| Assessment / Intervention | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 |
|---|---|---|---|---|---|
| Vital Signs | |||||
| Blood Pressure (mmHg) |
120/80
130/90
135/88
140/95
180/110
|
120/80
130/90
135/88
140/95
180/110
|
120/80
130/90
135/88
140/95
180/110
|
120/80
130/90
135/88
140/95
180/110
|
120/80
130/90
135/88
140/95
180/110
|
| Temperature (°F/°C) |
.
|
.
|
.
|
.
|
.
|
| Heart Rate (bpm) |
60
70
78
90
100
|
60
70
78
90
100
|
60
70
78
90
100
|
60
70
78
90
100
|
60
70
78
90
100
|
| Respiratory Rate (rpm) |
12
16
20
24
|
12
16
20
24
|
12
16
20
24
|
12
16
20
24
|
12
16
20
24
|
| O2 Saturation (%) |
94
95
98
100
|
94
95
98
100
|
94
95
98
100
|
94
95
98
100
|
94
95
98
100
|
| Neurological (WDL) | |||||
| Level of Consciousness |
Alert
Lethargic
Obtunded
Unresponsive
|
||||
| Orientation Level (x1–x4) |
x1
x2
x3
x4
|
||||
| Cognition |
Intact
Mildly impaired
Severely impaired
|
||||
| Speech |
Clear
Slurred
Aphasic
|
||||
| Eye Movement (R/L) |
Normal
Nystagmus
Limited
|
||||
| Pupil Size (R/L) mm |
2/2
3/3
4/4
3/2
|
||||
| Pupil Reactivity |
Brisk
Sluggish
Fixed
|
||||
| Extremity Movement RUE/LUE/RLE/LLE |
Normal
Weak
Paralysis
|
||||
| GCS Score (3-15) |
15
14
12
8
|
||||
| Sedation Scale (RASS) |
0 (Alert & Calm)
-1 (Drowsy)
+1 (Restless)
-2 (Light Sedation)
+2 (Agitated)
|
||||
| HEENT (WDL) | |||||
| Head and Face |
Symmetrical
Asymmetrical
|
||||
| Eyes (R/L) |
Clear sclera
Drainage noted
Red conjunctiva
|
||||
| Ears (R/L) |
Normal
Hearing impaired
Drainage
|
||||
| Nose |
Midline
Drainage
Deviation
|
||||
| Mouth/Lips |
Moist
Dry
Cracked
|
||||
| Throat |
Normal
Redness
Swelling
|
||||
| Neck |
Supple
Stiff
Swollen
|
||||
| Eye Care |
Given
Not Needed
Scheduled
|
||||
| Oral Hygiene |
Performed
Assisted
Refused
|
||||
| Respiratory (WDL) | |||||
| Respiratory Pattern |
Regular
Irregular
|
||||
| Depth/Rhythm |
Normal
Shallow
Deep
|
||||
| Effort |
Unlabored
Labored
Accessory muscles
|
||||
| Breath Sounds |
Clear
Wheezing
Rales
Rhonchi
|
||||
| Chest Assessment |
Symmetrical rise
Retractions
Barrel chest
|
||||
| O2 Administered |
None
Nasal Cannula 2L
Mask 5L
|
||||
| Suctioning |
Oral Q4H
Nasal PRN
None
|
||||
| Cardiac | |||||
| Heart Sounds |
S1 S2 Normal
Murmur
Rub
Gallop
|
||||
| Jugular Venous Distension |
Absent
Present
|
||||
| Cardiac Rhythm |
NSR
AFib
PVCs
Tachy
|
||||
| Ectopy |
Absent
Present
Frequent
|
||||
| Telemetry Monitor Status |
On, Alarms On
On, Alarms Off
Off
|
||||
| Pacemaker |
None
Atrial
Ventricular
Dual Chamber
|
||||
| Peripheral Vascular (WDL) | |||||
| Pulses (Radial, Pedal, PT) |
All present
Diminished Pedal
Absent PT
|
||||
| Capillary Refill |
<2s
>2s
|
||||
| Edema |
None
+2 Pitting
+3 Pitting
|
||||
| Skin Color & Temp (Extremities) |
Pink, Warm
Pale, Cool
Cyanotic, Cool
|
||||
| Integumentary (WDL) | |||||
| Skin Color |
Normal
Pale
Reddened
|
||||
| Skin Temp |
Warm
Cool
Hot
|
||||
| Skin Integrity |
Intact
Breakdown
Rash
Wound Present
|
||||
| Skin Turgor |
Elastic
Tenting
|
||||
| Wound Observations | |||||
| Braden Scale (if applicable) | |||||
| Musculoskeletal (WDL) | |||||
| RUE / LUE / RLE / LLE |
Full movement
Limited
Contracture
|
||||
| Gait |
Steady
Unsteady
Assisted
|
||||
| Muscle Strength (0–5) |
5
4
3
2
|
||||
| Joint Deformities |
None
Arthritic changes
|
||||
| Assistive Devices |
None
Cane
Walker
Crutches
|
||||
| Gastrointestinal (WDL) | |||||
| Abdominal Inspection |
Flat
Distended
Obese
|
||||
| Bowel Sounds |
Active (All quads)
Hypoactive RLQ
Absent LUQ
|
||||
| Tenderness |
Soft, Non-distended
Tender RLQ
|
||||
| Last BM Date | |||||
| Passing Flatus |
Yes
No
|
||||
| Bowel Incontinence |
No
Yes
Occasional
|
||||
| Stool Color / Appearance | |||||
| Nausea / Emesis | |||||
| GI Interventions | |||||
| Genitourinary (WDL) | |||||
| Urinary Incontinence |
No
Occasional
Frequent
|
||||
| Urine Color |
Yellow
Dark Amber
Red-tinged
|
||||
| Urine Appearance |
Clear
Cloudy
Sediment
|
||||
| Urine Odor |
None
Foul
Strong
|
||||
| Suprapubic Tenderness |
None
Present
|
||||
| Urinary Catheter Present |
Voiding spontaneously
Foley 16Fr
Suprapubic
External
None
|
||||
| GU Interventions | |||||
| Psychosocial (WDL) | |||||
| Behavior |
Calm
Agitated
Withdrawn
|
||||
| Support System |
Family Present
None
Friend Support
|
||||
| Interaction with Staff |
Cooperative
Anxious
Hostile
|
||||
| Psych Interventions | |||||
| Provider Notification | |||||
| Reason for Communication |
VS Change
New Symptoms
Family Concern
|
||||
| Time Notified | |||||
| Provider Response | |||||
| Pain Assessment | |||||
| Pain Score (0-10) |
0
3
5
7
10
|
||||
| Location / Quality | |||||
SnapShot
Demographics
Name: Panda Grayson
Age/Sex: 29 y/o M
Address: 77 Cherry Rd, Springfield
Phone: (555) 777-1212
Comm Pref: Email/Text
Problem List
1. Hypertension
2. Diabetes Type 2
3. Obesity
Tobacco History
Smoking Status: Ex-smoker
Smokeless Tobacco: Never
Vitals Trend
Last 24h: HR 70–90, BP 120/80–142/92, etc.
Chart Review
Latest Labs
| Lab Test | Value | Date/Time |
|---|---|---|
| Sodium | 140 mEq/L | 03/21/2025 03:07 |
| Potassium | 4.3 mEq/L | 03/21/2025 03:07 |
| WBC | 6.2 | 03/21/2025 03:07 |
| Creatinine | 1.0 mg/dL | 03/21/2025 03:07 |
Recent Notes
03/21/2025 – Progress Note: Pt stable, mild ankle edema...
Imaging
03/20/2025 – CXR: mild cardiomegaly, RLL infiltration suspected.
| Medication | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 |
|---|---|---|---|---|---|
| NS IV @ 75 mL/hr Continuous Infusion |
Running 75 |
Running 75 |
Running 75 |
Running 75 |
Running 75 |
| Lisinopril 10mg PO Daily |
Due | Due | |||
| Tylenol 650mg PO PRN Q4H |
10:15 RN |
22:05 RN |
|||
| Metformin 500mg PO BID |
Due | Due | |||
| Hydrocodone-APAP 5-325mg PRN Q6H |
Due |