S Situation Age: Current Wt. Allergies: Reason for admission: B Background Past Medical History: Primary Language: Current Meds Due Rational A Range VS: Temp HR RR PAIN (FACES,... FLACC) BP O2 sat Pulse Ox Site Assessment Isolation Reason for Isolation: Contact Air Droplet Droplet/Contact Neuro PERRLA: Activity: Mood/Affect: Fontanel: LOC: RESP 0800 1200 1600 RR: Pulse Ox: O2 requirements: (FiO2, oxygen delivery system) Breath Sounds: Work of Breathing: Trach: (size, type) Suction: Respiratory Treatments/Times: (aerosol, nebulized, CPT) CV 0800 1200 1600 HR: IV Access Site: Cap refill: Fluids: 08 09 10 11 12 2 4 6 BP: Temp: Diet Guidelines: Infant <6-9m BM/form Q 3H 9-12m BM/form Q 3-4H+ 1-3 puree meals ¼ -1/3 c variety Type diets; 12-18m form + 3 meals/ snacks soft/chunky, 18m+= toddler diet, than regular GI/GU Diet/Intake; mL (times) 8 10 12 2 4 6 Accu check: GI tubes: Bowel sounds: Urine output: (every 2-4 H) 08 10 12 2 4 6 Stool/color, consistency Amount: gm=mL Emesis: SKIN is study source was Bath/hygiene: Linen: downloaded by 100000815948112 from CourseHero.com on 04-30-2 Rash/wound site: 021 03:59:15 GMT -05:00 .......................CONTINUED............................................ [Show More]
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