NOC SHIFT RN REPORT<\/p>\n\n\n\n
History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@
@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@
MRN: @MRN@
SYNOPSIS<\/p>\n\n\n\n
@NAME@ is a @AGE@ @SEX@ ***<\/p>\n\n\n\n
Admitted for
@DIAG@<\/p>\n\n\n\n
@PROB@<\/p>\n\n\n\n
@PROBACTHOSP@<\/p>\n\n\n\n
RN CONCERNS\/UPDATES<\/p>\n\n\n\n
NOC SHIFT RN REPORT<\/p>\n\n\n\n
History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@
@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@
MRN: @MRN@
SYNOPSIS<\/p>\n\n\n\n
@NAME@ is a @AGE@ @SEX@ ***<\/p>\n\n\n\n
Admitted for
@DIAG@<\/p>\n\n\n\n
@PROB@<\/p>\n\n\n\n
@PROBACTHOSP@<\/p>\n\n\n\n
RN CONCERNS\/UPDATES<\/p>\n\n\n\n
\u2022 NEURO
1. Behavioral description:
2. Temperature:
3. Weakness\/Exceptions\/Aberrations:
4. FC\/MAE\/ROM?:
\u2022 CARDS
1. Majority rhythm:
2. Pertinent Meds
3. MAP Goal
1. PRNs
4. Blood Thinners?
\u2022 RESP
1. Vent Mode: AC\/
1. Settings @FLOW(3330031802,301580,301570,7074344,7074327,301650,7074356,316060,316040,7074336,3463)@
2. Daily ABGs?
3. Secretions:
4. Home equipment?
\u2022 GI
1. @DIETORDERS@
1. H2O Flushes?
2. Route:
3. BG Checks?:
\u2022 GU
1. Foley y\/n?
1. Indication:
2. Urine appearance:
3. 24 Hour I\/O @IOBRIEF@
4. NOC Shift Net: m L
\u2022 SKIN
1. Intact?
2. Wounds:
1. New\/old?
\u2022 PAIN
1. CPOT 0
2. Management:
\u2022 PROPHYLAXIS
1. Heparin subcutaneous
2. SCD
\u2022 LABS
1. Lytes repleted:
2. Serial collection?:
1. Daily CBC\/CMP
3. Criticals:
4. Microbio:
\u2022 RESTRAINTS
1. Y\/N:
2. Reason:
\u2022 MAIN PROBLEM TODAY
1.
\u2022 PT GOALS
1.
\u2022 PROVIDER PLANS
1.
2.
\u2022 OTHER
1. Family matters:
\u2022 PRECAUTIONS
1. Isolation
2. Inpatient
\u2022 CONSULTANTS
1. @CONORDS@<\/p>\n\n\n\n
DRIPS<\/p>\n\n\n\n
LINES:<\/p>\n\n\n\n
VENT<\/p>\n\n\n\n
VENT SETTINGS \/ ABGs
@VENTSETTINGS@<\/p>\n\n\n\n
Arterial Blood Gas result:
pH ***;
pO2 ***;
pCO2 ***;
HCO3 ***,
%O2 Sat ***.<\/p>\n\n\n\n
HISTORY\/SOCIAL<\/p>\n\n\n\n
@ALLERGY@
@PMH@
@PSH@
@FAMHX@
@FAMST@
@SOCHX@
@PTAMEDS@<\/p>\n\n\n\n
VITALS<\/p>\n\n\n\n
VITALS
24 Hour Min \/ Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@<\/p>\n\n\n\n
LABS<\/p>\n\n\n\n
@LABBRIEFBMT(K,MG,CA,PHOS,NA,CREAT,IACO2,IAPH)@<\/p>\n\n\n\n
Na @LABRESULT(NA)@ CL @LABRESULT(CL)@ BUN @LABRESULT(BUN)@ GLU
@LABRESULT(GLU)@
K @LABRESULT(K)@ CO2 @LABRESULT(BICARB)@ Cr @LABRESULT(CREAT)@<\/p>\n\n\n\n
WBC @LABRESULT(WBC)@ HGB @LABRESULT(hgb)@ PLT @LABRESULT(PLT)@
HCT @LABRESULT(hct)@<\/p>\n\n\n\n
PT @LABRESULT(PT)@ PTT @LABRESULT(PTT)@
INR @LABRESULT(INR)@<\/p>\n\n\n\n
IMAGING<\/p>\n\n\n\n
Imaging @ENCIMAGING@
Procedures @ENCPROC@
Other @ENCOTHERORDERS@<\/p>\n\n\n\n
MEDS & ACTIVE ORDERS<\/p>\n\n\n\n
See MAR<\/p>\n\n\n\n
@ACTIVEORD@<\/p>\n\n\n\n
@DCMED@<\/p>\n\n\n\n
CARE PLAN<\/p>\n\n\n\n
NURSING PLAN OF THE DAY<\/p>\n\n\n\n
Maintenance Tasks
-add\/maintain PIVs, check need for CVC\/Foley
-monitor electrolytes
-strict I\/o when ordered
-neuro checks periodically
-monitor HGB; check s\/s bleeding
-ensure airway trach patency
-elevate arms, if app
-d\/w attending pt status
-turned pt q2h
-fall risk observed
-wound care\/prevention as necessary<\/p>\n\n\n\n
Report given to oncoming RN, , at end of shift, who then assumed all care.<\/p>\n\n\n\n
@MEMD@, BSN, CCRN
Electronic Signature
@TD@ @NOW@<\/p>\n\n\n\n
DRIPS<\/p>\n\n\n\n
LINES:<\/p>\n\n\n\n
VENT<\/p>\n\n\n\n
VENT SETTINGS \/ ABGs
@VENTSETTINGS@<\/p>\n\n\n\n
Arterial Blood Gas result:
pH ***;
pO2 ***;
pCO2 ***;
HCO3 ***,
%O2 Sat ***.<\/p>\n\n\n\n
HISTORY\/SOCIAL<\/p>\n\n\n\n
@ALLERGY@
@PMH@
@PSH@
@FAMHX@
@FAMST@
@SOCHX@
@PTAMEDS@<\/p>\n\n\n\n
VITALS<\/p>\n\n\n\n
VITALS
24 Hour Min \/ Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@<\/p>\n\n\n\n
LABS<\/p>\n\n\n\n
@LABBRIEFBMT(K,MG,CA,PHOS,NA,CREAT,IACO2,IAPH)@<\/p>\n\n\n\n
Na @LABRESULT(NA)@ CL @LABRESULT(CL)@ BUN @LABRESULT(BUN)@ GLU
@LABRESULT(GLU)@
K @LABRESULT(K)@ CO2 @LABRESULT(BICARB)@ Cr @LABRESULT(CREAT)@<\/p>\n\n\n\n
WBC @LABRESULT(WBC)@ HGB @LABRESULT(hgb)@ PLT @LABRESULT(PLT)@
HCT @LABRESULT(hct)@<\/p>\n\n\n\n
PT @LABRESULT(PT)@ PTT @LABRESULT(PTT)@
INR @LABRESULT(INR)@<\/p>\n\n\n\n
IMAGING<\/p>\n\n\n\n
Imaging @ENCIMAGING@
Procedures @ENCPROC@
Other @ENCOTHERORDERS@<\/p>\n\n\n\n
MEDS & ACTIVE ORDERS<\/p>\n\n\n\n
See MAR<\/p>\n\n\n\n
@ACTIVEORD@<\/p>\n\n\n\n
@DCMED@<\/p>\n\n\n\n
CARE PLAN<\/p>\n\n\n\n
NURSING PLAN OF THE DAY<\/p>\n\n\n\n
NOC SHIFT RN REPORT<\/p>\n\n\n\n
History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@
@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@
MRN: @MRN@
SYNOPSIS<\/p>\n\n\n\n
@NAME@ is a @AGE@ @SEX@ ***<\/p>\n\n\n\n
Admitted for
@DIAG@<\/p>\n\n\n\n
@PROB@<\/p>\n\n\n\n
@PROBACTHOSP@<\/p>\n\n\n\n
RN CONCERNS\/UPDATES<\/p>\n\n\n\n
\u2022 NEURO
1. Behavioral description:
2. Temperature:
3. Weakness\/Exceptions\/Aberrations:
4. FC\/MAE\/ROM?:
\u2022 CARDS
1. Majority rhythm:
2. Pertinent Meds
3. MAP Goal
1. PRNs
4. Blood Thinners?
\u2022 RESP
1. Vent Mode: AC\/
1. Settings @FLOW(3330031802,301580,301570,7074344,7074327,301650,7074356,316060,316040,7074336,3463)@
2. Daily ABGs?
3. Secretions:
4. Home equipment?
\u2022 GI
1. @DIETORDERS@
1. H2O Flushes?
2. Route:
3. BG Checks?:
\u2022 GU
1. Foley y\/n?
1. Indication:
2. Urine appearance:
3. 24 Hour I\/O @IOBRIEF@
4. NOC Shift Net: m L
\u2022 SKIN
1. Intact?
2. Wounds:
1. New\/old?
\u2022 PAIN
1. CPOT 0
2. Management:
\u2022 PROPHYLAXIS
1. Heparin subcutaneous
2. SCD
\u2022 LABS
1. Lytes repleted:
2. Serial collection?
1. Daily CBC\/CMP
3. Criticals
\u2022 RESTRAINTS
1. Y\/N:
2. Reason:
\u2022 MAIN PROBLEM TODAY
1.
\u2022 PT GOALS
1.
\u2022 PROVIDER PLANS
1.
2.
\u2022 OTHER
1. Family matters:
\u2022 PRECAUTIONS
1. Isolation
2. Inpatient
\u2022 CONSULTANTS
1. @CONORDS@<\/p>\n\n\n\n
DRIPS<\/p>\n\n\n\n
LINES:<\/p>\n\n\n\n
VENT<\/p>\n\n\n\n
VENT SETTINGS \/ ABGs
@VENTSETTINGS@<\/p>\n\n\n\n
Arterial Blood Gas result:
pH ***;
pO2 ***;
pCO2 ***;
HCO3 ***,
%O2 Sat ***.<\/p>\n\n\n\n
HISTORY\/SOCIAL<\/p>\n\n\n\n
@ALLERGY@
@PMH@
@PSH@
@FAMHX@
@FAMST@
@SOCHX@
@PTAMEDS@<\/p>\n\n\n\n
VITALS<\/p>\n\n\n\n
VITALS
24 Hour Min \/ Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@<\/p>\n\n\n\n
LABS<\/p>\n\n\n\n
@LABBRIEFBMT(K,MG,CA,PHOS,NA,CREAT,IACO2,IAPH)@<\/p>\n\n\n\n
Na @LABRESULT(NA)@ CL @LABRESULT(CL)@ BUN @LABRESULT(BUN)@ GLU
@LABRESULT(GLU)@
K @LABRESULT(K)@ CO2 @LABRESULT(BICARB)@ Cr @LABRESULT(CREAT)@<\/p>\n\n\n\n
WBC @LABRESULT(WBC)@ HGB @LABRESULT(hgb)@ PLT @LABRESULT(PLT)@
HCT @LABRESULT(hct)@<\/p>\n\n\n\n
PT @LABRESULT(PT)@ PTT @LABRESULT(PTT)@
INR @LABRESULT(INR)@<\/p>\n\n\n\n
IMAGING<\/p>\n\n\n\n
Imaging @ENCIMAGING@
Procedures @ENCPROC@
Other @ENCOTHERORDERS@<\/p>\n\n\n\n
MEDS & ACTIVE ORDERS<\/p>\n\n\n\n
See MAR<\/p>\n\n\n\n
@ACTIVEORD@<\/p>\n\n\n\n
@DCMED@<\/p>\n\n\n\n
CARE PLAN<\/p>\n\n\n\n
NURSING PLAN OF THE DAY<\/p>\n\n\n\n
Maintenance Tasks
-add\/maintain PIVs, check need for CVC\/Foley
-monitor electrolytes
-strict I\/o when ordered
-neuro checks periodically
-monitor HGB; check s\/s bleeding
-ensure airway trach patency
-elevate arms, if app
-d\/w attending pt status
-turned pt q2h
-fall risk observed
-wound care\/prevention as necessary<\/p>\n\n\n\n
Report given to oncoming RN, , at end of shift, who then assumed all care.<\/p>\n\n\n\n
@MEMD@, BSN, CCRN
Electronic Signature
@TD@ @NOW@<\/p>\n\n\n\n
Report given to oncoming RN, , at end of shift, who then assumed all care.<\/p>\n\n\n\n
@MEMD@, BSN, CCRN
Electronic Signature
@TD@ @NOW@<\/p>\n","protected":false},"excerpt":{"rendered":"
NOC SHIFT RN REPORT History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@MRN: @MRN@SYNOPSIS @NAME@ is a @AGE@ @SEX@ *** Admitted for@DIAG@ @PROB@ @PROBACTHOSP@ RN CONCERNS\/UPDATES NOC SHIFT RN REPORT History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@MRN: @MRN@SYNOPSIS @NAME@ is a @AGE@ @SEX@ *** Admitted for@DIAG@ @PROB@ @PROBACTHOSP@ RN CONCERNS\/UPDATES \u2022…<\/p>\n","protected":false},"author":1,"featured_media":2837,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"om_disable_all_campaigns":false,"_uag_custom_page_level_css":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[64],"tags":[],"class_list":["post-2826","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uc-east"],"aioseo_notices":[],"uagb_featured_image_src":{"full":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc.jpg",900,1200,false],"thumbnail":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc-150x150.jpg",150,150,true],"medium":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc-225x300.jpg",225,300,true],"medium_large":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc-768x1024.jpg",768,1024,true],"large":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc-768x1024.jpg",768,1024,true],"1536x1536":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc.jpg",900,1200,false],"2048x2048":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc.jpg",900,1200,false],"portfolio-thumb":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc-500x380.jpg",500,380,true],"woocommerce_thumbnail":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc-300x300.jpg",300,300,true],"woocommerce_single":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc-600x800.jpg",600,800,true],"woocommerce_gallery_thumbnail":["https:\/\/nursehowie.net\/wp-content\/uploads\/2024\/06\/pkk0vys1xjc-100x100.jpg",100,100,true]},"uagb_author_info":{"display_name":"Howie","author_link":"https:\/\/nursehowie.net\/?author=1"},"uagb_comment_info":1,"uagb_excerpt":"NOC SHIFT RN REPORT History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@MRN: @MRN@SYNOPSIS @NAME@ is a @AGE@ @SEX@ *** Admitted for@DIAG@ @PROB@ @PROBACTHOSP@ RN CONCERNS\/UPDATES NOC SHIFT RN REPORT History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@MRN: @MRN@SYNOPSIS @NAME@ is a @AGE@ @SEX@ *** Admitted for@DIAG@ @PROB@ @PROBACTHOSP@ RN CONCERNS\/UPDATES \u2022…","_links":{"self":[{"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/posts\/2826","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2826"}],"version-history":[{"count":3,"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/posts\/2826\/revisions"}],"predecessor-version":[{"id":2829,"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/posts\/2826\/revisions\/2829"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/media\/2837"}],"wp:attachment":[{"href":"https:\/\/nursehowie.net\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2826"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2826"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2826"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}