening t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Inconsistently st: NotStopd id: GCS Total t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 107 n1: 107 u1: BPM st: NotStopd id: Heart Rhythm t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Abdominal Assessment t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Imp Skin Cleanse #1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soap & H20 st: NotStopd id: ImpSkin Character #1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Drain/Amt#1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: ImpSkin Treatment #1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: ImpSkin Wound Base#1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Red st: NotStopd id: Impaired Skin Site#1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Inc Cleansing #1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Saline st: NotStopd id: Inc Closure/Appear#1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Approximated v2: Clean and Dry st: NotStopd id: Inc Drainage/Amt #1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Purulent st: NotStopd id: Inc Dsg/Status #1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Dry Sterile Dsg v2: Intact st: NotStopd id: Incision/Wound #1 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 104 n1: 104 u1: mmHg v2: 73 n2: 73 u2: mmHg st: NotStopd id: NBP Mean t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Oral Cavity t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Location t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Type t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Position t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 27 n1: 27 u1: BPM st: NotStopd id: Responds to Stimuli t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Skin Integrity t0: [07:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Skin Integrity t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: SpO2 t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Spontaneous Movement t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 36.2222 n1: 36.2222 u1: Deg. C st: NotStopd id: Temperature F t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97.2 n1: 97.2 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Back Care t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Pt./Family Informed t0: [10:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: Braden Activity t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd id: Braden Moisture t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Prob. Inadequate st: NotStopd id: Braden Score t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: number st: NotStopd id: Braden SensoryPercep t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Sl. Limited st: NotStopd
id: TPN 1800.0ml t0: [12:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: TPN 1800.0ml t0: [13:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [12:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [13:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [12:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 90 vu: ml id: Urine Out Foley t0: [13:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 90 vu: ml
id: IV Infusion In Total t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 10 cv: 1440 ac: 24 ap: none re: 0 id: IV Nutrition Total t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 75 cv: 1800 ac: 24 ap: none re: 0 id: 24h Total In t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 85 cv: 3300 ac: 24 ap: none re: 0 id: Urine Out Total t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 80 cv: 3135 ac: 24 ap: none re: 0
pi: 4544662 hi: 27155 t0: [14:00:00 29/02/2016] pt: TPN st: Expired
id: Service Type t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: BPM st: NotStopd id: Heart Rhythm t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg v2: 73 n2: 73 u2: mmHg st: NotStopd id: NBP Mean t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 80 n1: 80 u1: mmHg st: NotStopd id: Precautions t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 20 n1: 20 u1: BPM st: NotStopd id: SpO2 t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [13:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Fingerstick Glucose t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 149 n1: 149 rs: Manual st: NotStopd
id: Stool Out Stool t0: [12:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vu: ml es: Medium
id: Stool Out Total t0: [23:00:00 29/02/2016] el: 3 cg: RN cu: CSRU cv: 0 ac: 24 ap: carryForward re: 0
id: Service Type t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: BPM st: NotStopd id: Heart Rhythm t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 105 n1: 105 u1: mmHg v2: 35 n2: 35 u2: mmHg st: NotStopd id: NBP Mean t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 54 n1: 54 u1: mmHg st: NotStopd id: Precautions t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 19 n1: 19 u1: BPM st: NotStopd id: SpO2 t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [14:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [14:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [14:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 160 vu: ml
id: Pain Level t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 6-Mod to Severe st: NotStopd id: Pain Present t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Assess Method t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Riker-SAS Scale t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [14:30:00 29/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: NBP t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: mmHg v2: 67 n2: 67 u2: mmHg st: NotStopd id: Pain Cause t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: At Rest st: NotStopd id: Pain Level (Rest) t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 6-Mod to Severe st: NotStopd id: Pain Location t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Other/Remarks st: NotStopd id: Pain Management t0: [14:30:00 29/02/2016] el: 1 cg: RN cu: CSRU v1: IV Push st: NotStopd id: Pain Type t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Aching st: NotStopd id: Respiratory Rate t0: [14:30:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 21 n1: 21 u1: BPM st: NotStopd
id: Service Type t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 89 n1: 89 u1: BPM st: NotStopd id: Heart Rhythm t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Level of Conscious t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Dozing Intermit st: NotStopd id: NBP t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 110 n1: 110 u1: mmHg v2: 71 n2: 71 u2: mmHg st: NotStopd id: NBP Mean t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 78 n1: 78 u1: mmHg st: NotStopd id: Precautions t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 22 n1: 22 u1: BPM st: NotStopd id: SpO2 t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [15:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [15:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [15:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 70 vu: ml
id: Less Restrict Meas. t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [16:00:00 29/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Eye Opening t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Family Communication t0: [12:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Family Called st: NotStopd id: Follows Commands t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: points st: NotStopd id: HOB t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: BPM st: NotStopd id: Heart Rhythm t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#4 Type/Site t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Impaired Skin Site#1 t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 110 n1: 110 u1: mmHg v2: 81 n2: 81 u2: mmHg st: NotStopd id: NBP Mean t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 86 n1: 86 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Oral Cavity t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 3 st: NotStopd id: AntiEmbDevice/Status t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Location t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Type t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Position t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Position Change t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 22 n1: 22 u1: BPM st: NotStopd id: Responds to Stimuli t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 u1: % st: NotStopd id: Spontaneous Movement t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Axillary st: NotStopd id: Temperature C (calc) t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 36.1667 n1: 36.1667 u1: Deg. C st: NotStopd id: Temperature F t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 97.1 n1: 97.1 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [15:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 5 Oriented st: NotStopd id: calprevflg t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd id: Pt./Family Informed t0: [14:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: intact
id: D5W 100.0ml t0: [16:00:00 29/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [16:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [16:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [16:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 180 vu: ml id: Drain Out #1 Jackson Pratt t0: [16:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 15 vu: ml
id: Service Type t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: BPM st: NotStopd id: Heart Rhythm t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: mmHg v2: 83 n2: 83 u2: mmHg st: NotStopd id: NBP Mean t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 87 n1: 87 u1: mmHg st: NotStopd id: Precautions t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 21 n1: 21 u1: BPM st: NotStopd id: SpO2 t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 94 n1: 94 u1: % st: NotStopd id: calprevflg t0: [17:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [17:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [17:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [17:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 160 vu: ml
pi: 4545373 hi: 27155 t0: [19:00:00 29/02/2016] tf: [18:00:00 01/03/2016] mn: Lidocaine 1% pt: Unit Dose st: Expired rt: SC fr: ONCE ds: 19 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
id: Less Restrict Meas. t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [18:00:00 29/02/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Education Barrier t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Not Given st: NotStopd id: Education Learner t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Understands st: NotStopd id: Education Topic #2 t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Activity st: NotStopd id: Eye Care t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: HOB t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: BPM st: NotStopd id: Heart Rhythm t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: NBP t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 118 n1: 118 u1: mmHg v2: 76 n2: 76 u2: mmHg st: NotStopd id: NBP Mean t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Nasal Cannula st: NotStopd id: O2 Flow (lpm) t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 u1: lpm st: NotStopd id: Oral Care t0: [16:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: AntiEmbDevice/Status t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Location t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Type t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Position t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Reason For Restraint t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Rate t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 23 n1: 23 u1: BPM st: NotStopd id: Restraint Location t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: SpO2 t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Therapeutic Bed t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: calprevflg t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Pt./Family Informed t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Fingerstick Glucose t0: [18:00:00 29/02/2016] el: 0 cg: RN cu: CSRU v1: 139 n1: 139 rs: Manual st: NotStopd
id: D5W 100.0ml t0: [18:00:00 29/02/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [18:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [18:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [18:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 180 vu: ml
id: TPN 1800.0ml t0: [19:00:00 29/02/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [19:00:00 29/02/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [19:00:00 29/02/2016] el: 1 cg: RN cu: CSRU vo: 60 vu: ml
id: Less Restrict Meas. t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [20:00:00 29/02/2016] el: 1 cg: RNs cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Alarms t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Education Barrier t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Not Given st: NotStopd id: Education Learner t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Reinforced st: NotStopd id: Education Topic #1 t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #2 t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Activity st: NotStopd id: Eye Opening t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Heart Rate t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 92 n1: 92 u1: BPM st: NotStopd id: Heart Rate t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 120 n1: 120 u1: BPM st: NotStopd id: Heart Rhythm t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Redness st: NotStopd id: Abdominal Assessment t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Soft st: NotStopd id: ImpSkin Character #1 t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Wound Base#1 t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Red st: NotStopd id: Impaired Skin Site#1 t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 96 n1: 96 u1: mmHg v2: 67 n2: 67 u2: mmHg st: NotStopd id: NBP t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 118 n1: 118 u1: mmHg v2: 85 n2: 85 u2: mmHg st: NotStopd id: NBP Mean t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 74 n1: 74 u1: mmHg st: NotStopd id: NBP Mean t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 93 n1: 93 u1: mmHg st: NotStopd id: Oral Cavity t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Oriented x 2 st: NotStopd id: Pain Location t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Not Indicated st: NotStopd id: Pain Type t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Position Change t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Precautions t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: NBP Alarm (Lo/Hi) t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 18 n1: 18 u1: BPM st: NotStopd id: Respiratory Rate t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 17 n1: 17 u1: BPM st: NotStopd id: Responds to Stimuli t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: All rails up st: NotStopd id: Skin Color t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal for Race st: NotStopd id: Skin Integrity t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: SpO2 t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: Spontaneous Movement t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 35.5556 n1: 35.5556 u1: Deg. C st: NotStopd id: Temperature F t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 96 n1: 96 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [19:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Calm st: NotStopd id: Insulin Guideline t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: On Guideline st: NotStopd id: Pt./Family Informed t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Present st: NotStopd id: JP DRAIN t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: intact id: Braden Activity t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Potential Prob st: NotStopd id: Braden Mobility t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Sl. Limited st: NotStopd id: Braden Moisture t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Adequate st: NotStopd id: Braden Score t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 15 n1: 15 u1: number st: NotStopd id: Braden SensoryPercep t0: [20:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Sl. Limited st: NotStopd
id: TPN 1800.0ml t0: [20:00:00 29/02/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [20:00:00 29/02/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [20:00:00 29/02/2016] el: 1 cg: RNs cu: CSRU vo: 90 vu: ml
id: Service Type t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 88 n1: 88 u1: BPM st: NotStopd id: Heart Rhythm t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 86 n1: 86 u1: mmHg v2: 59 n2: 59 u2: mmHg st: NotStopd id: NBP Mean t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 65 n1: 65 u1: mmHg st: NotStopd id: Precautions t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: SpO2 t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: calprevflg t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [21:00:00 29/02/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [21:00:00 29/02/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [21:00:00 29/02/2016] el: 1 cg: RNs cu: CSRU vo: 90 vu: ml
id: Service Type t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 79 n1: 79 u1: BPM st: NotStopd id: Heart Rate t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 86 n1: 86 u1: BPM st: NotStopd id: Heart Rhythm t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 97 n1: 97 u1: mmHg v2: 56 n2: 56 u2: mmHg st: NotStopd id: NBP Mean t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 66 n1: 66 u1: mmHg st: NotStopd id: Precautions t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: NBP Alarm (Lo/Hi) t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: Respiratory Rate t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: SpO2 t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: SpO2 t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [21:00:00 29/02/2016] el: 2 ai: 416 cg: RNs cu: CSRU vo: 100 vu: ml id: D5W 100.0ml t0: [22:00:00 29/02/2016] el: 2 ai: 416 cg: RNs cu: CSRU vo: 150 vu: ml id: TPN 1800.0ml t0: [22:00:00 29/02/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: TPN 1800.0ml t0: [23:00:00 29/02/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [22:00:00 29/02/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [23:00:00 29/02/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [22:00:00 29/02/2016] el: 1 cg: RNs cu: CSRU vo: 100 vu: ml id: Urine Out Foley t0: [23:00:00 29/02/2016] el: 1 cg: RNs cu: CSRU vo: 80 vu: ml
id: Total Hourly Output t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 80 cv: 80 ac: 1 ap: none re: 0 id: 24h Net Body Balance t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 5 cv: 130 ac: 24 ap: carryForward re: 0 id: LOS Net Body Balance t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 5 cv: 3654.1 ac: multiple days ap: carryForward re: 0 id: Net Hourly Balance t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 5 cv: 5 ac: 1 ap: none re: 0 id: 24h Total Out t0: [23:00:00 29/02/2016] el: 3 cg: RNs cu: CSRU pv: 80 cv: 3170 ac: 24 ap: carryForward re: 0
id: Less Restrict Meas. t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Orientation st: NotStopd id: Pain Level/Response t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 5-Moderate st: NotStopd id: Pain Present t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: bath t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: done id: Pain Assess Method t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [00:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Alarms t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Eye Care t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Eye Care t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Eye Opening t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 45 degrees st: NotStopd id: HOB t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#4 Type/Site t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: WNL st: NotStopd id: Abdominal Assessment t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Soft st: NotStopd id: Activity t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Bedrest st: NotStopd id: Activity t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Tolerated Well st: NotStopd id: Activity Tolerance t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Tolerated Well st: NotStopd id: ImpSkin Character #1 t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Wound Base#1 t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Red st: NotStopd id: Impaired Skin Site#1 t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Coarse st: NotStopd id: LU Strength/Movement t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 88 n1: 88 u1: mmHg v2: 57 n2: 57 u2: mmHg st: NotStopd id: NBP Mean t0: [23:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 65 n1: 65 u1: mmHg st: NotStopd id: Oral Care t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Oral Care t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Oral Cavity t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: AntiEmbDevice/Status t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Cause t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Movement/Turning st: NotStopd id: Pain Location t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Other/Remarks st: NotStopd id: Pain Management t0: [00:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU v1: IV Push st: NotStopd id: Pain Type t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Intermittent st: NotStopd id: Position t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Right Side st: NotStopd id: Position t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Position Change t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 Person Assist st: NotStopd id: Assistance Device t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: 1 Person Assist st: NotStopd id: Precautions t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: Responds to Stimuli t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Skin Color t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal for Race st: NotStopd id: Skin Integrity t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Spontaneous Movement t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Purposeful st: NotStopd id: INV#4 Cap Change t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 35.9444 n1: 35.9444 u1: Deg. C st: NotStopd id: Temperature F t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 96.7 n1: 96.7 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Therapeutic Bed t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Side to Side st: NotStopd id: Turn t0: [21:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Back st: NotStopd id: Urine Color/Appear t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 4 Confused st: NotStopd id: Back Care t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Insulin Guideline t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: On Guideline st: NotStopd id: Pt./Family Informed t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [22:00:00 29/02/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Present st: NotStopd
id: TPN 1800.0ml t0: [00:00:00 01/03/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [00:00:00 01/03/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [00:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU vo: 100 vu: ml
id: NBP t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 103 n1: 103 u1: mmHg v2: 68 n2: 68 u2: mmHg st: NotStopd id: NBP Mean t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 76 n1: 76 u1: mmHg st: NotStopd id: Fingerstick Glucose t0: [00:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 107 n1: 107 rs: Manual st: NotStopd
id: Service Type t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 92 n1: 92 u1: BPM st: NotStopd id: Heart Rhythm t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Sinus st: NotStopd id: Precautions t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: SpO2 t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [01:00:00 01/03/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [01:00:00 01/03/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [01:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU vo: 90 vu: ml
id: Service Type t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 99 n1: 99 u1: BPM st: NotStopd id: Heart Rhythm t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 82 n1: 82 u1: mmHg v2: 55 n2: 55 u2: mmHg st: NotStopd id: NBP Mean t0: [01:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 65 n1: 65 u1: mmHg st: NotStopd id: Precautions t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: SpO2 t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [02:00:00 01/03/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [02:00:00 01/03/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml
id: NBP t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 91 n1: 91 u1: mmHg v2: 54 n2: 54 u2: mmHg st: NotStopd id: NBP Mean t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 62 n1: 62 u1: mmHg st: NotStopd
id: D5W 100.0ml t0: [01:00:00 01/03/2016] el: 2 ai: 416 cg: RNs cu: CSRU vo: 75 vu: ml id: D5W 100.0ml t0: [02:00:00 01/03/2016] el: 2 ai: 416 cg: RNs cu: CSRU vo: 75 vu: ml id: Urine Out Foley t0: [02:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU vo: 110 vu: ml
id: Service Type t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: BPM st: NotStopd id: Heart Rhythm t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 94 n1: 94 u1: mmHg v2: 55 n2: 55 u2: mmHg st: NotStopd id: NBP Mean t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 65 n1: 65 u1: mmHg st: NotStopd id: Precautions t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: SpO2 t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: calprevflg t0: [03:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [03:00:00 01/03/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [03:00:00 01/03/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml
id: Less Restrict Meas. t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Agitated st: NotStopd id: Daily Wake Up t0: [04:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: None st: NotStopd id: Alarms t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Education Barrier t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Altered LOC st: NotStopd id: Education Handout t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Not Applicable st: NotStopd id: Education Learner t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Patient st: NotStopd id: Education Method t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Explanation st: NotStopd id: Education Readiness t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Education Response t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Reinforced st: NotStopd id: Education Topic #1 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #2 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Plan of Care st: NotStopd id: Eye Care t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Eye Opening t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 45 degrees st: NotStopd id: Heart Rate t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 110 n1: 110 u1: BPM st: NotStopd id: Heart Rhythm t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Sinus Tachy st: NotStopd id: INV Line#4 Type/Site t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: WNL st: NotStopd id: Abdominal Assessment t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Soft st: NotStopd id: Activity t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Tolerated Well st: NotStopd id: ImpSkin Character #1 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Abrasion st: NotStopd id: ImpSkin Treatment #1 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Other/Remarks st: NotStopd id: ImpSkin Wound Base#1 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Red st: NotStopd id: Impaired Skin Site#1 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Clear st: NotStopd id: Level of Conscious t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 97 n1: 97 u1: mmHg v2: 60 n2: 60 u2: mmHg st: NotStopd id: NBP Mean t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 69 n1: 69 u1: mmHg st: NotStopd id: Oral Care t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Oral Cavity t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Oriented x 2 st: NotStopd id: AntiEmbDevice/Status t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Pain Location t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Not Indicated st: NotStopd id: Position t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Position Change t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Clear st: NotStopd id: Reason For Restraint t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Reason For Restraint t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Ext/TXInterfere st: NotStopd id: Removed x 5 Mins t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: Responds to Stimuli t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Verbal v2: Localizes st: NotStopd id: Restraint Location t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Done st: NotStopd id: Skin Color t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Normal for Race st: NotStopd id: Skin Integrity t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Impaired st: NotStopd id: Skin Temp/Condition t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Warm v2: Dry st: NotStopd id: SpO2 t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Spontaneous Movement t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 35.5556 n1: 35.5556 u1: Deg. C st: NotStopd id: Temperature F t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 96 n1: 96 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Insulin Guideline t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: On Guideline st: NotStopd id: Pt./Family Informed t0: [02:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Present st: NotStopd id: Braden Activity t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Bedfast st: NotStopd id: Braden Frict/Shear t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Problem st: NotStopd id: Braden Mobility t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Very Limited st: NotStopd id: Braden Moisture t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Occ. Moist st: NotStopd id: Braden Nutrition t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Prob. Inadequate st: NotStopd id: Braden Score t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 11 n1: 11 u1: number st: NotStopd id: Braden SensoryPercep t0: [04:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: Very Limited st: NotStopd
id: TPN 1800.0ml t0: [04:00:00 01/03/2016] el: 1 ai: 168 cg: RNs cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [04:00:00 01/03/2016] el: 1 ai: 107 cg: RNs cu: CSRU vo: 10 vu: ml id: Stool Out Stool t0: [00:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU vu: ml es: Medium id: Urine Out Foley t0: [03:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU vo: 80 vu: ml id: Urine Out Foley t0: [04:00:00 01/03/2016] el: 1 cg: RNs cu: CSRU vo: 100 vu: ml
id: Stool Out Total t0: [23:00:00 01/03/2016] el: 3 cg: RNs cu: CSRU cv: 0 ac: 24 ap: carryForward re: 0
id: WBC (4-11,000) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 8.4 n1: 8.4 rs: Final st: NotStopd id: WBC t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 8.4 n1: 8.4 rs: Final st: NotStopd id: Hematocrit t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 31.7 n1: 31.7 u1: % rs: Final st: NotStopd id: Hemoglobin t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 10.9 n1: 10.9 u1: gm/dl rs: Final st: NotStopd id: Platelets t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 200 n1: 200 rs: Final st: NotStopd id: RBC t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 3.37 n1: 3.37 u1: /mic l rs: Final st: NotStopd id: WBC (4-11,000) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 8.4 n1: 8.4 rs: Final st: NotStopd
id: PT t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 15.4 n1: 15.4 rs: Final st: NotStopd id: INR t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 1.4 n1: 1.4 rs: Final st: NotStopd id: PTT t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 35.1 n1: 35.1 rs: Final st: NotStopd id: INR (2-4 ref. range) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 1.4 n1: 1.4 rs: Final st: NotStopd id: PT(11-13.5) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 15.4 n1: 15.4 rs: Final st: NotStopd id: PTT(22-35) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 35.1 n1: 35.1 rs: Final st: NotStopd
id: BUN t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 15 n1: 15 rs: Final st: NotStopd id: Calcium t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 8.8 n1: 8.8 u1: mg/dl rs: Final st: NotStopd id: Chloride t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 105 n1: 105 rs: Final st: NotStopd id: Creatinine t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 0.4 n1: 0.4 rs: Final st: NotStopd id: Glucose t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 98 n1: 98 rs: Final st: NotStopd id: Magnesium t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 2 n1: 2 rs: Final st: NotStopd id: Phosphorous t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 4.2 n1: 4.2 u1: mEq/L rs: Final st: NotStopd id: Potassium t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 4.2 n1: 4.2 rs: Final st: NotStopd id: Sodium t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 135 n1: 135 rs: Final st: NotStopd id: Total Bili t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 0.8 n1: 0.8 rs: Final st: NotStopd id: ALT t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 43 n1: 43 rs: Final st: NotStopd id: BUN (6-20) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 15 n1: 15 rs: Final st: NotStopd id: Calcium (8.4-10.2) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 8.8 n1: 8.8 u1: mg/dl rs: Final st: NotStopd id: Carbon Dioxide t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 20 n1: 20 rs: Final st: NotStopd id: Chloride (100-112) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 105 n1: 105 rs: Final st: NotStopd id: Creatinine (0-1.3) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 0.4 n1: 0.4 rs: Final st: NotStopd id: Glucose (70-105) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 98 n1: 98 rs: Final st: NotStopd id: Magnesium (1.6-2.6) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 2 n1: 2 rs: Final st: NotStopd id: Phosphorous(2.7-4.5) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 4.2 n1: 4.2 u1: mEq/L rs: Final st: NotStopd id: Potassium (3.5-5.3) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 4.2 n1: 4.2 rs: Final st: NotStopd id: Sodium (135-148) t0: [03:56:00 01/03/2016] el: 0 cg: 3161 cu: CSRU v1: 135 n1: 135 rs: Final st: NotStopd
id: Service Type t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: BPM st: NotStopd id: Heart Rate t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: BPM st: NotStopd id: Heart Rhythm t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: mmHg v2: 51 n2: 51 u2: mmHg st: NotStopd id: NBP t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: mmHg v2: 59 n2: 59 u2: mmHg st: NotStopd id: NBP Mean t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 68 n1: 68 u1: mmHg st: NotStopd id: Precautions t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: NBP Alarm (Lo/Hi) t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: Respiratory Rate t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 11 n1: 11 u1: BPM st: NotStopd id: SpO2 t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: SpO2 t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [05:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [06:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [06:00:00 01/03/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [06:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 150 vu: ml id: .9% Normal Saline 1000.0ml t0: [06:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: Urine Out Foley t0: [06:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: Fingerstick Glucose t0: [06:00:00 01/03/2016] el: 0 cg: RNs cu: CSRU v1: 118 n1: 118 rs: Manual st: NotStopd
id: Service Type t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 u1: BPM st: NotStopd id: Heart Rhythm t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: mmHg v2: 60 n2: 60 u2: mmHg st: NotStopd id: Precautions t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: SpO2 t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [07:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [07:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [07:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [07:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 180 vu: ml
id: Service Type t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Heart Rate t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: BPM st: NotStopd id: Heart Rhythm t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Impaired Skin Site#1 t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: NBP t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 51 n2: 51 u2: mmHg st: NotStopd id: Precautions t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: Side Rails t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Integrity t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: SpO2 t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Support Systems t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: calprevflg t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd id: Pt./Family Informed t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: Diet Type t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Eye Opening t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 3 To speech st: NotStopd id: GCS Total t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: points st: NotStopd id: Level of Conscious t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Dozing Intermit st: NotStopd id: Motor Response t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Orientation t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: Respiratory Pattern t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Urine Color/Appear t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Clear st: NotStopd id: Urine Source t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd
id: D5W 100.0ml t0: [08:00:00 01/03/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 250 vu: ml id: TPN 1800.0ml t0: [08:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [08:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [08:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: Temp. Site t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Axillary st: NotStopd id: Temperature C (calc) t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 37 n1: 37 u1: Deg. C st: NotStopd id: Temperature F t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 98.6 n1: 98.6 u1: Deg. F st: NotStopd
id: HOB t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: INV Line#4 Type/Site t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Abdominal Assessment t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: LL Strength/Movement t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Oral Cavity t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: AntiEmbDevice/Status t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Compress Sleeves v2: On st: NotStopd id: Position t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: INV#4 Dsg Change t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: RL Strength/Movement t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: RU Strength/Movement t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: INV#4 Cap Change t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Therapeutic Bed t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Bowel Sounds t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: Pain Present t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Riker-SAS Scale t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [08:00:00 01/03/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Pain Location t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd
id: Service Type t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 91 n1: 91 u1: BPM st: NotStopd id: Heart Rhythm t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: mmHg v2: 51 n2: 51 u2: mmHg st: NotStopd id: Precautions t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: SpO2 t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: calprevflg t0: [09:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [09:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [09:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [09:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 50 vu: ml
id: Service Type t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 83 n1: 83 u1: BPM st: NotStopd id: Heart Rhythm t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 92 n1: 92 u1: mmHg v2: 58 n2: 58 u2: mmHg st: NotStopd id: Precautions t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: SpO2 t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [10:00:00 01/03/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [10:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [10:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [10:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 140 vu: ml
id: Drain Out #1 Jackson Pratt t0: [10:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 10 vu: ml
id: Drain #1 Total Out t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: CSRU cv: 15 ac: 24 ap: none re: 0
id: bath t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: done id: Service Type t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Care t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: HOB t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 84 n1: 84 u1: BPM st: NotStopd id: Heart Rhythm t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: NBP t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: mmHg v2: 57 n2: 57 u2: mmHg st: NotStopd id: Oral Care t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Assistance Device t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: Skin Care t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: Therapeutic Bed t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Back Care t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [11:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [11:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [11:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [11:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 130 vu: ml
id: Pain Present t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Service Type t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [12:00:00 01/03/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Opening t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Heart Rate t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: BPM st: NotStopd id: Heart Rhythm t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Abdominal Assessment t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: LL Strength/Movement t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LU Strength/Movement t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: Level of Conscious t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Oral Cavity t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: Pain Location t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Precautions t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RU Strength/Movement t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: Respiratory Pattern t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: BPM st: NotStopd id: SpO2 t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: Spontaneous Movement t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Temp. Site t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 36.2778 n1: 36.2778 u1: Deg. C st: NotStopd id: Temperature F t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 97.3 n1: 97.3 u1: Deg. F st: NotStopd id: Urine Color/Appear t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Sediment st: NotStopd id: Urine Source t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: calprevflg t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Bowel Sounds t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: TPN 1800.0ml t0: [12:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [12:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [12:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 80 vu: ml
id: Less Restrict Meas. t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Range of Motion t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Circulation/SkinInt t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Education Topic #1 t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #1 t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Impaired Skin Site#1 t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#1 t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Impaired Skin Site#3 t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Incision/Wound #1 t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Position Change t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Reason For Restraint t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Reason For Restraint t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Reason For Restraint t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Removed x 5 Mins t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Restraint Location t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Integrity t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Support Systems t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Support Systems t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Behavior t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Restless st: NotStopd id: Pt./Family Informed t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
id: Alarms t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Learner t0: [08:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Learner t0: [10:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: Education Learner t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Patient st: NotStopd id: LLL Lung Sounds t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LUL Lung Sounds t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RLL Lung Sounds t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RUL Lung Sounds t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: JP DRAIN t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: yes
pi: 4547424 hi: 27155 t0: [22:00:00 01/03/2016] tf: [17:00:00 22/03/2016] mn: Haloperidol pt: Unit Dose st: Discontinued rt: IV fr: HS ds: 22 dn: 1 di: Ongoing xv: 36 xu: Hours pi: 4547425 hi: 27155 t0: [13:00:00 01/03/2016] tf: [18:00:00 02/03/2016] mn: Fentanyl Citrate pt: Unit Dose st: Discontinued rt: IV fr: Q2H:PRN di: Ongoing xv: 36 xu: Hours pi: 4547430 hi: 27155 t0: [13:00:00 01/03/2016] tf: [07:00:00 04/03/2016] mn: Fentanyl Patch pt: Unit Dose st: Inactive (Due to a change order) rt: TP fr: Q72H dn: 0 di: Ongoing xv: 36 xu: Hours
id: NBP t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 103 n1: 103 u1: mmHg v2: 66 n2: 66 u2: mmHg st: NotStopd
id: Service Type t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: BPM st: NotStopd id: Heart Rhythm t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Precautions t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: SpO2 t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [13:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [13:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [13:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 150 vu: ml
pi: 4547568 hi: 27155 t0: [13:00:00 01/03/2016] pt: TPN st: Expired
id: NBP t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 91 n1: 91 u1: mmHg v2: 56 n2: 56 u2: mmHg st: NotStopd
id: Fingerstick Glucose t0: [13:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 107 n1: 107 rs: Manual st: NotStopd
id: Service Type t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: BPM st: NotStopd id: Heart Rhythm t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: mmHg v2: 64 n2: 64 u2: mmHg st: NotStopd id: Precautions t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: SpO2 t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: HOB t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Activity t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Position t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Assistance Device t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Skin Care t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Therapeutic Bed t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Back Care t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd
id: TPN 1800.0ml t0: [14:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [14:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [14:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: Service Type t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 81 n1: 81 u1: BPM st: NotStopd id: Heart Rhythm t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: mmHg v2: 70 n2: 70 u2: mmHg st: NotStopd id: NBP Mean t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 76 n1: 76 u1: mmHg st: NotStopd id: Precautions t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 15 n1: 15 u1: BPM st: NotStopd id: SpO2 t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: calprevflg t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [15:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [15:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [15:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 120 vu: ml
id: INV Line#4 Type/Site t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4 Type/Site t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4InsertDate t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV Line#4SiteAppear t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: INV#4 Dsg Change t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Dsg Change t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Cap Change t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Cap Change t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [12:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd
id: Diet Type t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Ectopy Frequency t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Eye Opening t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: Heart Rhythm t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Abdominal Assessment t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: LL Strength/Movement t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LU Strength/Movement t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: Level of Conscious t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: Oral Cavity t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Orientation t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Oriented x 2 st: NotStopd id: RL Strength/Movement t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RU Strength/Movement t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: Respiratory Pattern t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Spontaneous Movement t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Urine Color/Appear t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Sediment st: NotStopd id: Urine Source t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: Bowel Sounds t0: [15:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: Service Type t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: BPM st: NotStopd id: Precautions t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: SpO2 t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 99 n1: 99 u1: % st: NotStopd id: Temp. Site t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 35.8889 n1: 35.8889 u1: Deg. C st: NotStopd id: Temperature F t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 96.6 n1: 96.6 u1: Deg. F st: NotStopd id: calprevflg t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: NBP t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: mmHg v2: 65 n2: 65 u2: mmHg st: NotStopd
id: Service Type t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 85 n1: 85 u1: BPM st: NotStopd id: Heart Rhythm t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP Mean t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 73 n1: 73 u1: mmHg st: NotStopd id: Precautions t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 16 n1: 16 u1: BPM st: NotStopd id: SpO2 t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: TPN 1800.0ml t0: [16:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: TPN 1800.0ml t0: [17:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [16:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: .9% Normal Saline 1000.0ml t0: [17:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml id: Urine Out Foley t0: [16:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 100 vu: ml id: Urine Out Foley t0: [17:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 220 vu: ml id: Drain Out #1 Jackson Pratt t0: [17:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 5 vu: ml
id: Less Restrict Meas. t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Circulation/SkinInt t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Riker-SAS Scale t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [17:00:00 01/03/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Education Topic #1 t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #1 t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Education Topic #1 t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: HOB t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Activity t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Impaired Skin Site#1 t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#1 t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#1 t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Impaired Skin Site#3 t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Impaired Skin Site#3 t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Incision/Wound #1 t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Incision/Wound #1 t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: Pain Location t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Position t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Supine st: NotStopd id: Position Change t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Assistance Device t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Reason For Restraint t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Reason For Restraint t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Removed x 5 Mins t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Restraint Location t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Care t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Skin Integrity t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: Support Systems t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Support Systems t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Support Systems t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: Therapeutic Bed t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Back st: NotStopd id: Back Care t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Behavior t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Restless st: NotStopd id: Pt./Family Informed t0: [14:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [16:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd
pi: 4548477 hi: 27155 t0: [18:00:00 01/03/2016] tf: [18:00:00 02/03/2016] mn: Ganciclovir pt: IV Piggyback st: Discontinued rt: IV fr: Q12H ds: 6, 18 dn: 2 di: Ongoing xu: Enter on Label
id: Diet Type t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Abdominal Assessment t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: LLL Lung Sounds t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LUL Lung Sounds t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Oral Cavity t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: RLL Lung Sounds t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RUL Lung Sounds t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Respiratory Pattern t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Urine Color/Appear t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Sediment st: NotStopd id: Urine Source t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Bowel Sounds t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: D5W 100.0ml t0: [16:30:00 01/03/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml
id: Service Type t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Risk for Falls t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Heart Rate t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 70 n1: 70 u1: BPM st: NotStopd id: Heart Rhythm t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: NBP t0: [17:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 101 n1: 101 u1: mmHg v2: 60 n2: 60 u2: mmHg st: NotStopd id: NBP t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 93 n1: 93 u1: mmHg v2: 61 n2: 61 u2: mmHg st: NotStopd id: Precautions t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 12 n1: 12 u1: BPM st: NotStopd id: SpO2 t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 100 n1: 100 u1: % st: NotStopd id: calprevflg t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [18:00:00 01/03/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [18:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [18:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: Urine Out Foley t0: [18:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 200 vu: ml
id: Fingerstick Glucose t0: [18:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 114 n1: 114 rs: Manual st: NotStopd
id: TPN 1800.0ml t0: [19:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [19:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: Less Restrict Meas. t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Less Restrict Meas. t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Orientation st: NotStopd id: Pain Present t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Range of Motion t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Range of Motion t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Assess Method t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Service Type t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Circulation/SkinInt t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Circulation/SkinInt t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Circulation Adeq st: NotStopd id: Code Status t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Code Status t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [20:00:00 01/03/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Risk for Falls t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Diet Type t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: TPN st: NotStopd id: Dorsal PedPulse R/L t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Ectopy Frequency t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Frequency t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Alarms t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: ON st: NotStopd id: Parameters Checked t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Health Care Proxy t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Education Topic #1 t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Disease Process st: NotStopd id: Eye Opening t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 4 Spontaneously st: NotStopd id: Follows Commands t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Consistently st: NotStopd id: GCS Total t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 14 n1: 14 u1: points st: NotStopd id: HOB t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: BPM st: NotStopd id: Heart Rate t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 74 n1: 74 u1: BPM st: NotStopd id: Heart Rhythm t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Heart Rhythm t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: INV Line#4 Type/Site t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Multi-lumen v2: Left Subclavian st: NotStopd id: INV Line#4InsertDate t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 12 n2: 12 st: NotStopd id: INV Line#4SiteAppear t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: WNL st: NotStopd id: Abdominal Assessment t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft st: NotStopd id: Activity t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: Impaired Skin Site#1 t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coccyx st: NotStopd id: Impaired Skin Site#3 t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right knee st: NotStopd id: Incision/Wound #1 t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Abdominal st: NotStopd id: LL Strength/Movement t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LLL Lung Sounds t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: LU Strength/Movement t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: LUL Lung Sounds t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Level of Conscious t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Alert st: NotStopd id: Motor Response t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 6 Obeys Commands st: NotStopd id: NBP t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 86 n1: 86 u1: mmHg v2: 55 n2: 55 u2: mmHg st: NotStopd id: NBP Mean t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 62 n1: 62 u1: mmHg st: NotStopd id: O2 Delivery Device t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Oral Cavity t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Teeth/Tissue WNL st: NotStopd id: Pain Location t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Position t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Right Side st: NotStopd id: Position Change t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Position Change t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: PostTib. Pulses R/L t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Easily Palpable v2: Easily Palpable st: NotStopd id: Assistance Device t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: Precautions t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: INV#4 Dsg Change t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: HR Alarm (Lo/Hi) t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: HR Alarm (Lo/Hi) t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: NBP Alarm (Lo/Hi) t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: Resp Alarm (Lo/Hi) t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: RL Strength/Movement t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RLL Lung Sounds t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Diminished st: NotStopd id: RU Strength/Movement t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Strength st: NotStopd id: RUL Lung Sounds t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Coarse st: NotStopd id: Reason For Restraint t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Reason For Restraint t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Agitated st: NotStopd id: Removed x 5 Mins t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Removed x 5 Mins t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Respiratory Pattern t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Regular st: NotStopd id: Respiratory Rate t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 13 n1: 13 u1: BPM st: NotStopd id: Respiratory Rate t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 10 n1: 10 u1: BPM st: NotStopd id: Restraint Location t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Location t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Both Arms st: NotStopd id: Restraint Type t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraint Type t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Soft Limb st: NotStopd id: Restraints Evaluated t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Restraints Evaluated t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: RestraintReapply st: NotStopd id: Side Rails t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Side Rails t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: All rails up st: NotStopd id: Skin Integrity t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Impaired st: NotStopd id: SpO2 t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 98 n1: 98 u1: % st: NotStopd id: SpO2 t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 96 n1: 96 u1: % st: NotStopd id: Spontaneous Movement t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Purposeful st: NotStopd id: Support Systems t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Relative st: NotStopd id: INV#4 Cap Change t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: INV#4 Tubing Change t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 n1: 2 v2: 18 n2: 18 st: NotStopd id: Temp. Site t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Oral st: NotStopd id: Temperature C (calc) t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 35.8333 n1: 35.8333 u1: Deg. C st: NotStopd id: Temperature F t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 96.5 n1: 96.5 u1: Deg. F st: NotStopd id: Therapeutic Bed t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Urine Color/Appear t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yellow v2: Sediment st: NotStopd id: Urine Source t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Indwelling Cath st: NotStopd id: Verbal Response t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 4 Confused st: NotStopd id: calprevflg t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: calprevflg t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd id: Behavior t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Calm st: NotStopd id: Pt./Family Informed t0: [19:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pt./Family Informed t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Bowel Sounds t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Present st: NotStopd
id: TPN 1800.0ml t0: [20:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 75 vu: ml id: .9% Normal Saline 1000.0ml t0: [20:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 10 vu: ml
id: D5W 100.0ml t0: [20:00:00 01/03/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 400 vu: ml id: Gastric Meds t0: [20:00:00 01/03/2016] el: 2 ai: 155 cg: RN cu: CSRU vo: 100 vu: ml
id: PO/Gastric In Total t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 100 ac: 24 ap: none re: 0
id: Pain Level t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 4-Mild to Mod st: NotStopd id: Pain Present t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Pain Present t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: No st: NotStopd id: Pain Assess Method t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Pain Assess Method t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Pt Verbalized st: NotStopd id: Service Type t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: MICU st: NotStopd id: Code Status t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Full Code st: NotStopd id: Riker-SAS Scale t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Riker-SAS Scale t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Calm/Cooperative st: NotStopd id: Daily Wake Up t0: [21:00:00 01/03/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Daily Wake Up t0: [22:00:00 01/03/2016] el: 1 cg: RN cu: CSRU v1: No/Not Sedated st: NotStopd id: Risk for Falls t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Ectopy Frequency t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Ectopy Type t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: None st: NotStopd id: Health Care Proxy t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Yes st: NotStopd id: Eye Care t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: HOB t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 30 degrees st: NotStopd id: Heart Rate t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 78 n1: 78 u1: BPM st: NotStopd id: Heart Rhythm t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Normal Sinus st: NotStopd id: Activity t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Bedrest st: NotStopd id: Activity Tolerance t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Tolerated Well st: NotStopd id: NBP t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 95 n1: 95 u1: mmHg v2: 62 n2: 62 u2: mmHg st: NotStopd id: NBP Mean t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 73 n1: 73 u1: mmHg st: NotStopd id: Oral Care t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: Pain Cause t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: At Rest st: NotStopd id: Pain Level (Rest) t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 4-Mild to Mod st: NotStopd id: Pain Location t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Incisional st: NotStopd id: Pain Location t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Not Indicated st: NotStopd id: Pain Management t0: [21:00:00 01/03/2016] el: 1 cg: RN cu: CSRU v1: IV Push st: NotStopd id: Pain Type t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Aching st: NotStopd id: Position t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Left Side st: NotStopd id: Assistance Device t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 2 Person Assist st: NotStopd id: Precautions t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Contact st: NotStopd id: HR Alarm (Lo/Hi) t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 60 n1: 60 u1: BPM v2: 120 n2: 120 u2: BPM st: NotStopd id: NBP Alarm (Lo/Hi) t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: mmHg v2: 160 n2: 160 u2: mmHg st: NotStopd id: Resp Alarm (Lo/Hi) t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 8 n1: 8 u1: BPM v2: 30 n2: 30 u2: BPM st: NotStopd id: SpO2 Alarm (Lo/Hi) t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 90 n1: 90 u1: % v2: 100 n2: 100 u2: % st: NotStopd id: Respiratory Rate t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 10 n1: 10 u1: BPM st: NotStopd id: Skin Care t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: SpO2 t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 97 n1: 97 u1: % st: NotStopd id: Therapeutic Bed t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: AtmosAir Mattres st: NotStopd id: Turn t0: [22:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Side to Side st: NotStopd id: Back Care t0: [20:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: Done st: NotStopd id: calprevflg t0: [21:00:00 01/03/2016] el: 0 cg: RN cu: CSRU v1: 1 n1: 1 u1: kg st: NotStopd
id: D5W 100.0ml t0: [22:00:00 01/03/2016] el: 2 ai: 416 cg: RN cu: CSRU vo: 100 vu: ml id: TPN 1800.0ml t0: [22:00:00 01/03/2016] el: 1 ai: 168 cg: RN cu: CSRU vo: 150 vu: ml id: .9% Normal Saline 1000.0ml t0: [22:00:00 01/03/2016] el: 1 ai: 107 cg: RN cu: CSRU vo: 20 vu: ml id: Urine Out Foley t0: [22:00:00 01/03/2016] el: 1 cg: RN cu: CSRU vo: 400 vu: ml
id: IV Infusion In Total t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 1530 ac: 24 ap: none re: 0 id: IV Nutrition Total t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 1725 ac: 24 ap: none re: 0 id: 24h Total In t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 3355 ac: 24 ap: none re: 0 id: Total Hourly Output t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 0 ac: 1 ap: none re: 0 id: Urine Out Total t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 2770 ac: 24 ap: none re: 0 id: 24h Net Body Balance t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 570 ac: 24 ap: carryForward re: 0 id: LOS Net Body Balance t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 4224.1 ac: multiple days ap: carryForward re: 0 id: Net Hourly Balance t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 0 ac: 1 ap: none re: 0 id: 24h Total Out t0: [23:00:00 01/03/2016] el: 3 cg: RN cu: -1 cv: 2785 ac: 24 ap: carryForward re: 0
ci: 38817 t0: [20:27:00 24/02/2016] cu: CSRU de: Regular ward dt: 10161
pi: 4549420 hi: 27155 t0: [23:00:00 01/03/2016] tf: [10:00:00 03/03/2016] mn: Heparin Flush CVL (100 units/ml) pt: Unit Dose st: Discontinued rt: IV fr: DAILY:PRN di: Ongoing xv: 36 xu: Hours
pi: 4550384 hi: 27155 t0: [10:00:00 02/03/2016] pt: TPN st: Expired
pi: 4552282 hi: 27155 t0: [19:00:00 02/03/2016] tf: [07:00:00 04/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q4H:PRN di: Ongoing xv: 36 xu: Hours pi: 4552283 hi: 27155 t0: [19:00:00 02/03/2016] tf: [07:00:00 04/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q4H:PRN di: Ongoing xv: 36 xu: Hours pi: 4552284 hi: 27155 t0: [19:00:00 02/03/2016] tf: [07:00:00 04/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q4H:PRN di: Ongoing xv: 36 xu: Hours pi: 4552285 hi: 27155 t0: [10:00:00 02/03/2016] tf: [18:00:00 03/03/2016] mn: ValGANCIclovir pt: Unit Dose st: Discontinued rt: PO fr: DAILY ds: 10 dn: 1 di: Ongoing xv: 36 xu: Hours
pi: 4552495 hi: 27155 t0: [20:00:00 02/03/2016] tf: [09:00:00 12/04/2016] mn: Heparin Flush PICC (100 units/ml) pt: Unit Dose st: Discontinued rt: IV fr: DAILY:PRN di: Ongoing xv: 36 xu: Hours
pi: 4554360 hi: 27155 t0: [10:00:00 03/03/2016] tf: [16:00:00 13/04/2016] mn: Sulfameth/Trimethoprim SS pt: Unit Dose st: Discontinued via patient discharge rt: PO fr: DAILY ds: 10 dn: 1 di: Ongoing xv: 36 xu: Hours
pi: 4554464 hi: 27155 t0: [14:00:00 03/03/2016] tf: [16:00:00 13/04/2016] mn: Heparin pt: Unit Dose st: Discontinued via patient discharge rt: SC fr: TID ds: 08, 14, 20 dn: 3 di: Ongoing xv: 36 xu: Hours
pi: 4555276 hi: 27155 t0: [16:00:00 03/03/2016] tf: [07:00:00 04/03/2016] pt: TPN st: Inactive (Due to a change order)
pi: 4557632 hi: 27155 t0: [08:00:00 04/03/2016] tf: [07:00:00 04/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q4H:PRN di: Ongoing xv: 36 xu: Hours pi: 4557633 hi: 27155 t0: [08:00:00 04/03/2016] tf: [12:00:00 06/03/2016] mn: Lorazepam pt: Unit Dose st: Discontinued rt: IV fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4557634 hi: 27155 t0: [08:00:00 04/03/2016] tf: [07:00:00 04/03/2016] mn: Fentanyl Patch pt: Unit Dose st: Inactive (Due to a change order) rt: TP fr: Q72H dn: 0 di: Ongoing xv: 36 xu: Hours pi: 4557635 hi: 27155 t0: [08:00:00 04/03/2016] tf: [07:00:00 04/03/2016] mn: Haloperidol pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: TID:PRN di: Ongoing xv: 36 xu: Hours pi: 4557681 hi: 27155 t0: [08:00:00 04/03/2016] tf: [16:00:00 13/04/2016] mn: Fentanyl Patch pt: Unit Dose st: Discontinued via patient discharge rt: TP fr: Q72H dn: 0 di: Ongoing xv: 36 xu: Hours pi: 4557682 hi: 27155 t0: [08:00:00 04/03/2016] tf: [08:00:00 11/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4557683 hi: 27155 t0: [08:00:00 04/03/2016] tf: [11:00:00 07/03/2016] mn: Haloperidol pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4557684 hi: 27155 t0: [08:00:00 04/03/2016] tf: [16:00:00 13/04/2016] mn: Albuterol 0.083% Neb Soln pt: Unit Dose st: Discontinued via patient discharge rt: IH fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4557685 hi: 27155 t0: [08:00:00 04/03/2016] tf: [13:00:00 29/03/2016] mn: Ipratropium Bromide Neb pt: Unit Dose st: Discontinued rt: IH fr: Q6H ds: 8, 14, 20, 2 dn: 4 di: Ongoing xv: 36 xu: Hours
pi: 4558152 hi: 27155 t0: [11:00:00 04/03/2016] tf: [10:00:00 05/03/2016] mn: Potassium Chloride pt: IV Piggyback st: Expired rt: IV fr: ONCE ds: 11 dn: 1 dt: 1 di: Doses xu: Enter on Label
pi: 4558208 hi: 27155 t0: [11:00:00 04/03/2016] pt: TPN st: Expired
pi: 4561836 hi: 27155 t0: [12:00:00 05/03/2016] pt: TPN st: Expired
pi: 4563741 hi: 27155 t0: [10:00:00 06/03/2016] tf: [09:00:00 07/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 500 ml NS Bolus 500 ml Over 20 mins it: B dt: 1 di: Doses xu: Enter on Label
pi: 4564029 hi: 27155 t0: [12:00:00 06/03/2016] tf: [11:00:00 07/03/2016] mn: Potassium Chloride pt: IV Piggyback st: Expired rt: IV fr: ONCE ds: 12 dn: 1 dt: 1 di: Doses xu: Enter on Label
pi: 4564083 hi: 27155 t0: [12:00:00 06/03/2016] pt: TPN st: Expired
pi: 4565268 hi: 27155 t0: [23:00:00 06/03/2016] tf: [22:00:00 07/03/2016] mn: Haloperidol pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 23 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4565445 hi: 27155 t0: [02:00:00 07/03/2016] tf: [01:00:00 08/03/2016] mn: Olanzapine (Disintegrating Tablet) pt: Unit Dose st: Expired rt: PO fr: ONCE ds: 2 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4565866 hi: 27155 t0: [09:00:00 07/03/2016] tf: [08:00:00 08/03/2016] mn: Potassium Chloride pt: IV Piggyback st: Expired rt: IV fr: ONCE ds: 9 dn: 1 dt: 1 di: Doses xu: Enter on Label
pi: 4566279 hi: 27155 t0: [11:00:00 07/03/2016] pt: TPN st: Expired
pi: 4566563 hi: 27155 t0: [12:00:00 07/03/2016] tf: [16:00:00 13/04/2016] mn: Haloperidol pt: Unit Dose st: Discontinued via patient discharge rt: IV fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4566564 hi: 27155 t0: [12:00:00 07/03/2016] tf: [17:00:00 22/03/2016] mn: Olanzapine (Disintegrating Tablet) pt: Unit Dose st: Discontinued rt: PO fr: BID:PRN di: Ongoing xv: 36 xu: Hours
pi: 4567680 hi: 27155 t0: [18:00:00 07/03/2016] tf: [16:00:00 18/03/2016] mn: Voriconazole pt: Unit Dose st: Discontinued rt: PO fr: Q12H ds: 18, 6 dn: 2 di: Ongoing xv: 36 xu: Hours
pi: 4569485 hi: 27155 t0: [08:00:00 08/03/2016] tf: [17:00:00 22/03/2016] mn: Potassium Chloride pt: IV Piggyback st: Discontinued rt: IV fr: 2X dn: 0 di: Ongoing xu: Enter on Label
pi: 4570561 hi: 27155 t0: [14:00:00 08/03/2016] pt: TPN st: Expired
pi: 4574201 hi: 27155 t0: [12:00:00 09/03/2016] pt: TPN st: Expired
pi: 4576356 hi: 27155 t0: [00:00:00 10/03/2016] tf: [23:00:00 10/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 0 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4577968 hi: 27155 t0: [12:00:00 10/03/2016] pt: TPN st: Expired
pi: 4579550 hi: 27155 t0: [20:00:00 10/03/2016] tf: [19:00:00 11/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 20 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4580295 hi: 27155 t0: [01:00:00 11/03/2016] tf: [00:00:00 12/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 1 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4580557 hi: 27155 t0: [05:00:00 11/03/2016] tf: [04:00:00 12/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 250 ml NS Bolus 250 ml Over 30 mins it: B dt: 1 di: Doses xu: Enter on Label
pi: 4580607 hi: 27155 t0: [06:00:00 11/03/2016] tf: [05:00:00 12/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 250 ml NS Bolus 250 ml Over 30 mins it: B dt: 1 di: Doses xu: Enter on Label
pi: 4580865 hi: 27155 t0: [09:00:00 11/03/2016] tf: [08:00:00 13/03/2016] mn: OxycoDONE (Immediate Release) pt: Unit Dose st: Discontinued rt: PO fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4580866 hi: 27155 t0: [09:00:00 11/03/2016] tf: [08:00:00 13/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Inactive (Due to a change order) rt: IV fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours
pi: 4581316 hi: 27155 t0: [11:00:00 11/03/2016] pt: TPN st: Expired
pi: 4583841 hi: 27155 t0: [02:00:00 12/03/2016] tf: [15:00:00 12/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 1000 ml D5 1/2NS Continuous at 75 ml/hr for 1000 ml ir: 75 it: C ss: N dt: 13 di: Hours xu: Enter on Label
pi: 4585357 hi: 27155 t0: [15:00:00 12/03/2016] tf: [18:00:00 12/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 500 ml NS Continuous at 150 ml/hr for 500 ml ir: 150 it: C ss: N dt: 3 di: Hours xu: Enter on Label pi: 4585373 hi: 27155 t0: [15:00:00 12/03/2016] tf: [14:00:00 13/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ONCE ds: 15 iv: Amino Acid 4.25% with Electrolytes in 5% Dextrose 1000 ml dn: 1 dt: 1 di: Doses xu: Enter on Label
pi: 4586417 hi: 27155 t0: [01:00:00 13/03/2016] tf: [00:00:00 14/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 500 ml NS Bolus 500 ml Over 30 mins it: B dt: 1 di: Doses xu: Enter on Label
pi: 4586863 hi: 27155 t0: [09:00:00 13/03/2016] tf: [23:00:00 21/03/2016] mn: Morphine Sulfate IR pt: Unit Dose st: Inactive (Due to a change order) rt: PO fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4586864 hi: 27155 t0: [09:00:00 13/03/2016] tf: [14:00:00 20/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Discontinued rt: IV fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours
pi: 4587253 hi: 27155 t0: [11:00:00 13/03/2016] tf: [10:00:00 14/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ONCE ds: 11 iv: Amino Acid 4.25% with Electrolytes in 5% Dextrose 1000 ml dn: 1 dt: 1 di: Doses xu: Enter on Label
pi: 4590317 hi: 27155 t0: [13:00:00 14/03/2016] tf: [16:00:00 13/04/2016] mn: Heparin Flush PICC (100 units/ml) pt: Unit Dose st: Discontinued via patient discharge rt: IV fr: DAILY:PRN di: Ongoing xv: 36 xu: Hours
pi: 4590492 hi: 27155 t0: [14:00:00 14/03/2016] pt: TPN st: Expired
pi: 4593308 hi: 27155 t0: [10:00:00 15/03/2016] tf: [09:00:00 16/03/2016] mn: Magnesium Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 10 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4594081 hi: 27155 t0: [13:00:00 15/03/2016] tf: [12:00:00 15/03/2016] pt: TPN st: Inactive (Due to a change order) pi: 4594099 hi: 27155 t0: [13:00:00 15/03/2016] pt: TPN st: Expired
pi: 4597333 hi: 27155 t0: [12:00:00 16/03/2016] pt: TPN st: Expired
pi: 4598108 hi: 27155 t0: [16:00:00 16/03/2016] tf: [15:00:00 17/03/2016] mn: Cosyntropin pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 16 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4601189 hi: 27155 t0: [14:00:00 17/03/2016] pt: TPN st: Expired
pi: 4603755 hi: 27155 t0: [09:00:00 18/03/2016] tf: [08:00:00 19/03/2016] mn: Alteplase (Catheter Clearance) pt: Unit Dose st: Expired rt: IV fr: ONCE MR1 ds: 9 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4604101 hi: 27155 t0: [11:00:00 18/03/2016] tf: [10:00:00 19/03/2016] mn: Alteplase (Catheter Clearance) pt: Unit Dose st: Expired rt: IV fr: ONCE MR1 ds: 11 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4604653 hi: 27155 t0: [14:00:00 18/03/2016] pt: TPN st: Expired
pi: 4605122 hi: 27155 t0: [20:00:00 18/03/2016] tf: [16:00:00 13/04/2016] mn: Miconazole Powder 2% pt: Unit Dose st: Discontinued via patient discharge rt: TP fr: BID ds: 08, 20 dn: 2 di: Ongoing xv: 36 xu: Hours
pi: 4607455 hi: 27155 t0: [11:00:00 19/03/2016] pt: TPN st: Expired
pi: 4607908 hi: 27155 t0: [16:00:00 19/03/2016] tf: [04:00:00 20/03/2016] pt: IV Large Volume st: Expired rt: IV fr: ASDIR iv: 1000 ml NS Continuous at 120 ml/hr for 1500 ml ir: 120 it: C ss: N dt: 12 di: Hours xu: Enter on Label
pi: 4609622 hi: 27155 t0: [12:00:00 20/03/2016] pt: TPN st: Expired
pi: 4611648 hi: 27155 t0: [17:00:00 24/02/2016] tf: [08:00:00 02/04/2016] mn: Daptomycin pt: IV Piggyback st: Inactive (Due to a change order) rt: IV fr: Q24H ds: 6 dn: 1 di: Ongoing xu: Enter on Label pi: 4611677 hi: 27155 t0: [23:00:00 24/02/2016] tf: [16:00:00 13/04/2016] mn: Meropenem pt: IV Piggyback st: Discontinued via patient discharge rt: IV fr: Q6H ds: 2, 8, 14, 20 dn: 4 di: Ongoing xv: 36 xu: Hours
pi: 4611848 hi: 27155 t0: [12:00:00 21/03/2016] pt: TPN st: Expired
pi: 4614432 hi: 27155 t0: [00:00:00 22/03/2016] tf: [23:00:00 22/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 0 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours pi: 4614433 hi: 27155 t0: [00:00:00 22/03/2016] tf: [16:00:00 13/04/2016] mn: Morphine Sulfate IR pt: Unit Dose st: Discontinued via patient discharge rt: PO fr: Q6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4614434 hi: 27155 t0: [00:00:00 22/03/2016] tf: [16:00:00 13/04/2016] mn: Acetaminophen pt: Unit Dose st: Discontinued via patient discharge rt: PO fr: Q4-6H:PRN di: Ongoing xv: 36 xu: Hours pi: 4614435 hi: 27155 t0: [00:00:00 22/03/2016] tf: [16:00:00 13/04/2016] mn: Acetaminophen pt: Unit Dose st: Discontinued via patient discharge rt: PR fr: Q4-6H:PRN di: Ongoing xv: 36 xu: Hours
pi: 4615919 hi: 27155 t0: [12:00:00 22/03/2016] pt: TPN st: Expired
pi: 4616475 hi: 27155 t0: [15:00:00 22/03/2016] tf: [14:00:00 23/03/2016] mn: Bupivacaine 0.75% pt: Unit Dose st: Expired rt: SC fr: ONCE ds: 15 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4617895 hi: 27155 t0: [21:00:00 22/03/2016] tf: [20:00:00 23/03/2016] mn: Morphine Sulfate IR pt: Unit Dose st: Expired rt: PO fr: ONCE ds: 21 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4619253 hi: 27155 t0: [10:00:00 23/03/2016] tf: [09:00:00 24/03/2016] mn: Alteplase (Catheter Clearance) pt: Unit Dose st: Expired rt: IV fr: ONCE MR1 ds: 10 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4619636 hi: 27155 t0: [12:00:00 23/03/2016] pt: TPN st: Expired
pi: 4621803 hi: 27155 t0: [22:00:00 23/03/2016] tf: [21:00:00 24/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE MR1 ds: 22 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4623497 hi: 27155 t0: [12:00:00 24/03/2016] pt: TPN st: Expired
pi: 4625166 hi: 27155 t0: [20:00:00 24/03/2016] tf: [19:00:00 25/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE MR1 ds: 20 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4627151 hi: 27155 t0: [13:00:00 25/03/2016] pt: TPN st: Expired
pi: 4628944 hi: 27155 t0: [22:00:00 25/03/2016] tf: [21:00:00 26/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 22 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4630066 hi: 27155 t0: [11:00:00 26/03/2016] pt: TPN st: Expired
pi: 4631500 hi: 27155 t0: [01:00:00 27/03/2016] tf: [00:00:00 28/03/2016] mn: traZODONE HCl pt: Unit Dose st: Expired rt: PO fr: ONCE ds: 1 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4631597 hi: 27155 t0: [03:00:00 27/03/2016] tf: [02:00:00 28/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE MR1 ds: 3 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4632081 hi: 27155 t0: [10:00:00 27/03/2016] pt: TPN st: Expired
pi: 4632623 hi: 27155 t0: [15:00:00 27/03/2016] tf: [14:00:00 28/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 15 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4634355 hi: 27155 t0: [11:00:00 28/03/2016] pt: TPN st: Expired
pi: 4637060 hi: 27155 t0: [00:00:00 29/03/2016] tf: [23:00:00 29/03/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE ds: 0 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4638510 hi: 27155 t0: [13:00:00 29/03/2016] pt: TPN st: Expired
pi: 4640106 hi: 27155 t0: [19:00:00 29/03/2016] tf: [16:00:00 13/04/2016] mn: Morphine Sulfate pt: Unit Dose st: Discontinued via patient discharge rt: IV fr: HS:PRN di: Ongoing xv: 36 xu: Hours
pi: 4642093 hi: 27155 t0: [12:00:00 30/03/2016] pt: TPN st: Expired
pi: 4645590 hi: 27155 t0: [12:00:00 31/03/2016] pt: TPN st: Expired
pi: 4647892 hi: 27155 t0: [23:00:00 31/03/2016] tf: [22:00:00 01/04/2016] mn: Morphine Sulfate pt: Unit Dose st: Expired rt: IV fr: ONCE MR1 ds: 23 dn: 1 dt: 1 di: Doses xv: 36 xu: Hours
pi: 4649827 hi: 27155 t0: [12:00:00 01/04/2016] pt: TPN st: Expired
pi: 4652394 hi: 27155 t0: [06:00:00 02/04/2016] tf: [16:00:00 13/04/2016] mn: Daptomycin pt: IV Piggyback st: Discontinued via patient discharge rt: IV fr: Q24H ds: 6 dn: 1 di: Ongoing xu: Enter on Label
pi: 4653048 hi: 27155 t0: [12:00:00 02/04/2016] pt: TPN st: Expired
pi: 4653442 hi: 27155 t0: [17:00:00 02/04/2016] tf: [18:00:00 02/04/2016] mn: Magnesium Citrate pt: Unit Dose st: Expired rt: PO fr: 2X dn: 0 dt: 2 di: Doses xv: 36 xu: Hours
pi: 4655135 hi: 27155 t0: [12:00:00 03/04/2016] pt: TPN st: Expired
pi: 4656823 hi: 27155 t0: [10:00:00 04/04/2016] tf: [22:00:00 05/04/2016] mn: Magnesium Citrate pt: Unit Dose st: Expired rt: PO fr: 2X dn: 0 dt: 2 di: Doses xv: 36 xu: Hours
pi: 4656866 hi: 27155 t0: [10:00:00 04/04/2016] pt: TPN st: Expired
pi: 4660317 hi: 27155 t0: [10:00:00 05/04/2016] tf: [16:00:00 13/04/2016] mn: Azithromycin pt: Unit Dose st: Discontinued via patient discharge rt: PO fr: 1X/WEEK ds: 10 di: Ongoing xv: 36 xu: Hours
pi: 4660865 hi: 27155 t0: [11:00:00 05/04/2016] pt: TPN st: Expired
pi: 4664485 hi: 27155 t0: [10:00:00 06/04/2016] tf: [11:00:00 06/04/2016] pt: TPN st: Inactive (Due to a change order) pi: 4664535 hi: 27155 t0: [10:00:00 06/04/2016] tf: [16:00:00 13/04/2016] mn: Loperamide pt: Unit Dose st: Discontinued via patient discharge rt: PO fr: QID:PRN di: Ongoing xv: 36 xu: Hours
pi: 4664959 hi: 27155 t0: [12:00:00 06/04/2016] pt: TPN st: Expired
pi: 4668540 hi: 27155 t0: [12:00:00 07/04/2016] pt: TPN st: Expired
pi: 4672125 hi: 27155 t0: [10:00:00 08/04/2016] pt: TPN st: Expired