Patient Worksheet - Nicu 2-patient

Air

ABDs? // GFR? // Sats? Sucking Coordination?

Gest Age:

Name:

DOL/DOB:

Dr:

♂/♀

Allergies: Dx:

Font: soft / flat / depressed / bulging // CRF? Color: pink / cyanotic / jaundiced / Water IV: none // piv / picc // L / R // hand / saph / Form: MBM / Nipple: well / fair / poor // ↑ // na: Food BF: well / fair / poor / none // ↑ // pumping

Elimination

Activity/Safety

@

↓

u/s

@

↑

↓

u/s

@

↑

↓

u/s

@

↑

↓

u/s

@

↑

↓

u/s

strict / diaper- stool?

: BVM / O2 / Sxn / IV Behavior: sleeping / quiet / active / lethargic

↑

@

P

R

O

T

-

@

P

R

O

T

-

@

P

R

O

T

-

@

P

R

O

T

-

BP

Labs/Meds/Tx/Notes:

Lactation Teaching? y / n / Social/Devel

Air

ABDs? // GFR? // Sats? Sucking Coordination?

Gest Age:

Name:

DOL/DOB:

Dr:

♂/♀

Allergies:

Font: soft / flat / depressed / bulging // CRF? Color: pink / cyanotic / jaundiced / Water IV: none // piv / picc // L / R // hand / saph / Form: MBM / Nipple: well / fair / poor // ↑ // na: Food BF: well / fair / poor / none // ↑ // pumping

Elimination

Activity/Safety

Dx:

@

↓

u/s

@

↑

↓

u/s

@

↑

↓

u/s

@

↑

↓

u/s

@

↑

↓

u/s

strict / diaper- stool?

: BVM / O2 / Sxn / IV Behavior: sleeping / quiet / active / lethargic

↑

@

P

R

O

T

-

@

P

R

O

T

-

@

P

R

O

T

-

@

P

R

O

T

-

BP

Labs/Meds/Tx/Notes:

Lactation Teaching? y / n / Social/Devel

Date:

Bed:

Bed:

0700–0800

report;

report;

report;  charts

report;  charts

0800–0900 0900–1000 1000–1100 1100–1200 1200–1300 1300–1400 1400–1500 1500–1530

Report: bed, name, age, Dx, ABDs, O2, IV, void/stool, girth, last/next feed, last/next meds, next labs, Tx, etc.

Air:

Dx:

Water:

1

Food:

♂/♀ Labs:

DOL/DOB:

Safety/Social/Devel:

Dr: Dx:

Water: Food:

♂/♀ Labs:

Safety/Social/Devel:

Dr:

Food:

Dx:

♂/♀ Labs:

Safety/Social/Devel:

Dr: Dx:

Food:

Dr: Dx:

Water: Food:

♂/♀ Labs:

DOL/DOB: Dr:

Food:

Dx:

Name:

♂/♀ Labs:

Gest Age:

Elim:

DOL/DOB:

Safety/Social/Devel:

Dr:

Air:

Dx:

Water: Food:

Name:

♂/♀ Labs:

Gest Age:

Elim:

DOL/DOB:

Safety/Social/Devel:

Dr:

Air:

Dx:

Water: Food:

Name:

♂/♀ Labs:

Gest Age:

Elim:

DOL/DOB:

Safety/Social/Devel:

Dr:

Air:

Dx:

Water: Food:

Dr: Dx:

Water: Food:

Gest Age: DOL/DOB:

Safety/Social/Devel: Air:

Name:

♂/♀ Labs:

Elim:

10

Gest Age:

Safety/Social/Devel:

Water:

9

Name:

Elim:

Air:

8

Gest Age: DOL/DOB:

Safety/Social/Devel: Air:

Name:

♂/♀ Labs:

Elim:

7

Gest Age: DOL/DOB:

Water:

6

Name:

Elim:

Air:

5

Gest Age: DOL/DOB:

Water:

4

Name:

Elim:

Air:

3

Gest Age:

Elim:

Air:

2

Name:

Name:

♂/♀ Labs:

Gest Age:

Elim:

DOL/DOB:

Safety/Social/Devel:

Dr: