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/24 vital signs Fluid Balance Chart (FBC) IV Antibiotics and…

 

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Fluid Balance Chart (FBC)

IV Antibiotics and analgesics (PRN only)

Oxygen: 1-4 Litres/minute to maintain target SaO2 > 92%

24-hour Urine Test & FBC

FBE, U&E

Examination findings

LOC: alert and oriented Height: 163cm Weight: 98kg

Vital signs:

T= 38.20C, P=94/min R=28/min BP=149/86 mm of Hg

SaO2=92% on 2 l of O2/min via nasal prongs

Pain: 6 out of 10 around the rib cage; aggravated with coughing

Investigations:

FBE, U&E, LFT, urine MC&S, Blood Cultures x two, Sputum specimen,

CXR – NAD

Current Nursing Care Plan

Observation: Vital signs x 4/24, QID BSL, Strict Fluid Balance Chart

Mobility: Assist x 1, walks with 4-wheeled frame

Transfers: Assist x 2

Hygiene: Assist x 1 with showers. Independent with oral care

Toileting: Assist x 1 with toileting on toilet seat, IDC insitu

Nutrition: Soft diabetic diet/ restricted protein/ low sodium

Hydration: Normal texture liquids

Pain management: PRN medications

Use a table to insert all normal values on the left and abnormal in the middle and then the interpretation to the right.

Objective Subjective Normal data range Interpretation
       
     

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