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A&Ox - (Disoriented To - ) - VSS On - (O2 Source) - Pills - (Whole or crushed/NPO) - Bathroom (Up To Toilet or

The patient is oriented but disoriented to some context. They receive oxygen and are on telemetry monitoring. Neurological checks and alcohol withdrawal assessments are performed if applicable. The patient denies pain or identifies location and treatment. They swallow pills whole or crushed depending on diet status. Mobility status ranges from independent toilet use to total assistance with a bedpan. Skin integrity is assessed and any wounds or interventions addressed. Restraint use and intravenous lines are noted if present. Plans include continuing current treatment or discharging to another level of care.

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80 views2 pages

A&Ox - (Disoriented To - ) - VSS On - (O2 Source) - Pills - (Whole or crushed/NPO) - Bathroom (Up To Toilet or

The patient is oriented but disoriented to some context. They receive oxygen and are on telemetry monitoring. Neurological checks and alcohol withdrawal assessments are performed if applicable. The patient denies pain or identifies location and treatment. They swallow pills whole or crushed depending on diet status. Mobility status ranges from independent toilet use to total assistance with a bedpan. Skin integrity is assessed and any wounds or interventions addressed. Restraint use and intravenous lines are noted if present. Plans include continuing current treatment or discharging to another level of care.

Uploaded by

ChrFa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Plan of Care Note

A&Ox _____ (disoriented to_____). VSS on _____ (O2 source).


Telemetry (if present). CIWA (if present). Neuro checks (if
present). Denies pain (or location and intervention). Swallows
pills _______ (whole or crushed/NPO). Bathroom (Up to toilet or
BSC, assisted with bed pan, incontinent). Skin (if any interventions
performed). Restraints (if present). Lines (if applicable, any CVAD or
continuous fluids). Bed mobility (independent, T&R q2h with assist
of 1 or 2). Ambulating (independently, with Ax1 or 2 with RW).
Specialty bed or Accumax (if applicable). Bed alarm on (if
applicable). Safety maintained. Hourly rounding performed. See
flowsheet for further details.
Patient Report Guide
Name/Age/Sex: 
Code Status:
Allergies:  (if more than 2 say "multiple allergies, see chart for details")
Chief Complaint: (also any pertinent history)
Neuro: A&Ox
Pain/CIWA/Neuro checks/Language interpreter (if applicable)
Resp: O2 Source
Cardiac: Tele/HR/BP (if applicable or abnormal)
GI/GU: Swallows pills
Diet /Fingerstick if applicable
Continent/incontinent or foley/ostomies (toilet/bedpan/commode with Ax_)
Last BM
P/V: IV's and CVADs
Any continuous infusions
Edema (If applicable)
Skin: Intact or wounds & locations
Activity: Independent/Ax1-2/RW, cane etc. *Restraints (if applicable)
Plan: ex. "IV abx" or "D/C to STR" or "Continue workup"

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