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BASIC
PRINCIPAL:
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Monitor
only parameters that can change rapidly (during the 1 - 2 hrs in
the ER) and which would reflect a need for intervention, or a response
to treatment (e.g. change of pain level, GCS, peak flow, ABG's,
urine output, etc.) |
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FREQUENCY:
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depends
on conditions/events |
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VITAL
SIGNS:
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STANDARD,
including pulse oximetry (when heart rate rapid or irregular, BP
should be done manually before relying on automated equipment) |
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ADDITIONAL PHYSIOLOGIC OPTIONS
TO MONITOR:
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AMS -- GCS
or AVPU, pupillary size/reactivity
Pain - 0-10
Respiratory problem: Peak flow rate
Dyspnea 0-4
Seizures - each occurrence
Hypoglycemic reaction - glucose
Circulation - capillary refill time
(Personal set of suggested parameters
to be monitored in specific conditions is available upon request)
|
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IV
FLUIDS:
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IV fluids
- 3 columns provided for I & O: use / in the box, recording the
amount of fluids given in the most recent time frame BEFORE the
slash , and the TOTAL received to date after the slash, e.g.
| Intake
|
Output
|
| 150/150
|
50/50 |
| 200/350 |
200/250 |
|
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MEDICATIONS:
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record
medication at top of column, amount & route (IV, IM) in the row
(box) |
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INITIALS:
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three
areas - adjacent to VS's, at end of comments and adjacent to signature,
right, lower corner. |
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COMMENTS:
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use
space on right hand side for this. If more than one line needed,
make next time entry on the line BELOW last entry in comments. If
a long entry, make a note to that effect and write on a continuation
sheet. |
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BLANKS:
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Like
in other notation systems (e.g. music), not every space is filled.
When action is taken (e.g. blood drawn for ABG's or K+)- indicate
in the appropriate box/time line with a check-mark for three reasons
- alerts
staff to fact that specimen obtained (when report delayed -
becomes evident not due to lack of sample.
- time of
sampling.
- location
for recording result in the appropriate box/time line.
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LABELS:
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Pre-printed,
gummed labels for common parameters, IV solutions & medications
improve legibility (Available upon request) |
