This log is also available as text (s04286.txt) and as a (binary) annotation file (s04286.log).
Generated: Monday, 07-Jun-2010 13:20:16 EDT
(All dates below are surrogates.)
t0: [09:20:47 23/10/2016] tf: [13:30:56 31/10/2016] id: a40264 [view]
t0: 10:29:01 tf: [13:29:59 31/10/2016] id: a40264n [view]
id: Pre-Admission Intake el: 1 cu: CCU cg: RN io: Pre-Admission Intake Pre-Admission Intake du: cc rt: Intravenous Push id: TF Residual el: 1 cu: CCU cg: RN io: TF Residual Gastric/TF Residual du: ml rt: Gastric/Feeding Tube
tf: [13:44:00 31/10/2016] dt: 11918 cu: CCU de: CC7
id: D5W el: 1 cu: CCU cg: -1 io: D5W 100.0ml IV Infusions vo: 100 du: ml rt: Intravenous Push id: Po Intake el: 1 cu: CCU cg: -1 io: Po Intake PO/Gastric du: ml rt: Oral
t0: [08:00:00 23/10/2016] tf: [18:31:00 27/10/2016] dt: 6391 id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [08:00:00 23/10/2016] tf: [18:31:00 27/10/2016] dt: 6391 id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 18 gauge st: NotStopd t0: [08:00:00 23/10/2016] tf: [18:31:00 27/10/2016] dt: 6391 id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [08:00:00 23/10/2016] tf: [18:31:00 27/10/2016] dt: 6391 id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Left Hand v2: 20 gauge st: NotStopd
t0: [08:00:00 23/10/2016] tf: [23:00:00 26/10/2016] dt: 5220 id: Pre-Admission Intake Pre-Admission Intake el: 1 cu: CCU cg: RN ai: 189 vo: 800 vu: ml t0: [08:00:00 23/10/2016] tf: [23:00:00 26/10/2016] dt: 5220 id: Pre-Admission Output Pre-Admission Output el: 1 cu: CCU cg: RN vo: 1000 vu: ml
tf: [15:00:00 23/10/2016] pt: Unit Dose rt: IV fr: Q1-2H:PRN m1: Lorazepam v1: 1 u1: mg tf: [19:00:00 23/10/2016] pt: Unit Dose rt: IV DRIP fr: TITRATE TO m1: Propofol (Generic) v1: 1000 u1: mg tf: [01:00:00 24/10/2016] pt: Unit Dose rt: PO fr: Q4-6H:PRN m1: Acetaminophen v1: 325-650 u1: mg tf: [18:00:00 03/11/2016] pt: IV Piggyback rt: IV fr: Q12H fs: 0, 12 dn: 2 m1: Famotidine v1: 20 u1: mg m2: Iso-Osmotic Sodium Chloride v2: 50 u2: ml tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: Q4-6H:PRN m1: Acetaminophen (Liquid) v1: 325-650 u1: mg
id: Propofol el: 100 cu: CCU cg: RN io: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions am: 500 du: mcgkgmin rt: IV Drip id: Propofol el: 100 cu: CCU cg: RN io: N/A 100.0vl + 1000mcgkgmin Propofol IV Infusions am: 500 du: mcgkgmin rt: IV Drip id: Propofol el: 101 cu: CCU cg: RN io: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions am: 1000 du: mcgkgmin rt: IV Drip id: Propofol el: 101 cu: CCU cg: RN io: N/A 100.0vl + 1000mcgkgmin Propofol IV Infusions am: 1000 du: mcgkgmin rt: IV Drip
io: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions el: 1 cu: CCU cg: RN ra: 24 ru: ml/hr io: N/A 100.0vl + 1000mcgkgmin Propofol IV Infusions el: 1 cu: CCU cg: RN ra: 24 ru: ml/hr
id: N/A el: 1 cu: CCU cg: RN io: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions vo: 100 du: vl rt: Intravenous Push id: N/A el: 1 cu: CCU cg: RN io: N/A 100.0vl + 1000mcgkgmin Propofol IV Infusions vo: 100 du: vl rt: Intravenous Push
t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Heart Rate el: 0 cu: CCU cg: RN v1: 100 u1: BPM st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Bronchial st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: NBP el: 0 cu: CCU cg: RN v1: 139 u1: mmHg v2: 85 u2: mmHg st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: NBP Mean el: 0 cu: CCU cg: RN v1: 103 u1: mmHg st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [09:30:00 23/10/2016] tf: [06:00:00 31/10/2016] dt: 11310 id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 700 vu: ml
t0: [09:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11804 id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 42.6439 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [09:35:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 66.9865 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 43.75 u1: ml/cmH st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 50 u1: cmH2O st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 9 u1: cmH2O st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 12.5 u1: L/min st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 21 u1: cmH2O st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 18 u1: cmH2O st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Pressure Support el: 0 cu: CCU cg: RRT v1: 5 u1: . st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 28 u1: BPM st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 650 u1: ml/B st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 350 u1: ml/B st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: SIMV+PS st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: RN v1: 7.9 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: BUN el: 0 cu: CCU cg: RN v1: 12 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Chloride Chemistry el: 0 cu: CCU cg: RN v1: 106 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Creatinine Chemistry el: 0 cu: CCU cg: RN v1: 0.6 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Glucose Chemistry el: 0 cu: CCU cg: RN v1: 102 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Potassium Chemistry el: 0 cu: CCU cg: RN v1: 3.3 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Sodium Chemistry el: 0 cu: CCU cg: RN v1: 141 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Total Bili Chemistry el: 0 cu: CCU cg: RN v1: 0.3 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: WBC Hematology el: 0 cu: CCU cg: RN v1: 7.9 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: ALT Enzymes el: 0 cu: CCU cg: RN v1: 23 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: AST Enzymes el: 0 cu: CCU cg: RN v1: 23 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Alk. Phosphate Enzymes el: 0 cu: CCU cg: RN v1: 72 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Amylase Enzymes el: 0 cu: CCU cg: RN v1: 94 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: BUN (6-20) Chemistry el: 0 cu: CCU cg: RN v1: 12 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: CPK Enzymes el: 0 cu: CCU cg: RN v1: 101 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: RN v1: 106 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: RN v1: 0.6 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: RN v1: 102 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Hematocrit Hematology el: 0 cu: CCU cg: RN v1: 47.1 u1: % rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Platelets Hematology el: 0 cu: CCU cg: RN v1: 229 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: RN v1: 3.3 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: RN v1: 141 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: Total Bili (0-1.5) Chemistry el: 0 cu: CCU cg: RN v1: 0.3 rs: Manual st: NotStopd t0: [03:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12149 id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: RN v1: 7.9 rs: Manual st: NotStopd t0: [05:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 12044 id: Ethanol Drug Level el: 0 cu: CCU cg: RN v1: 372 rs: Manual st: NotStopd
t0: [10:00:00 23/10/2016] tf: [16:00:00 28/10/2016] dt: 7560 id: Gastric Nasogastric el: 1 cu: CCU cg: RN vo: 420 vu: ml
id: KCL el: 100 cu: CCU cg: RN io: .9% Normal Saline 1000.0ml IV Infusions am: 40 du: mEq rt: Intravenous Push
io: .9% Normal Saline 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ra: 125 ru: ml/hr
tf: [11:00:00 24/10/2016] pt: IV Piggyback rt: IV fr: QD fs: 10 dn: 1 m1: Folic Acid v1: 1 u1: mg m2: Syringe (IV Room) v2: 1 u2: SYR tf: [11:00:00 24/10/2016] pt: Unit Dose rt: IV fr: QD fs: 10 dn: 1 m1: Thiamine HCl v1: 100 u1: mg
id: .9% Normal Saline el: 1 cu: CCU cg: RN io: .9% Normal Saline 1000.0ml IV Infusions vo: 1000 du: ml rt: Intravenous Push
t0: [10:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 99 u1: BPM st: NotStopd t0: [10:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 109 u1: mmHg v2: 50 u2: mmHg st: NotStopd t0: [10:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 69.6667 u1: mmHg st: NotStopd t0: [10:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [10:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [10:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [11:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 90 u1: BPM st: NotStopd t0: [11:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [11:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 103 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [11:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 68.3333 u1: mmHg st: NotStopd t0: [11:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [11:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [11:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:00:00 23/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 0 vu: ml nb: 1
t0: [10:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 66.9865 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [11:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [11:00:00 23/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [11:00:00 23/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [11:00:00 23/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [11:00:00 23/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 45 u1: cmH2O st: NotStopd t0: [11:00:00 23/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [11:00:00 23/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [11:00:00 23/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [11:00:00 23/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [11:00:00 23/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 4 st: NotStopd t0: [11:00:00 23/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 9 u1: cmH2O st: NotStopd t0: [11:00:00 23/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 10 u1: L/min st: NotStopd t0: [11:00:00 23/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [11:00:00 23/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 10 u1: . st: NotStopd t0: [11:00:00 23/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 20 u1: BPM st: NotStopd t0: [11:00:00 23/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [11:00:00 23/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 500 u1: ml/B st: NotStopd t0: [11:00:00 23/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [11:00:00 23/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: PT el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: INR Coags el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: PTT Coags el: 0 cu: CCU cg: 140 v1: 24.9 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: INR (2-4 ref. range) Coags el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: PT(11-13.5) Coags el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: PTT(22-35) Coags el: 0 cu: CCU cg: 140 v1: 24.9 rs: Final st: NotStopd
t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.35 rs: Final st: NotStopd t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: -1 rs: Final st: NotStopd t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 25 rs: Final st: NotStopd t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 44 u1: mmHg rs: Final st: NotStopd t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 117 u1: mmHg rs: Final st: NotStopd t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.35 rs: Final st: NotStopd
t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Lactic Acid Chemistry el: 0 cu: CCU cg: 140 v1: 2.1 rs: Final st: NotStopd t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Ionized Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 1.21 rs: Final st: NotStopd t0: [11:34:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11650 id: Lactic Acid(0.5-2.0) Chemistry el: 0 cu: CCU cg: 140 v1: 2.1 rs: Final st: NotStopd
t0: [08:00:00 23/10/2016] tf: [18:31:00 27/10/2016] dt: 6391 id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [08:00:00 23/10/2016] tf: [18:31:00 27/10/2016] dt: 6391 id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [09:30:00 23/10/2016] tf: [23:00:00 26/10/2016] dt: 5130 id: Communication el: 0 cu: CCU cg: RN v1: Nodding st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: GCS Total el: 0 cu: CCU cg: RN v1: 11 u1: points st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [09:30:00 23/10/2016] tf: [23:00:00 26/10/2016] dt: 5130 id: Speech el: 0 cu: CCU cg: RN v1: Flushed st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Skin Color el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Behavior el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Braden Mobility el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Braden Score el: 0 cu: CCU cg: RN v1: 13 u1: number st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [11:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11684 id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [11:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11684 id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [11:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11684 id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [11:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11684 id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [11:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11684 id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.2778 u1: Deg. C st: NotStopd t0: [11:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11684 id: Temperature F el: 0 cu: CCU cg: RN v1: 99.1 u1: Deg. F st: NotStopd t0: [11:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11684 id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [11:49:00 23/10/2016] id: BSA el: 1033 cu: CCU cg: -1 t0: [11:49:00 23/10/2016] id: Admit Wt el: 1032 cu: CCU cg: -1 v1: 93.8 u1: kg t0: [11:49:00 23/10/2016] id: Allergy 1 el: 1020 cu: CCU cg: -1 t0: [11:49:00 23/10/2016] id: Diagnosis/op el: 1023 cu: CCU cg: -1 v1: HYPOXIA t0: [11:49:00 23/10/2016] id: Service el: 1026 cu: CCU cg: -1 v1: MED t0: [11:49:00 23/10/2016] id: Admit Ht el: 1034 cu: CCU cg: -1 t0: [11:49:00 23/10/2016] id: Readmission el: 1014 cu: CCU cg: -1 t0: [11:49:00 23/10/2016] id: Marital Status el: 1006 cu: CCU cg: -1 t0: [11:49:00 23/10/2016] id: Religion el: 1000 cu: CCU cg: -1 v1: OTR t0: [11:49:00 23/10/2016] id: Allergy 2 el: 1021 cu: CCU cg: -1 t0: [11:49:00 23/10/2016] id: Ext el: 1010 cu: CCU cg: -1 t0: [11:49:00 23/10/2016] id: PIN el: 1012 cu: CCU cg: -1 t0: [11:49:00 23/10/2016] id: Allergy 3 el: 1022 cu: CCU cg: -1
t0: [11:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11684 id: .9% Normal Saline 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [11:00:00 23/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 360 vu: ml
t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Previous Weight el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Weight Change el: 0 cu: CCU cg: RN v1: 0 u1: kg st: NotStopd t0: [09:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11774 id: Daily Weight el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [10:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [11:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd
t0: [10:45:00 23/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 11 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Albumin Chemistry el: 0 cu: CCU cg: 140 v1: 3.9 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 9 u1: mg/dl rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 113 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.8 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 95 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 4.3 u1: mEq/L rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 4.3 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 149 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Albumin (>3.2) Chemistry el: 0 cu: CCU cg: 140 v1: 3.9 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 11 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 9 u1: mg/dl rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 25 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 113 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.8 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 95 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 4.3 u1: mEq/L rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 4.3 rs: Final st: NotStopd t0: [10:45:00 23/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 149 rs: Final st: NotStopd
t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Aggitation el: 0 cu: CCU cg: RN v1: ..... st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Anxiety el: 0 cu: CCU cg: RN v1: Acute panic stat st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 17 u1: sum st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Disorien per/pla st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [12:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11624 id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 126 u1: mmHg v2: 82 u2: mmHg st: NotStopd t0: [12:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 96.6667 u1: mmHg st: NotStopd t0: [12:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 30 u1: BPM st: NotStopd
t0: [12:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 104 u1: BPM st: NotStopd t0: [12:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [12:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [12:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [13:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 135 u1: BPM st: NotStopd t0: [13:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 148 u1: mmHg v2: 97 u2: mmHg st: NotStopd t0: [13:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 114 u1: mmHg st: NotStopd t0: [13:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [13:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 27 u1: BPM st: NotStopd t0: [13:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [13:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [12:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 30 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [13:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 30 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:30:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:30:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:30:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 114 u1: BPM st: NotStopd t0: [13:30:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [13:30:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 126 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [13:30:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 80.6667 u1: mmHg st: NotStopd t0: [13:30:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [13:30:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [13:30:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:30:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:30:00 23/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 22.5806 u1: ml/cmH st: NotStopd t0: [13:30:00 23/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [13:30:00 23/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [13:30:00 23/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [13:30:00 23/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 50 u1: cmH2O st: NotStopd t0: [13:30:00 23/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [13:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11534 id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:3.8 st: NotStopd t0: [13:30:00 23/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [13:30:00 23/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [13:30:00 23/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [13:30:00 23/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [13:30:00 23/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [13:30:00 23/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 12 u1: cmH2O st: NotStopd t0: [13:30:00 23/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 14 u1: L/min st: NotStopd t0: [13:30:00 23/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [13:30:00 23/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 36 u1: cmH2O st: NotStopd t0: [13:30:00 23/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 14 u1: cmH2O st: NotStopd t0: [13:30:00 23/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 0 u1: . st: NotStopd t0: [13:30:00 23/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 7 u1: BPM st: NotStopd t0: [13:30:00 23/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 21 u1: BPM st: NotStopd t0: [13:30:00 23/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [13:30:00 23/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 2 u1: cmH2O st: NotStopd t0: [13:30:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [13:30:00 23/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 750 u1: ml/B st: NotStopd t0: [13:30:00 23/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [13:30:00 23/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [13:30:00 23/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [13:30:00 23/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd
tf: [11:00:00 24/10/2016] pt: Unit Dose rt: IV fr: Q24H fs: 14 dn: 1 m1: Multivitamins v1: 10 u1: ml
t0: [14:00:00 23/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [14:00:00 23/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ...... st: NotStopd t0: [14:00:00 23/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [14:00:00 23/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 18 u1: sum st: NotStopd t0: [14:00:00 23/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [14:00:00 23/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [14:00:00 23/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Disorien per/pla st: NotStopd t0: [14:00:00 23/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: Beads/ forehead st: NotStopd t0: [14:00:00 23/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 23/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [14:00:00 23/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 108 u1: BPM st: NotStopd t0: [14:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [14:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 111 u1: mmHg v2: 55 u2: mmHg st: NotStopd t0: [14:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 73.6667 u1: mmHg st: NotStopd t0: [14:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [14:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [14:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [14:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:00:00 23/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 375 vu: ml t0: [14:00:00 23/10/2016] id: Gastric Nasogastric el: 1 cu: CCU cg: RN vo: 200 vu: ml t0: [14:00:00 23/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 280 vu: ml
t0: [14:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 23/10/2016] dt: 24 id: Gastric Out Total el: 1 cu: CCU cg: RN cv: 620 ap: none
t0: [10:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11744 id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [12:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [13:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Very Agitated st: NotStopd t0: [15:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Very Agitated st: NotStopd t0: [15:00:00 23/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: ..... st: NotStopd t0: [15:00:00 23/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Acute panic stat st: NotStopd t0: [15:00:00 23/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [15:00:00 23/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 23 u1: sum st: NotStopd t0: [15:00:00 23/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [15:00:00 23/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [15:00:00 23/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Disorien per/pla st: NotStopd t0: [15:00:00 23/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ...... st: NotStopd t0: [15:00:00 23/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 23/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [15:00:00 23/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 122 u1: BPM st: NotStopd t0: [15:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [15:00:00 23/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [15:00:00 23/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 18 gauge st: NotStopd t0: [15:00:00 23/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [15:00:00 23/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [15:00:00 23/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [15:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 140 u1: mmHg v2: 78 u2: mmHg st: NotStopd t0: [15:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 98.6667 u1: mmHg st: NotStopd t0: [15:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [15:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 26 u1: BPM st: NotStopd t0: [15:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [15:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [15:00:00 23/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml
t0: [15:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
tf: [16:00:00 23/10/2016] pt: Unit Dose rt: IV fr: Q1-2H:PRN m1: Lorazepam v1: 1-2 u1: mg
t0: [16:10:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11374 id: RSBI (<100) el: 0 cu: CCU cg: RRT v1: 128.571 u1: units st: NotStopd t0: [16:10:00 23/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [16:10:00 23/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [16:10:00 23/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 50 u1: cmH2O st: NotStopd t0: [16:10:00 23/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 40 u1: BPM st: NotStopd t0: [16:10:00 23/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [16:10:00 23/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [16:10:00 23/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 9 u1: cmH2O st: NotStopd t0: [16:10:00 23/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 12 u1: L/min st: NotStopd t0: [16:10:00 23/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [16:10:00 23/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 10 u1: . st: NotStopd t0: [16:10:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11374 id: RSBI (<200) el: 0 cu: CCU cg: RRT v1: 128.571 u1: units st: NotStopd t0: [16:10:00 23/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 29 u1: BPM st: NotStopd t0: [16:10:00 23/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 2 u1: cmH2O st: NotStopd t0: [16:10:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11374 id: Spon RR (Mech.) el: 0 cu: CCU cg: RRT v1: 45 u1: BPM st: NotStopd t0: [16:10:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11374 id: Spon. Vt (L) (Mech.) el: 0 cu: CCU cg: RRT v1: 0.35 u1: L st: NotStopd t0: [16:10:00 23/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 600 u1: ml/B st: NotStopd t0: [16:10:00 23/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd
t0: [16:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [16:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 113 u1: BPM st: NotStopd t0: [16:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [16:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 122 u1: mmHg v2: 74 u2: mmHg st: NotStopd t0: [16:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 90 u1: mmHg st: NotStopd t0: [16:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [16:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 26 u1: BPM st: NotStopd t0: [16:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [16:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:00:00 23/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [16:00:00 23/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 200 vu: ml
t0: [16:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:30:00 23/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 5 u1: . st: NotStopd t0: [16:30:00 23/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 48 u1: BPM st: NotStopd t0: [16:30:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 93 u1: % st: NotStopd t0: [16:30:00 23/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 370 u1: ml/B st: NotStopd t0: [16:30:00 23/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd
t0: [16:00:00 23/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: ..... st: NotStopd t0: [16:00:00 23/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ...... st: NotStopd t0: [16:00:00 23/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [16:00:00 23/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 21 u1: sum st: NotStopd t0: [16:00:00 23/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [16:00:00 23/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [16:00:00 23/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Disorien per/pla st: NotStopd t0: [16:00:00 23/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ..... st: NotStopd t0: [16:00:00 23/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 23/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [16:00:00 23/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd
tf: [19:00:00 23/10/2016] pt: Unit Dose rt: IV fr: Q1H:PRN m1: Lorazepam v1: 2-6 u1: mg
t0: [17:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [17:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 116 u1: BPM st: NotStopd t0: [17:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [17:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 128 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [17:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 85.3333 u1: mmHg st: NotStopd t0: [17:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [17:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 47 u1: BPM st: NotStopd t0: [17:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 90 u1: % st: NotStopd t0: [17:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [17:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 20 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [17:15:00 23/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 26.9231 u1: ml/cmH st: NotStopd t0: [17:15:00 23/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [17:15:00 23/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [17:15:00 23/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [17:15:00 23/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 50 u1: cmH2O st: NotStopd t0: [17:15:00 23/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 50 u1: BPM st: NotStopd t0: [17:15:00 23/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:4 st: NotStopd t0: [17:15:00 23/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [17:15:00 23/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [17:15:00 23/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [17:15:00 23/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [17:15:00 23/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [17:15:00 23/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 9 u1: cmH2O st: NotStopd t0: [17:15:00 23/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 15.7 u1: L/min st: NotStopd t0: [17:15:00 23/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [17:15:00 23/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 31 u1: cmH2O st: NotStopd t0: [17:15:00 23/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 15 u1: cmH2O st: NotStopd t0: [17:15:00 23/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 0 u1: . st: NotStopd t0: [17:15:00 23/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 11 u1: BPM st: NotStopd t0: [17:15:00 23/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 25 u1: BPM st: NotStopd t0: [17:15:00 23/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [17:15:00 23/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 2 u1: cmH2O st: NotStopd t0: [17:15:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 91 u1: % st: NotStopd t0: [17:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11309 id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: Yellow v2: Thick st: NotStopd t0: [17:15:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11309 id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Small st: NotStopd t0: [17:15:00 23/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 680 u1: ml/B st: NotStopd t0: [17:15:00 23/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [17:15:00 23/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [17:15:00 23/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [17:15:00 23/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [17:26:00 23/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.39 rs: Final st: NotStopd t0: [17:26:00 23/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: -1 rs: Final st: NotStopd t0: [17:26:00 23/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 23 rs: Final st: NotStopd t0: [17:26:00 23/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 37 u1: mmHg rs: Final st: NotStopd t0: [17:26:00 23/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 74 u1: mmHg rs: Final st: NotStopd t0: [17:26:00 23/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.39 rs: Final st: NotStopd
t0: [17:30:00 23/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.6 u1: torr st: NotStopd t0: [17:30:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 95 u1: % st: NotStopd
t0: [17:45:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:45:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:45:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 107 u1: BPM st: NotStopd t0: [17:45:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [17:45:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 104 u1: mmHg v2: 54 u2: mmHg st: NotStopd t0: [17:45:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 70.6667 u1: mmHg st: NotStopd t0: [17:45:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [17:45:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [17:45:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 91 u1: % st: NotStopd t0: [17:45:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [18:00:00 23/10/2016] id: Previous Weight el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd
t0: [17:00:00 23/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [17:00:00 23/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 130 vu: ml
t0: [17:45:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
pt: Miscellaneous Charges m1: LORAZEPAM
t0: [15:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11444 id: IV #2 Reason DC'D el: 0 cu: CCU cg: RN v1: Phlebitis st: NotStopd t0: [15:00:00 23/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Left Hand v2: 18 gauge st: NotStopd t0: [17:00:00 23/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [17:00:00 23/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 18 gauge st: NotStopd t0: [17:00:00 23/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [17:00:00 23/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [17:00:00 23/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [17:00:00 23/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd
io: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ra: 100 ru: ml/hr
tf: [20:00:00 23/10/2016] pt: IV Piggyback rt: IV DRIP fr: TITRATE TO m1: Lorazepam v1: 40 u1: mg m2: D5W v2: 400 u2: ml
id: D5/.45NS el: 1 cu: CCU cg: RN io: D5/.45NS 1000.0ml IV Infusions vo: 1000 du: ml rt: Intravenous Push
t0: [19:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Very Agitated st: NotStopd t0: [19:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 110 u1: BPM st: NotStopd t0: [19:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [19:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 111 u1: mmHg v2: 80 u2: mmHg st: NotStopd t0: [19:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 90.3333 u1: mmHg st: NotStopd t0: [19:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [19:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [19:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [19:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [20:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [20:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 101 u1: BPM st: NotStopd t0: [20:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [20:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 115 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [20:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 79.6667 u1: mmHg st: NotStopd t0: [20:00:00 23/10/2016] id: Previous Weight el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [20:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [20:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [20:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 92 u1: % st: NotStopd t0: [20:00:00 23/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [20:00:00 23/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.2222 u1: Deg. C st: NotStopd t0: [20:00:00 23/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.8 u1: Deg. F st: NotStopd t0: [20:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [19:00:00 23/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml nb: 1 t0: [20:00:00 23/10/2016] tf: [11:00:00 24/10/2016] dt: 900 id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 500 vu: ml
t0: [19:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [20:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [20:15:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:15:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:15:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 100 u1: BPM st: NotStopd t0: [20:15:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [20:15:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 124 u1: mmHg v2: 81 u2: mmHg st: NotStopd t0: [20:15:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 95.3333 u1: mmHg st: NotStopd t0: [20:15:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [20:15:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [20:15:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 85 u1: % st: NotStopd t0: [20:15:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [20:00:00 23/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 160 vu: ml
t0: [20:15:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [19:00:00 23/10/2016] tf: [08:00:00 25/10/2016] dt: 2220 id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 6 st: NotStopd t0: [20:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11114 id: Insomnia el: 0 cu: CCU cg: RN v1: ...... st: NotStopd t0: [20:30:00 23/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ...... st: NotStopd t0: [20:30:00 23/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [20:30:00 23/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 19 u1: sum st: NotStopd t0: [20:30:00 23/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [20:30:00 23/10/2016] id: Insomnia el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [20:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11114 id: Seizure el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [20:30:00 23/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [20:30:00 23/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ...... st: NotStopd t0: [20:30:00 23/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [20:30:00 23/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:30:00 23/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [20:30:00 23/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11114 id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [20:30:00 23/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [20:30:00 23/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [20:30:00 23/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [20:30:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11114 id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [20:30:00 23/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 3 st: NotStopd
t0: [20:45:00 23/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 35 u1: ml/cmH st: NotStopd t0: [20:45:00 23/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [20:45:00 23/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [20:45:00 23/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.6 u1: torr st: NotStopd t0: [20:45:00 23/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 50 u1: cmH2O st: NotStopd t0: [20:45:00 23/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [20:45:00 23/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [20:45:00 23/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [20:45:00 23/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [20:45:00 23/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [20:45:00 23/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [20:45:00 23/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [20:45:00 23/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 9.3 u1: L/min st: NotStopd t0: [20:45:00 23/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [20:45:00 23/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 25 u1: cmH2O st: NotStopd t0: [20:45:00 23/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 19 u1: cmH2O st: NotStopd t0: [20:45:00 23/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 4 u1: BPM st: NotStopd t0: [20:45:00 23/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 18 u1: BPM st: NotStopd t0: [20:45:00 23/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [20:45:00 23/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [20:45:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 94 u1: % st: NotStopd t0: [20:45:00 23/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: Yellow v2: Thick st: NotStopd t0: [20:45:00 23/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Moderate st: NotStopd t0: [20:45:00 23/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 642 u1: ml/B st: NotStopd t0: [20:45:00 23/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [20:45:00 23/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [20:45:00 23/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [20:45:00 23/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
tf: [11:00:00 24/10/2016] pt: Unit Dose rt: IV fr: Q1H:PRN m1: Lorazepam v1: 2-6 u1: mg tf: [09:00:00 25/10/2016] pt: Unit Dose rt: IV DRIP fr: TITRATE TO m1: Propofol (Generic) v1: 1000 u1: mg
t0: [20:00:00 23/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN st: NotStopd t0: [21:00:00 23/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [21:00:00 23/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 4 st: NotStopd t0: [21:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [21:00:00 23/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Mod rigid/restle st: NotStopd t0: [21:00:00 23/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mod anxiety st: NotStopd t0: [21:00:00 23/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [21:00:00 23/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 15 u1: sum st: NotStopd t0: [21:00:00 23/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [21:00:00 23/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [21:00:00 23/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [21:00:00 23/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ...... st: NotStopd t0: [21:00:00 23/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 23/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [21:00:00 23/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 100 u1: BPM st: NotStopd t0: [21:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [21:00:00 23/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [21:00:00 23/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 18 gauge st: NotStopd t0: [21:00:00 23/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [21:00:00 23/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [21:00:00 23/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [21:00:00 23/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [21:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 121 u1: mmHg v2: 74 u2: mmHg st: NotStopd t0: [21:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 89.6667 u1: mmHg st: NotStopd t0: [21:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [21:00:00 23/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [21:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [21:00:00 23/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [21:00:00 23/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [21:00:00 23/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [21:00:00 23/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [21:00:00 23/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [21:00:00 23/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [21:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [21:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [21:00:00 23/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [21:00:00 23/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [21:00:00 23/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [21:00:00 23/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Consist. Moist st: NotStopd t0: [21:00:00 23/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [21:00:00 23/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 10 u1: number st: NotStopd t0: [21:00:00 23/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd
t0: [21:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
io: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ra: 0 ru: ml/hr
id: .9% Normal Saline el: 2 cu: CCU cg: RN io: .9% Normal Saline 1000.0ml IV Infusions vo: 1000 du: ml rt: Intravenous Push
t0: [22:00:00 23/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [22:00:00 23/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [22:00:00 23/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Mod rigid/restle st: NotStopd t0: [22:00:00 23/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ..... st: NotStopd t0: [22:00:00 23/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [22:00:00 23/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 13 u1: sum st: NotStopd t0: [22:00:00 23/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [22:00:00 23/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [22:00:00 23/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [22:00:00 23/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [22:00:00 23/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 23/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [22:00:00 23/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 101 u1: BPM st: NotStopd t0: [22:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [22:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 123 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [22:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 79 u1: mmHg st: NotStopd t0: [22:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [22:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [22:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [22:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [22:00:00 23/10/2016] tf: [09:00:00 24/10/2016] dt: 660 id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 375 vu: ml t0: [22:00:00 23/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 170 vu: ml
t0: [22:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 23/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 23/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 23/10/2016] dt: 24 id: IV Infusion In Total el: 1 cu: CCU cg: RN cv: 2036.16 ap: none t0: [23:00:00 23/10/2016] dt: 24 id: 24h Total In el: 1 cu: CCU cg: RN cv: 2836.16 ap: none t0: [23:00:00 23/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN cv: 2000 ap: none t0: [23:00:00 23/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: RN cv: -783.844 ap: none t0: [23:00:00 23/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: RN cv: 3620 ap: none t0: [23:00:00 23/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: RN cv: -783.844 ap: none
t0: [20:30:00 23/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 11 u1: points st: NotStopd t0: [20:30:00 23/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [22:00:00 23/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [22:00:00 23/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [22:00:00 23/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [22:00:00 23/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [22:00:00 23/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 11 u1: points st: NotStopd t0: [22:00:00 23/10/2016] tf: [07:00:00 30/10/2016] dt: 9180 id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [22:00:00 23/10/2016] tf: [07:00:00 30/10/2016] dt: 9180 id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [22:00:00 23/10/2016] tf: [12:00:00 30/10/2016] dt: 9480 id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [22:00:00 23/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [22:00:00 23/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 15 degrees st: NotStopd t0: [22:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11024 id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [22:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11024 id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [22:00:00 23/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [22:00:00 23/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [22:00:00 23/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [22:00:00 23/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [22:00:00 23/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [22:00:00 23/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [22:00:00 23/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 3 st: NotStopd t0: [22:00:00 23/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [22:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11024 id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [22:00:00 23/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [22:00:00 23/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [22:00:00 23/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [22:00:00 23/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal st: NotStopd t0: [22:00:00 23/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [22:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11024 id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [22:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11024 id: Urine Source el: 0 cu: CCU cg: RN v1: Amber v2: Clear st: NotStopd t0: [22:00:00 23/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [22:00:00 23/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [22:00:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11024 id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd
t0: [22:40:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 150 u1: BPM st: NotStopd t0: [22:40:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [22:40:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 96 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [22:40:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 71.3333 u1: mmHg st: NotStopd t0: [22:40:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [22:40:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [22:40:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [22:40:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [22:40:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [22:50:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:50:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:50:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 95 u1: BPM st: NotStopd t0: [22:50:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:50:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 110 u1: mmHg v2: 66 u2: mmHg st: NotStopd t0: [22:50:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 80.6667 u1: mmHg st: NotStopd t0: [22:50:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [22:50:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [22:50:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [22:50:00 23/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [22:50:00 23/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.9444 u1: Deg. C st: NotStopd t0: [22:50:00 23/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.3 u1: Deg. F st: NotStopd t0: [22:50:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [22:50:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 23/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [23:00:00 23/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Mod rigid/restle st: NotStopd t0: [23:00:00 23/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ..... st: NotStopd t0: [23:00:00 23/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [23:00:00 23/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 13 u1: sum st: NotStopd t0: [23:00:00 23/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [23:00:00 23/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [23:00:00 23/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [23:00:00 23/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [23:00:00 23/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 23/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [23:00:00 23/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 95 u1: BPM st: NotStopd t0: [23:00:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [23:00:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 115 u1: mmHg v2: 67 u2: mmHg st: NotStopd t0: [23:00:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 83 u1: mmHg st: NotStopd t0: [23:00:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [23:00:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [23:00:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [23:00:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [23:00:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:15:00 23/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [23:15:00 23/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:15:00 23/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:15:00 23/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 95 u1: BPM st: NotStopd t0: [23:15:00 23/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [23:15:00 23/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 108 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [23:15:00 23/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 77.3333 u1: mmHg st: NotStopd t0: [23:15:00 23/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [23:15:00 23/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [23:15:00 23/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [23:15:00 23/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [23:15:00 23/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [21:00:00 23/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thin st: NotStopd t0: [21:00:00 23/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd t0: [23:00:00 23/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thin st: NotStopd t0: [23:00:00 23/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Small st: NotStopd t0: [00:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [00:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Mod rigid/restle st: NotStopd t0: [00:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mod anxiety st: NotStopd t0: [00:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [00:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 12 u1: sum st: NotStopd t0: [00:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [00:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [00:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [00:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [00:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [00:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [00:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 11 u1: points st: NotStopd t0: [00:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 95 u1: BPM st: NotStopd t0: [00:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [00:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [00:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 97 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [00:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 71.6667 u1: mmHg st: NotStopd t0: [00:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 3 st: NotStopd t0: [00:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [00:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [00:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [00:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [00:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [00:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 250 vu: ml t0: [00:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 70 vu: ml
t0: [00:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:00:00 24/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd
t0: [00:00:00 24/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 38.8889 u1: ml/cmH st: NotStopd t0: [00:00:00 24/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [00:00:00 24/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [00:00:00 24/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.6 u1: torr st: NotStopd t0: [00:00:00 24/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 50 u1: cmH2O st: NotStopd t0: [00:00:00 24/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [00:00:00 24/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [00:00:00 24/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [00:00:00 24/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [00:00:00 24/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [00:00:00 24/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 15 u1: cmH2O st: NotStopd t0: [00:00:00 24/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 10.9 u1: L/min st: NotStopd t0: [00:00:00 24/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [00:00:00 24/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 28 u1: cmH2O st: NotStopd t0: [00:00:00 24/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 19 u1: cmH2O st: NotStopd t0: [00:00:00 24/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 2 u1: BPM st: NotStopd t0: [00:00:00 24/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 16 u1: BPM st: NotStopd t0: [00:00:00 24/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [00:00:00 24/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [00:00:00 24/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [00:00:00 24/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [00:00:00 24/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [00:00:00 24/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [00:00:00 24/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [01:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Calm/Cooperative st: NotStopd t0: [01:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [01:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [01:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [01:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 10 u1: sum st: NotStopd t0: [01:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [01:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [01:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [01:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [01:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [01:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 96 u1: BPM st: NotStopd t0: [01:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [01:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 125 u1: mmHg v2: 73 u2: mmHg st: NotStopd t0: [01:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 90.3333 u1: mmHg st: NotStopd t0: [01:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [01:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [01:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [01:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: IH fr: Q4H:PRN m1: Albuterol-Ipratropium v1: 1-2 u1: PUFF
t0: [01:00:00 24/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [01:00:00 24/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [01:00:00 24/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38 u1: Deg. C st: NotStopd t0: [01:00:00 24/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.4 u1: Deg. F st: NotStopd
t0: [02:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [02:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [02:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [02:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [02:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 5 u1: sum st: NotStopd t0: [02:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [02:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [02:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [02:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [02:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [02:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 97 u1: BPM st: NotStopd t0: [02:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [02:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 134 u1: mmHg v2: 63 u2: mmHg st: NotStopd t0: [02:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 86.6667 u1: mmHg st: NotStopd t0: [02:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [02:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [02:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [02:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [03:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [03:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: > Norm activity st: NotStopd t0: [03:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [03:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [03:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 4 u1: sum st: NotStopd t0: [03:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [03:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [03:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [03:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [03:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [03:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 95 u1: BPM st: NotStopd t0: [03:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [03:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 133 u1: mmHg v2: 88 u2: mmHg st: NotStopd t0: [03:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 103 u1: mmHg st: NotStopd t0: [03:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [03:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [03:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [03:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [03:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [03:00:00 24/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Cloudy st: NotStopd t0: [03:00:00 24/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd
t0: [03:00:00 24/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 70 vu: ml t0: [03:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 375 vu: ml t0: [03:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 100 vu: ml
t0: [04:00:00 24/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 36.8421 u1: ml/cmH st: NotStopd t0: [04:00:00 24/10/2016] id: RSBI (<100) el: 0 cu: CCU cg: RRT u1: units st: NotStopd t0: [04:00:00 24/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [04:00:00 24/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [04:00:00 24/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.6 u1: torr st: NotStopd t0: [04:00:00 24/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 50 u1: cmH2O st: NotStopd t0: [04:00:00 24/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [04:00:00 24/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [04:00:00 24/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [04:00:00 24/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [04:00:00 24/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [04:00:00 24/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 15.2 u1: cmH2O st: NotStopd t0: [04:00:00 24/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 13.2 u1: L/min st: NotStopd t0: [04:00:00 24/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [04:00:00 24/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 29 u1: cmH2O st: NotStopd t0: [04:00:00 24/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 22 u1: cmH2O st: NotStopd t0: [04:00:00 24/10/2016] id: RSBI (<200) el: 0 cu: CCU cg: RRT u1: units st: NotStopd t0: [04:00:00 24/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 7 u1: BPM st: NotStopd t0: [04:00:00 24/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 21 u1: BPM st: NotStopd t0: [04:00:00 24/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [04:00:00 24/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [04:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 97 u1: % st: NotStopd t0: [04:00:00 24/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 702 u1: ml/B st: NotStopd t0: [04:00:00 24/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [04:00:00 24/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [04:00:00 24/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [04:00:00 24/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [04:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [04:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: > Norm activity st: NotStopd t0: [04:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [04:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [04:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 4 u1: sum st: NotStopd t0: [04:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [04:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [04:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [04:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [04:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [04:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 99 u1: BPM st: NotStopd t0: [04:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 131 u1: mmHg v2: 79 u2: mmHg st: NotStopd t0: [04:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 96.3333 u1: mmHg st: NotStopd t0: [04:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [04:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [04:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [04:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [03:47:00 24/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.38 rs: Final st: NotStopd t0: [03:47:00 24/10/2016] id: Lactic Acid Chemistry el: 0 cu: CCU cg: 140 v1: 1.4 rs: Final st: NotStopd t0: [03:47:00 24/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 0 rs: Final st: NotStopd t0: [03:47:00 24/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 27 rs: Final st: NotStopd t0: [03:47:00 24/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 44 u1: mmHg rs: Final st: NotStopd t0: [03:47:00 24/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 164 u1: mmHg rs: Final st: NotStopd t0: [03:47:00 24/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.38 rs: Final st: NotStopd t0: [03:47:00 24/10/2016] id: Lactic Acid(0.5-2.0) Chemistry el: 0 cu: CCU cg: 140 v1: 1.4 rs: Final st: NotStopd
t0: [05:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [05:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: > Norm activity st: NotStopd t0: [05:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [05:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [05:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 4 u1: sum st: NotStopd t0: [05:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [05:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [05:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [05:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [05:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [05:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 95 u1: BPM st: NotStopd t0: [05:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [05:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 143 u1: mmHg v2: 85 u2: mmHg st: NotStopd t0: [05:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 104.333 u1: mmHg st: NotStopd t0: [05:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [05:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [05:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [05:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [05:00:00 24/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 20 vu: ml t0: [05:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 250 vu: ml t0: [05:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 50 vu: ml
t0: [05:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [05:00:00 24/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [05:00:00 24/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.8333 u1: Deg. C st: NotStopd t0: [05:00:00 24/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.1 u1: Deg. F st: NotStopd
t0: [05:00:00 24/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [05:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [05:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 9 u1: points st: NotStopd t0: [05:00:00 24/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [05:00:00 24/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [05:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [05:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [05:00:00 24/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [05:00:00 24/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [05:00:00 24/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [05:00:00 24/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [05:00:00 24/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [05:00:00 24/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [05:00:00 24/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [05:00:00 24/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [05:00:00 24/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [05:00:00 24/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [05:00:00 24/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thick st: NotStopd t0: [05:00:00 24/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Scant st: NotStopd t0: [05:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [05:00:00 24/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [05:00:00 24/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [05:00:00 24/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [05:00:00 24/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Consist. Moist st: NotStopd t0: [05:00:00 24/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [05:00:00 24/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 10 u1: number st: NotStopd t0: [05:00:00 24/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd
t0: [05:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10604 id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd
t0: [05:05:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [05:30:00 24/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 4 st: NotStopd t0: [05:30:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Very Agitated st: NotStopd t0: [05:30:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Mod rigid/restle st: NotStopd t0: [05:30:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mod anxiety st: NotStopd t0: [05:30:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [05:30:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 13 u1: sum st: NotStopd t0: [05:30:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [05:30:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [05:30:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: No addit/ ? date st: NotStopd t0: [05:30:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: Beads/ forehead st: NotStopd t0: [05:30:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:30:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [05:30:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:30:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:30:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:30:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 97 u1: BPM st: NotStopd t0: [05:30:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [05:30:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 148 u1: mmHg v2: 101 u2: mmHg st: NotStopd t0: [05:30:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 116.667 u1: mmHg st: NotStopd t0: [05:30:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [05:30:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [05:30:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [05:30:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [05:30:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [06:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [06:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 95 u1: BPM st: NotStopd t0: [06:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [06:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 139 u1: mmHg v2: 82 u2: mmHg st: NotStopd t0: [06:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 101 u1: mmHg st: NotStopd t0: [06:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [06:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [06:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [06:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [06:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [05:00:00 24/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 8.9 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: WBC Hematology el: 0 cu: CCU cg: 140 v1: 8.9 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10604 id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 43.8 u1: % rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 13.9 u1: gm/dl rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Platelets Hematology el: 0 cu: CCU cg: 140 v1: 196 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10604 id: RBC Hematology el: 0 cu: CCU cg: 140 v1: 4.57 u1: /mic l rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 8.9 rs: Final st: NotStopd
t0: [05:00:00 24/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 13 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 8.6 u1: mg/dl rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 111 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.7 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 104 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 1.8 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 2.2 u1: mEq/L rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 3.6 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 144 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: BUN (6-20) Chemistry el: 0 cu: CCU cg: 140 v1: 13 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 8.6 u1: mg/dl rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 26 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 111 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.7 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 104 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 1.8 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 2.2 u1: mEq/L rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 3.6 rs: Final st: NotStopd t0: [05:00:00 24/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 144 rs: Final st: NotStopd
t0: [07:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [07:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [07:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 93 u1: BPM st: NotStopd t0: [07:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [07:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 145 u1: mmHg v2: 101 u2: mmHg st: NotStopd t0: [07:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 115.667 u1: mmHg st: NotStopd t0: [07:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [07:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [07:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [07:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [08:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [08:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10424 id: Daily Wake Up el: 1 cu: CCU cg: RN v1: Yes st: NotStopd t0: [08:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 94 u1: BPM st: NotStopd t0: [08:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 133 u1: mmHg v2: 78 u2: mmHg st: NotStopd t0: [08:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 96.3333 u1: mmHg st: NotStopd t0: [08:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [08:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [08:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [08:00:00 24/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.6667 u1: Deg. C st: NotStopd t0: [08:00:00 24/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 99.8 u1: Deg. F st: NotStopd t0: [08:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [08:00:00 24/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 30 vu: ml t0: [08:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 120 vu: ml
t0: [07:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [08:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 24/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: Mouthing Words st: NotStopd t0: [08:00:00 24/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10424 id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: > Norm activity st: NotStopd t0: [08:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mod anxiety st: NotStopd t0: [08:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [08:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 5 u1: sum st: NotStopd t0: [08:00:00 24/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [08:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [08:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [08:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [08:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [08:00:00 24/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [08:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10424 id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [08:00:00 24/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [08:00:00 24/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RN v1: 21cm v2: Lip st: NotStopd t0: [08:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [08:00:00 24/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [08:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [08:00:00 24/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [08:00:00 24/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 24/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [08:00:00 24/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 24/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [08:00:00 24/10/2016] id: Airway Size el: 0 cu: CCU cg: RN v1: 7.5 mm st: NotStopd t0: [08:00:00 24/10/2016] id: Airway Type el: 0 cu: CCU cg: RN v1: Endotracheal st: NotStopd t0: [09:00:00 24/10/2016] tf: [08:00:00 31/10/2016] dt: 10020 id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [08:00:00 24/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 24/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [08:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [08:00:00 24/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [08:00:00 24/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [08:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10424 id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [08:00:00 24/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [08:00:00 24/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [08:00:00 24/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 24/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 24/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [08:00:00 24/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [08:00:00 24/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 24/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [08:00:00 24/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [08:00:00 24/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thick st: NotStopd t0: [08:00:00 24/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Scant st: NotStopd t0: [08:00:00 24/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 24/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RN v1: Drager st: NotStopd t0: [08:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [08:00:00 24/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Hypoactive st: NotStopd t0: [09:00:00 24/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Orientation st: NotStopd t0: [09:00:00 24/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [09:00:00 24/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [09:00:00 24/10/2016] tf: [08:00:00 31/10/2016] dt: 10020 id: Inc Cleansing #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [09:00:00 24/10/2016] tf: [08:00:00 31/10/2016] dt: 10020 id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Healed v2: Ecchymotic st: NotStopd t0: [09:00:00 24/10/2016] tf: [08:00:00 31/10/2016] dt: 10020 id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 24/10/2016] tf: [08:00:00 31/10/2016] dt: 10020 id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 24/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [09:00:00 24/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [09:00:00 24/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [09:00:00 24/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [09:00:00 24/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [09:00:00 24/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [09:00:00 24/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [09:00:00 24/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [09:00:00 24/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [09:00:00 24/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [09:00:00 24/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [09:00:00 24/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd t0: [09:00:00 24/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [09:00:00 24/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [09:00:00 24/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 14 u1: number st: NotStopd t0: [09:00:00 24/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd
t0: [08:43:00 24/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 38.8889 u1: ml/cmH st: NotStopd t0: [08:43:00 24/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [08:43:00 24/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [08:43:00 24/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [08:43:00 24/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 45 u1: cmH2O st: NotStopd t0: [08:43:00 24/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [08:43:00 24/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [08:43:00 24/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [08:43:00 24/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [08:43:00 24/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [08:43:00 24/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [08:43:00 24/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [08:43:00 24/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 16 u1: cmH2O st: NotStopd t0: [08:43:00 24/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 13 u1: L/min st: NotStopd t0: [08:43:00 24/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [08:43:00 24/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 28 u1: cmH2O st: NotStopd t0: [08:43:00 24/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 19 u1: cmH2O st: NotStopd t0: [08:43:00 24/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 5 u1: BPM st: NotStopd t0: [08:43:00 24/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 19 u1: BPM st: NotStopd t0: [08:43:00 24/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [08:43:00 24/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [08:43:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 97 u1: % st: NotStopd t0: [08:43:00 24/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 730 u1: ml/B st: NotStopd t0: [08:43:00 24/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [08:43:00 24/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [08:43:00 24/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [08:43:00 24/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
tf: [08:00:00 25/10/2016] pt: IV Piggyback rt: IV fr: ONCE fs: 9 dn: 1 m1: Potassium Phosphate v1: 15 u1: mmol m2: NS v2: 250 u2: ml tf: [08:00:00 25/10/2016] pt: Unit Dose rt: IV fr: ONCE fs: 9 dn: 1 m1: Magnesium Sulfate v1: 2 u1: gm tf: [18:00:00 03/11/2016] pt: Unit Dose rt: SC fr: Q12H fs: 9, 21 dn: 2 m1: Heparin v1: 5000 u1: UNIT
t0: [09:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10364 id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [08:00:00 24/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 18 gauge st: NotStopd t0: [08:00:00 24/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [08:00:00 24/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [09:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10364 id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [08:00:00 24/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [09:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 91 u1: BPM st: NotStopd t0: [09:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [09:00:00 24/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [09:00:00 24/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 18 gauge st: NotStopd t0: [09:00:00 24/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [09:00:00 24/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [09:00:00 24/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [09:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10364 id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: RU Ant Forearm v2: 20 gauge st: NotStopd t0: [09:00:00 24/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [09:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 124 u1: mmHg v2: 80 u2: mmHg st: NotStopd t0: [09:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 94.6667 u1: mmHg st: NotStopd t0: [09:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [09:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10364 id: Radiologic Study el: 0 cu: CCU cg: RN v1: Chest Xray st: NotStopd t0: [09:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [09:00:00 24/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [09:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [09:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [06:00:00 24/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [07:00:00 24/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [08:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [09:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10364 id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 100 vu: ml t0: [09:00:00 24/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [09:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [09:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 30 vu: ml
t0: [09:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [10:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [10:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [10:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [10:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [10:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:00:00 24/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [10:00:00 24/10/2016] tf: [14:00:00 24/10/2016] dt: 240 id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [10:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 20 vu: ml
t0: [10:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
id: Potassium Phosphate el: 100 cu: CCU cg: RN io: D5W 250.0ml IV Infusions am: 15 du: mEq rt: Intravenous Push
io: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: RN ra: 42 ru: ml/hr
id: D5W el: 1 cu: CCU cg: RN io: D5W 250.0ml IV Infusions vo: 250 du: ml rt: Intravenous Infusion
t0: [10:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Stimul st: NotStopd t0: [10:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 130 u1: mmHg v2: 83 u2: mmHg st: NotStopd t0: [10:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 98.6667 u1: mmHg st: NotStopd t0: [10:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [11:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [11:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [11:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [11:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [11:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [11:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [11:00:00 24/10/2016] tf: [17:00:00 24/10/2016] dt: 360 id: D5W 250.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 107 vo: 0 vu: ml t0: [11:00:00 24/10/2016] id: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 42 vu: ml t0: [11:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [11:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 12 vu: ml t0: [11:01:00 24/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 2 cu: CCU cg: -1 ai: 107 vo: 0 st: D/C'd
t0: [11:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [12:00:00 24/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 41.1765 u1: ml/cmH st: NotStopd t0: [12:00:00 24/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [12:00:00 24/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [12:00:00 24/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [12:00:00 24/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 45 u1: cmH2O st: NotStopd t0: [12:00:00 24/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [12:00:00 24/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [12:00:00 24/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [12:00:00 24/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [12:00:00 24/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [12:00:00 24/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [12:00:00 24/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [12:00:00 24/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 16 u1: cmH2O st: NotStopd t0: [12:00:00 24/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 11 u1: L/min st: NotStopd t0: [12:00:00 24/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [12:00:00 24/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 27 u1: cmH2O st: NotStopd t0: [12:00:00 24/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 19 u1: cmH2O st: NotStopd t0: [12:00:00 24/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 2 u1: BPM st: NotStopd t0: [12:00:00 24/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 16 u1: BPM st: NotStopd t0: [12:00:00 24/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [12:00:00 24/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [12:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 98 u1: % st: NotStopd t0: [12:00:00 24/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [12:00:00 24/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [12:00:00 24/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [12:00:00 24/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [12:00:00 24/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [08:00:00 24/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 45 degrees st: NotStopd t0: [08:00:00 24/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [08:00:00 24/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [08:00:00 24/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [08:00:00 24/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [08:00:00 24/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Side to Side st: NotStopd t0: [10:00:00 24/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 24/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [10:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [10:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [10:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [10:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 0 u1: sum st: NotStopd t0: [10:00:00 24/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [10:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [10:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [10:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [10:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [10:00:00 24/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [10:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [10:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 24/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [10:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 1 No Response st: NotStopd t0: [10:00:00 24/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [10:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 7 u1: points st: NotStopd t0: [10:00:00 24/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [10:00:00 24/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [10:00:00 24/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [10:00:00 24/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [10:00:00 24/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [10:00:00 24/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [10:00:00 24/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [10:00:00 24/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [10:00:00 24/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [10:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [10:00:00 24/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [10:00:00 24/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [10:00:00 24/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [10:00:00 24/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [10:00:00 24/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [10:00:00 24/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [10:00:00 24/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [10:00:00 24/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [10:00:00 24/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Localizes st: NotStopd t0: [10:00:00 24/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 24/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [10:00:00 24/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [10:00:00 24/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Side to Side st: NotStopd t0: [10:00:00 24/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [10:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [10:00:00 24/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Hypoactive st: NotStopd t0: [11:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 129 u1: mmHg v2: 82 u2: mmHg st: NotStopd t0: [11:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 97.6667 u1: mmHg st: NotStopd t0: [12:00:00 24/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [12:00:00 24/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 24/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [12:00:00 24/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 24/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [12:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [12:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [12:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 0 u1: sum st: NotStopd t0: [12:00:00 24/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [12:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [12:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [12:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [12:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [12:00:00 24/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [12:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 24/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [12:00:00 24/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [12:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [12:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [12:00:00 24/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [12:00:00 24/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [12:00:00 24/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [12:00:00 24/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 24/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [12:00:00 24/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [12:00:00 24/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [12:00:00 24/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [12:00:00 24/10/2016] id: Inc Cleansing #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [12:00:00 24/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Healed v2: Erythema st: NotStopd t0: [12:00:00 24/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 24/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 24/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [12:00:00 24/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 24/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [12:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [12:00:00 24/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [12:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [12:00:00 24/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [12:00:00 24/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 24/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [12:00:00 24/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [12:00:00 24/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [12:00:00 24/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [12:00:00 24/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 24/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 24/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [12:00:00 24/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 24/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [12:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [12:00:00 24/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Localizes st: NotStopd t0: [12:00:00 24/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [12:00:00 24/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [12:00:00 24/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [12:00:00 24/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 24/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [12:00:00 24/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [12:00:00 24/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 24/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [12:00:00 24/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [12:00:00 24/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Side to Side st: NotStopd t0: [12:00:00 24/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [12:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [12:00:00 24/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [12:00:00 24/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [12:00:00 24/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [12:00:00 24/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [12:00:00 24/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [12:00:00 24/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [12:00:00 24/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 12 u1: number st: NotStopd t0: [12:00:00 24/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd
t0: [12:00:00 24/10/2016] id: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 42 vu: ml t0: [12:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 150 vu: ml
tf: [08:00:00 25/10/2016] pt: IV Large Volume rt: IV fr: ONCE fs: 12 dn: 1 m1: Thiamine HCl v1: 100 u1: mg m2: D5 1/2NS v2: 1000 u2: ml m3: Folic Acid v3: 1 u3: mg m4: Multivitamin 12 v4: 10 tf: [14:00:00 25/10/2016] pt: Unit Dose rt: IV fr: Q1H:PRN m1: Lorazepam v1: 2-6 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: QID:PRN m1: Nystatin Oral Suspension v1: 5 u1: ml
t0: [12:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 87 u1: BPM st: NotStopd t0: [12:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 106 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [12:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 74 u1: mmHg st: NotStopd t0: [12:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [12:00:00 24/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [12:00:00 24/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 36.8889 u1: Deg. C st: NotStopd t0: [12:00:00 24/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98.4 u1: Deg. F st: NotStopd t0: [12:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [12:00:00 24/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 50 vu: ml t0: [12:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 26 vu: ml
t0: [12:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
id: MVI el: 100 cu: CCU cg: RN io: D5W 1000.0ml IV Infusions am: 10 du: ml rt: Intravenous Push id: Thiamine el: 100 cu: CCU cg: RN io: D5W 1000.0ml IV Infusions am: 100 du: mg rt: Intravenous Push id: Folate el: 100 cu: CCU cg: RN io: D5W 1000.0ml IV Infusions am: 1 du: mg rt: Intravenous Push
io: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ra: 125 ru: ml/hr
id: D5W el: 1 cu: CCU cg: RN io: D5W 1000.0ml IV Infusions vo: 1000 du: ml rt: Intravenous Infusion
t0: [13:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [13:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 133 u1: mmHg v2: 82 u2: mmHg st: NotStopd t0: [13:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 99 u1: mmHg st: NotStopd t0: [13:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [13:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [13:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [13:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 24/10/2016] id: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 42 vu: ml t0: [13:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 150 vu: ml t0: [13:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 30 vu: ml
t0: [13:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:30:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:30:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:30:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [13:30:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:30:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 133 u1: mmHg v2: 82 u2: mmHg st: NotStopd t0: [13:30:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 99 u1: mmHg st: NotStopd t0: [13:30:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [13:30:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [13:30:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [13:30:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:30:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 30 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [14:00:00 24/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [14:00:00 24/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [14:00:00 24/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 35 u1: cmH2O st: NotStopd t0: [14:00:00 24/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [14:00:00 24/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [14:00:00 24/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [14:00:00 24/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [14:00:00 24/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 10 u1: . st: NotStopd t0: [14:00:00 24/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 18 u1: BPM st: NotStopd t0: [14:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 97 u1: % st: NotStopd t0: [14:00:00 24/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 600 u1: ml/B st: NotStopd t0: [14:00:00 24/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [14:00:00 24/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [14:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 24/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [14:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [14:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [14:00:00 24/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [14:00:00 24/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [14:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 120 u1: mmHg v2: 72 u2: mmHg st: NotStopd t0: [14:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [14:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10064 id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [14:00:00 24/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [14:00:00 24/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [14:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [14:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 27 u1: BPM st: NotStopd t0: [14:00:00 24/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Side to Side st: NotStopd t0: [14:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:00:00 24/10/2016] id: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 42 vu: ml t0: [14:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [14:00:00 24/10/2016] tf: [01:00:00 25/10/2016] dt: 660 id: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [14:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 30 vu: ml
t0: [14:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 30 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [14:42:00 24/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.41 rs: Final st: NotStopd t0: [14:42:00 24/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 2 rs: Final st: NotStopd t0: [14:42:00 24/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 28 rs: Final st: NotStopd t0: [14:42:00 24/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 42 u1: mmHg rs: Final st: NotStopd t0: [14:42:00 24/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 121 u1: mmHg rs: Final st: NotStopd t0: [14:42:00 24/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.41 rs: Final st: NotStopd
t0: [08:00:00 24/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Amber v2: Cloudy st: NotStopd t0: [10:00:00 24/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Amber v2: Sediment st: NotStopd t0: [12:00:00 24/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Amber v2: Clear st: NotStopd t0: [14:00:00 24/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Orientation st: NotStopd t0: [14:00:00 24/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [14:00:00 24/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [14:00:00 24/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: Nodding st: NotStopd t0: [14:00:00 24/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [14:00:00 24/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [14:00:00 24/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [14:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [14:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 13 u1: points st: NotStopd t0: [14:00:00 24/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [14:00:00 24/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [14:00:00 24/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [14:00:00 24/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [14:00:00 24/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [14:00:00 24/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [14:00:00 24/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [14:00:00 24/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [14:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [14:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [14:00:00 24/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [14:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [14:00:00 24/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [14:00:00 24/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [14:00:00 24/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [14:00:00 24/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [14:00:00 24/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [14:00:00 24/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [14:00:00 24/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [14:00:00 24/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [14:00:00 24/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [14:00:00 24/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [14:00:00 24/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [14:00:00 24/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [14:00:00 24/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 24/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [14:00:00 24/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [14:00:00 24/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [14:00:00 24/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Amber v2: Clear st: NotStopd t0: [14:00:00 24/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [14:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 4 Confused st: NotStopd t0: [14:00:00 24/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [15:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: > Norm activity st: NotStopd t0: [15:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mod anxiety st: NotStopd t0: [15:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Very mild st: NotStopd t0: [15:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 10 u1: sum st: NotStopd t0: [15:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [15:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: Mild Nau, No Vom st: NotStopd t0: [15:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: ? date > 2 days st: NotStopd t0: [15:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [15:00:00 24/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [15:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [15:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [15:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [15:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [15:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 39 u1: BPM st: NotStopd t0: [15:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [15:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [15:00:00 24/10/2016] id: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 42 vu: ml t0: [15:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [15:00:00 24/10/2016] id: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [15:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml
t0: [15:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 30 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10424 id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [10:00:00 24/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [15:00:00 24/10/2016] tf: [13:44:00 31/10/2016] dt: 10004 id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [15:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [15:00:00 24/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: Yes st: NotStopd t0: [15:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 120 u1: mmHg v2: 74 u2: mmHg st: NotStopd t0: [15:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 89.3333 u1: mmHg st: NotStopd
t0: [16:00:00 24/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [16:00:00 24/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [16:00:00 24/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [16:00:00 24/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 35 u1: cmH2O st: NotStopd t0: [16:00:00 24/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [16:00:00 24/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [16:00:00 24/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [16:00:00 24/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [16:00:00 24/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [16:00:00 24/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [16:00:00 24/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [16:00:00 24/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 14 u1: cmH2O st: NotStopd t0: [16:00:00 24/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 9.6 u1: L/min st: NotStopd t0: [16:00:00 24/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [16:00:00 24/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 12 u1: . st: NotStopd t0: [16:00:00 24/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 12 u1: BPM st: NotStopd t0: [16:00:00 24/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [16:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 98 u1: % st: NotStopd t0: [16:00:00 24/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 800 u1: ml/B st: NotStopd t0: [16:00:00 24/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [16:00:00 24/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [12:00:00 24/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [14:00:00 24/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [14:00:00 24/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [14:00:00 24/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 24/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: Nodding st: NotStopd t0: [16:00:00 24/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 24/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [16:00:00 24/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [16:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [16:00:00 24/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [16:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 11 u1: points st: NotStopd t0: [16:00:00 24/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [16:00:00 24/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [16:00:00 24/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [16:00:00 24/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 24/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 45 degrees st: NotStopd t0: [16:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [16:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:00:00 24/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [16:00:00 24/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [16:00:00 24/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [16:00:00 24/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 24/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [16:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [16:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 120 u1: mmHg v2: 66 u2: mmHg st: NotStopd t0: [16:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [16:00:00 24/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [16:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 1 st: NotStopd t0: [16:00:00 24/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [16:00:00 24/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [16:00:00 24/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [16:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [16:00:00 24/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [16:00:00 24/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [16:00:00 24/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 24/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 24/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [16:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 41 u1: BPM st: NotStopd t0: [16:00:00 24/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [16:00:00 24/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 24/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [16:00:00 24/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [16:00:00 24/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [16:00:00 24/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.1111 u1: Deg. C st: NotStopd t0: [16:00:00 24/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98.8 u1: Deg. F st: NotStopd t0: [16:00:00 24/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Side to Side st: NotStopd t0: [16:00:00 24/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [16:00:00 24/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [16:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [16:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [16:00:00 24/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [17:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [17:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [17:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mildly anxious st: NotStopd t0: [17:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [17:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 2 u1: sum st: NotStopd t0: [17:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [17:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [17:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: No addit/ ? date st: NotStopd t0: [17:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [17:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [17:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [17:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [17:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [17:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [17:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [17:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:00:00 24/10/2016] id: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 42 vu: ml t0: [16:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [16:00:00 24/10/2016] id: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [16:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 36 vu: ml t0: [17:00:00 24/10/2016] id: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [17:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [17:00:00 24/10/2016] id: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [17:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 35 vu: ml
t0: [16:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 30 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [17:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [17:01:00 24/10/2016] id: D5W 250.0ml IV Infusions el: 1 cu: CCU cg: -1 ai: 189 vo: 0 st: D/C'd
t0: [08:00:00 24/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN st: NotStopd t0: [10:00:00 24/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN st: NotStopd t0: [12:00:00 24/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN st: NotStopd t0: [14:00:00 24/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN st: NotStopd t0: [16:00:00 24/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [16:00:00 24/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 24/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [16:00:00 24/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN st: NotStopd t0: [16:00:00 24/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [16:00:00 24/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [16:00:00 24/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 24/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [16:00:00 24/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [16:00:00 24/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 24/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [16:00:00 24/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [16:00:00 24/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [16:00:00 24/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [18:00:00 24/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [18:00:00 24/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [18:00:00 24/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 24/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [18:00:00 24/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [18:00:00 24/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [18:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [18:00:00 24/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [18:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [18:00:00 24/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [18:00:00 24/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [18:00:00 24/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [18:00:00 24/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [18:00:00 24/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [18:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [18:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:00:00 24/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [18:00:00 24/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [18:00:00 24/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [18:00:00 24/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [18:00:00 24/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [18:00:00 24/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [18:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [18:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [18:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [18:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82.3333 u1: mmHg st: NotStopd t0: [18:00:00 24/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [18:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [18:00:00 24/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [18:00:00 24/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [18:00:00 24/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [18:00:00 24/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [18:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [18:00:00 24/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [18:00:00 24/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [18:00:00 24/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [18:00:00 24/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [18:00:00 24/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [18:00:00 24/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [18:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [18:00:00 24/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Localizes st: NotStopd t0: [18:00:00 24/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [18:00:00 24/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [18:00:00 24/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [18:00:00 24/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 24/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [18:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [18:00:00 24/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [18:00:00 24/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [18:00:00 24/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Side to Side st: NotStopd t0: [18:00:00 24/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [18:00:00 24/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [18:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [18:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [18:00:00 24/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd
t0: [18:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [18:00:00 24/10/2016] id: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [18:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 35 vu: ml
t0: [18:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [19:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 91 u1: BPM st: NotStopd t0: [19:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [19:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84.3333 u1: mmHg st: NotStopd t0: [19:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [19:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [19:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:00:00 24/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thin st: NotStopd t0: [19:00:00 24/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd t0: [19:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [19:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [20:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [20:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [20:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [20:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [20:00:00 24/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thin st: NotStopd t0: [20:00:00 24/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Small st: NotStopd t0: [20:00:00 24/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [20:00:00 24/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.9444 u1: Deg. C st: NotStopd t0: [20:00:00 24/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.3 u1: Deg. F st: NotStopd t0: [20:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [20:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [20:00:00 24/10/2016] id: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 250 vu: ml t0: [20:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 60 vu: ml
t0: [20:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [20:00:00 24/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: Mouthing Words st: NotStopd t0: [20:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Very Agitated st: NotStopd t0: [20:00:00 24/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [20:00:00 24/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [20:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [20:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 11 u1: points st: NotStopd t0: [20:00:00 24/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [20:00:00 24/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [20:00:00 24/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [20:00:00 24/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [20:00:00 24/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [20:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [20:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [20:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 1 st: NotStopd t0: [20:00:00 24/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [20:00:00 24/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [20:00:00 24/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [20:00:00 24/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Amber v2: Sediment st: NotStopd t0: [20:00:00 24/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [20:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1 No Response st: NotStopd t0: [20:00:00 24/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [20:00:00 24/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [20:00:00 24/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [20:00:00 24/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [20:00:00 24/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Consist. Moist st: NotStopd t0: [20:00:00 24/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [20:00:00 24/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 10 u1: number st: NotStopd t0: [20:00:00 24/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [20:15:00 24/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thin st: NotStopd t0: [20:15:00 24/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd
t0: [20:00:00 24/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [20:00:00 24/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [20:00:00 24/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [20:00:00 24/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 35 u1: cmH2O st: NotStopd t0: [20:00:00 24/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [20:00:00 24/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [20:00:00 24/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [20:00:00 24/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [20:00:00 24/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [20:00:00 24/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [20:00:00 24/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 12 u1: cmH2O st: NotStopd t0: [20:00:00 24/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 8.3 u1: L/min st: NotStopd t0: [20:00:00 24/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [20:00:00 24/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 10 u1: . st: NotStopd t0: [20:00:00 24/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 11 u1: BPM st: NotStopd t0: [20:00:00 24/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [20:00:00 24/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 710 u1: ml/B st: NotStopd t0: [20:00:00 24/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [20:00:00 24/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [20:00:00 24/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [21:00:00 24/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [21:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 87 u1: BPM st: NotStopd t0: [21:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [21:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 70 u2: mmHg st: NotStopd t0: [21:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 90.6667 u1: mmHg st: NotStopd t0: [21:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [21:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 36 u1: BPM st: NotStopd t0: [21:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [21:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [21:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [20:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [20:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [20:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [20:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 7 u1: sum st: NotStopd t0: [20:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [20:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [20:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: No addit/ ? date st: NotStopd t0: [20:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [20:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [20:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [22:00:00 24/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [22:00:00 24/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mildly anxious st: NotStopd t0: [22:00:00 24/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [22:00:00 24/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 6 u1: sum st: NotStopd t0: [22:00:00 24/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [22:00:00 24/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [22:00:00 24/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: No addit/ ? date st: NotStopd t0: [22:00:00 24/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [22:00:00 24/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 24/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [22:00:00 24/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 24/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [22:00:00 24/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [22:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 90 u1: BPM st: NotStopd t0: [22:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:00:00 24/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [22:00:00 24/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [22:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [22:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82 u1: mmHg st: NotStopd t0: [22:00:00 24/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 1 st: NotStopd t0: [22:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [22:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [22:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [22:00:00 24/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [22:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [22:00:00 24/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [22:00:00 24/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 90 vu: ml
t0: [22:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 24/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 24/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN cv: 824 ap: none t0: [23:00:00 24/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: RN cv: 824 ap: none
t0: [22:00:00 24/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [22:00:00 24/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [22:00:00 24/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [22:00:00 24/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [22:00:00 24/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [22:00:00 24/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [22:00:00 24/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thin st: NotStopd t0: [22:00:00 24/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Copious st: NotStopd
t0: [23:00:00 24/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [23:00:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 141 u1: BPM st: NotStopd t0: [23:00:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [23:00:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 102 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [23:00:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 77.3333 u1: mmHg st: NotStopd t0: [23:00:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [23:00:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [23:00:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [23:00:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [23:00:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:05:00 24/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:05:00 24/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:05:00 24/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 90 u1: BPM st: NotStopd t0: [23:05:00 24/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [23:05:00 24/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [23:05:00 24/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82.3333 u1: mmHg st: NotStopd t0: [23:05:00 24/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [23:05:00 24/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [23:05:00 24/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [23:05:00 24/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [23:05:00 24/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [00:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 125 u1: mmHg v2: 75 u2: mmHg st: NotStopd t0: [00:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 91.6667 u1: mmHg st: NotStopd t0: [00:00:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [00:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [00:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [00:00:00 25/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [00:00:00 25/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.1111 u1: Deg. C st: NotStopd t0: [00:00:00 25/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.6 u1: Deg. F st: NotStopd t0: [00:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [00:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:00:00 25/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [00:00:00 25/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [00:00:00 25/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [00:00:00 25/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 35 u1: cmH2O st: NotStopd t0: [00:00:00 25/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [00:00:00 25/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [00:00:00 25/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [00:00:00 25/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [00:00:00 25/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [00:00:00 25/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [00:00:00 25/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 13 u1: cmH2O st: NotStopd t0: [00:00:00 25/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 11.3 u1: L/min st: NotStopd t0: [00:00:00 25/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [00:00:00 25/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 22 u1: BPM st: NotStopd t0: [00:00:00 25/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [00:00:00 25/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: Tan v2: Thick st: NotStopd t0: [00:00:00 25/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Copious st: NotStopd t0: [00:00:00 25/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 610 u1: ml/B st: NotStopd t0: [00:00:00 25/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [00:00:00 25/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [00:00:00 25/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 10 u1: . st: NotStopd
t0: [01:00:00 25/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 4 st: NotStopd t0: [01:00:00 25/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [01:00:00 25/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [01:00:00 25/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mod anxiety st: NotStopd t0: [01:00:00 25/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [01:00:00 25/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 10 u1: sum st: NotStopd t0: [01:00:00 25/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [01:00:00 25/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [01:00:00 25/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: No addit/ ? date st: NotStopd t0: [01:00:00 25/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [01:00:00 25/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 25/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [01:00:00 25/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 90 u1: BPM st: NotStopd t0: [01:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [01:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [01:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 83 u1: mmHg st: NotStopd t0: [01:00:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [01:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 46 u1: BPM st: NotStopd t0: [01:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [01:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [01:00:00 25/10/2016] id: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: -1 ai: 107 vo: 0 st: D/C'd
t0: [01:30:00 25/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [01:30:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:30:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:30:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 141 u1: BPM st: NotStopd t0: [01:30:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [01:30:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 124 u1: mmHg v2: 72 u2: mmHg st: NotStopd t0: [01:30:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 89.3333 u1: mmHg st: NotStopd t0: [01:30:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [01:30:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [01:30:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [01:30:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:30:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [22:00:00 24/10/2016] id: D5W 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 107 vo: 125 vu: ml t0: [00:00:00 25/10/2016] tf: [13:00:00 25/10/2016] dt: 780 id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vu: ml nb: 1 t0: [00:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 150 vu: ml t0: [01:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 150 vu: ml t0: [01:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 160 vu: ml
t0: [23:00:00 24/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 24/10/2016] dt: 24 id: IV Infusion In Total el: 1 cu: CCU cg: RN cv: 3635.44 ap: none t0: [23:00:00 24/10/2016] dt: 24 id: 24h Total In el: 1 cu: CCU cg: RN cv: 3635.44 ap: none t0: [23:00:00 24/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: RN cv: 2811.44 ap: none t0: [23:00:00 24/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: RN cv: 2027.6 ap: none
t0: [01:40:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:40:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:40:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [01:40:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [01:40:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 113 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [01:40:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 77 u1: mmHg st: NotStopd t0: [01:40:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [01:40:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 10 u1: BPM st: NotStopd t0: [01:40:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [01:40:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:40:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [02:00:00 25/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [02:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [02:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [02:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 113 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [02:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 77 u1: mmHg st: NotStopd t0: [02:00:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [02:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [02:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [02:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 40 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [02:00:00 25/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thin st: NotStopd t0: [02:00:00 25/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd
t0: [02:30:00 25/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 2 st: NotStopd t0: [02:30:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:30:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:30:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [02:30:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [02:30:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 99 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [02:30:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 71 u1: mmHg st: NotStopd t0: [02:30:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [02:30:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 44 u1: BPM st: NotStopd t0: [02:30:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [02:30:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:30:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [03:15:00 25/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: RN v1: Ativan v2: 4 st: NotStopd t0: [03:15:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:15:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:15:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [03:15:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [03:15:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 140 u1: mmHg v2: 63 u2: mmHg st: NotStopd t0: [03:15:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 88.6667 u1: mmHg st: NotStopd t0: [03:15:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [03:15:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 25 u1: BPM st: NotStopd t0: [03:15:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [03:15:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [03:15:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [03:00:00 25/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 12 u1: . st: NotStopd
t0: [03:00:00 25/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [03:00:00 25/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ..... st: NotStopd t0: [03:00:00 25/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [03:00:00 25/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 13 u1: sum st: NotStopd t0: [03:00:00 25/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [03:00:00 25/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [03:00:00 25/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: ? date > 2 days st: NotStopd t0: [03:00:00 25/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [03:00:00 25/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 25/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [03:00:00 25/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 25/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [03:00:00 25/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [03:00:00 25/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [03:00:00 25/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [03:00:00 25/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [03:00:00 25/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [03:00:00 25/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [03:00:00 25/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [03:00:00 25/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [03:00:00 25/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [03:00:00 25/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thin st: NotStopd t0: [03:00:00 25/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Copious st: NotStopd t0: [03:00:00 25/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd
t0: [03:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 300 vu: ml t0: [03:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 50 vu: ml
t0: [04:00:00 25/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 41.1765 u1: ml/cmH st: NotStopd t0: [04:00:00 25/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 22 t0: [04:00:00 25/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [04:00:00 25/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [04:00:00 25/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [04:00:00 25/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [04:00:00 25/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:3.3 st: NotStopd t0: [04:00:00 25/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [04:00:00 25/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [04:00:00 25/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [04:00:00 25/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [04:00:00 25/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5.5 st: NotStopd t0: [04:00:00 25/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [04:00:00 25/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 14 u1: cmH2O st: NotStopd t0: [04:00:00 25/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 10.7 u1: L/min st: NotStopd t0: [04:00:00 25/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [04:00:00 25/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 27 u1: cmH2O st: NotStopd t0: [04:00:00 25/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 26 u1: cmH2O st: NotStopd t0: [04:00:00 25/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 0 u1: . st: NotStopd t0: [04:00:00 25/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 3 u1: BPM st: NotStopd t0: [04:00:00 25/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 17 u1: BPM st: NotStopd t0: [04:00:00 25/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [04:00:00 25/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [04:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 96 u1: % st: NotStopd t0: [04:00:00 25/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: None st: NotStopd t0: [04:00:00 25/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [04:00:00 25/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [04:00:00 25/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [04:00:00 25/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [04:00:00 25/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [04:00:00 25/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [04:00:00 25/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [04:00:00 25/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [04:00:00 25/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [04:00:00 25/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 4 u1: sum st: NotStopd t0: [04:00:00 25/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [04:00:00 25/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [04:00:00 25/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: ? date > 2 days st: NotStopd t0: [04:00:00 25/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: Palms moist st: NotStopd t0: [04:00:00 25/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 25/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [04:00:00 25/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [04:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 96 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [04:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 66 u1: mmHg st: NotStopd t0: [04:00:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [04:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [04:00:00 25/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [04:00:00 25/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.9444 u1: Deg. C st: NotStopd t0: [04:00:00 25/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.3 u1: Deg. F st: NotStopd t0: [04:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [04:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [05:00:00 25/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [05:00:00 25/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [05:00:00 25/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [05:00:00 25/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [05:00:00 25/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [05:00:00 25/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [05:00:00 25/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [05:00:00 25/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 25/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [05:00:00 25/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 25/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [05:00:00 25/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [05:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [05:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [05:00:00 25/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [05:00:00 25/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [05:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 102 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [05:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [05:00:00 25/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [05:00:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [05:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [05:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [05:00:00 25/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thin st: NotStopd t0: [05:00:00 25/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Small st: NotStopd t0: [05:00:00 25/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [05:00:00 25/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.6667 u1: Deg. C st: NotStopd t0: [05:00:00 25/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 101.6 u1: Deg. F st: NotStopd t0: [05:00:00 25/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [05:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [05:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 50 vu: ml
t0: [05:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [05:20:00 25/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 11.2 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: WBC Hematology el: 0 cu: CCU cg: 140 v1: 11.2 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 39 u1: % rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 13.4 u1: gm/dl rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Platelets Hematology el: 0 cu: CCU cg: 140 v1: 142 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: RBC Hematology el: 0 cu: CCU cg: 140 v1: 4.07 u1: /mic l rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 11.2 rs: Final st: NotStopd
t0: [06:00:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 9104 id: RSBI Not Completed el: 0 cu: CCU cg: RRT v1: PEEP >10 st: NotStopd
t0: [06:00:00 25/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [06:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 80 u1: BPM st: NotStopd t0: [06:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [06:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 107 u1: mmHg v2: 61 u2: mmHg st: NotStopd t0: [06:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 76.3333 u1: mmHg st: NotStopd t0: [06:00:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [06:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [06:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [06:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [06:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [05:20:00 25/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 7 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 8.2 u1: mg/dl rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 109 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.6 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 119 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 2.1 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 2.2 u1: mEq/L rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 3.4 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 140 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: BUN (6-20) Chemistry el: 0 cu: CCU cg: 140 v1: 7 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 8.2 u1: mg/dl rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 26 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 109 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.6 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 119 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 2.1 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 2.2 u1: mEq/L rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 3.4 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 140 rs: Final st: NotStopd
t0: [08:00:00 25/10/2016] id: Med Wasted/Amt el: 0 cu: CCU cg: -1 st: D/C'd
t0: [08:00:00 25/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 41.1765 u1: ml/cmH st: NotStopd t0: [08:00:00 25/10/2016] id: RSBI Not Completed el: 0 cu: CCU cg: RRT v1: PEEP >10 st: NotStopd t0: [08:00:00 25/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [08:00:00 25/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [08:00:00 25/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [08:00:00 25/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [08:00:00 25/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [08:00:00 25/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:3.3 st: NotStopd t0: [08:00:00 25/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [08:00:00 25/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [08:00:00 25/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [08:00:00 25/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [08:00:00 25/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [08:00:00 25/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [08:00:00 25/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 15 u1: cmH2O st: NotStopd t0: [08:00:00 25/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 10.4 u1: L/min st: NotStopd t0: [08:00:00 25/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [08:00:00 25/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 27 u1: cmH2O st: NotStopd t0: [08:00:00 25/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 19 u1: cmH2O st: NotStopd t0: [08:00:00 25/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 0 u1: . st: NotStopd t0: [08:00:00 25/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 2 u1: BPM st: NotStopd t0: [08:00:00 25/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 16 u1: BPM st: NotStopd t0: [08:00:00 25/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [08:00:00 25/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [08:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 98 u1: % st: NotStopd t0: [08:00:00 25/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: White v2: Thick st: NotStopd t0: [08:00:00 25/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Moderate st: NotStopd t0: [08:00:00 25/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 663 u1: ml/B st: NotStopd t0: [08:00:00 25/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [08:00:00 25/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [08:00:00 25/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [08:00:00 25/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [05:20:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 9144 id: Differential-Bands Hematology el: 0 cu: CCU cg: 140 v1: 0 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 9144 id: Differential-Basos Hematology el: 0 cu: CCU cg: 140 v1: 0.1 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 9144 id: Differential-Eos Hematology el: 0 cu: CCU cg: 140 v1: 1.4 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 9144 id: Differential-Lymphs Hematology el: 0 cu: CCU cg: 140 v1: 9.5 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 9144 id: Differential-Monos Hematology el: 0 cu: CCU cg: 140 v1: 3.8 rs: Final st: NotStopd t0: [05:20:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 9144 id: Differential-Polys Hematology el: 0 cu: CCU cg: 140 v1: 85.2 rs: Final st: NotStopd
t0: [21:00:00 24/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [21:00:00 24/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 18 gauge st: NotStopd t0: [21:00:00 24/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [21:00:00 24/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [21:00:00 24/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [21:00:00 24/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: RU Ant Forearm v2: 20 gauge st: NotStopd t0: [05:00:00 25/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [05:00:00 25/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 18 gauge st: NotStopd t0: [05:00:00 25/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [05:00:00 25/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [05:00:00 25/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [05:00:00 25/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: RU Ant Forearm v2: 20 gauge st: NotStopd t0: [08:00:00 25/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 25/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 25/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [08:00:00 25/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [08:00:00 25/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [08:00:00 25/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [08:00:00 25/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [08:00:00 25/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 11 u1: sum st: NotStopd t0: [08:00:00 25/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [08:00:00 25/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [08:00:00 25/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: No addit/ ? date st: NotStopd t0: [08:00:00 25/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: Beads/ forehead st: NotStopd t0: [08:00:00 25/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 25/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [08:00:00 25/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 25/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [08:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 25/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [08:00:00 25/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 9 u1: points st: NotStopd t0: [08:00:00 25/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [08:00:00 25/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [08:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [08:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:00:00 25/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Healed v2: Ecchymotic st: NotStopd t0: [08:00:00 25/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 25/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [08:00:00 25/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [08:00:00 25/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [08:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 108 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [08:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 74.6667 u1: mmHg st: NotStopd t0: [08:00:00 25/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [08:00:00 25/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 8984 id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [08:00:00 25/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [08:00:00 25/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [08:00:00 25/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 25/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [08:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [08:00:00 25/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [08:00:00 25/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [08:00:00 25/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [08:00:00 25/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [08:00:00 25/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [08:00:00 25/10/2016] tf: [13:44:00 31/10/2016] dt: 8984 id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 25/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Sediment st: NotStopd t0: [08:00:00 25/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 25/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [08:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [08:00:00 25/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [08:00:00 25/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [08:00:00 25/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [08:00:00 25/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [08:00:00 25/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [08:00:00 25/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 13 u1: number st: NotStopd t0: [08:00:00 25/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd
t0: [08:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 60 vu: ml
t0: [08:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 25/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [08:00:00 25/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.7778 u1: Deg. C st: NotStopd t0: [08:00:00 25/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 101.8 u1: Deg. F st: NotStopd
t0: [05:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [08:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 30 vu: ml
tf: [08:00:00 25/10/2016] pt: IV Large Volume rt: IV fr: ONCE fs: 10 dn: 1 m1: Thiamine HCl v1: 1 u1: mg m2: NS v2: 1000 u2: ml m3: Folic Acid v3: 10 u3: ml m4: Multivitamin 12 v4: 100 tf: [08:00:00 26/10/2016] pt: IV Large Volume rt: IV fr: ONCE fs: 10 dn: 1 m1: Thiamine HCl v1: 100 u1: mg m2: NS v2: 1000 u2: ml m3: Folic Acid v3: 1 u3: mg m4: Multivitamin 12 v4: 10
t0: [09:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [09:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [09:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 102 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [09:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [09:00:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [09:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [09:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [09:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [09:30:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:30:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:30:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [09:30:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [09:30:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 110 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [09:30:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 76.6667 u1: mmHg st: NotStopd t0: [09:30:00 25/10/2016] id: Previous WeightF el: 0 cu: CCU cg: RN v1: 93.8 u1: kg st: NotStopd t0: [09:30:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [09:30:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [09:30:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [09:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 20 vu: ml
t0: [09:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [09:30:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [09:30:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 5 vu: ml t0: [09:30:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 26 vu: ml
id: MVI el: 100 cu: CCU cg: RN io: .9% Normal Saline IV Infusions am: 10 du: ml rt: Intravenous Push id: Thiamine el: 100 cu: CCU cg: RN io: .9% Normal Saline IV Infusions am: 100 du: mg rt: Intravenous Push id: Folate el: 100 cu: CCU cg: RN io: .9% Normal Saline IV Infusions am: 1 du: mg rt: Intravenous Push
io: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: RN ra: 200 ru: ml/hr
tf: [09:00:00 26/10/2016] pt: Unit Dose rt: PO fr: ONCE fs: 10 dn: 1 m1: Potassium Chloride v1: 60 u1: mEq tf: [18:00:00 03/11/2016] pt: Unit Dose rt: IV DRIP fr: TITRATE TO m1: Propofol (Generic) v1: 1000 u1: mg
id: Gastric Meds el: 1 cu: CCU cg: RN io: Gastric Meds PO/Gastric du: ml rt: Gastric/Feeding Tube id: .9% Normal Saline el: 1 cu: CCU cg: RN io: .9% Normal Saline IV Infusions du: ml rt: Intravenous Infusion
t0: [10:00:00 25/10/2016] id: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: RN ai: 115 vu: ml nb: 1
t0: [10:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [10:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 112 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [10:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 76.6667 u1: mmHg st: NotStopd t0: [10:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [10:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [10:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [10:30:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:30:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:30:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 74 u1: BPM st: NotStopd t0: [10:30:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:30:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 105 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [10:30:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 74.3333 u1: mmHg st: NotStopd t0: [10:30:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [10:30:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [10:30:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:30:00 25/10/2016] tf: [17:00:00 25/10/2016] dt: 390 id: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: RN ai: 115 vo: 100 vu: ml t0: [10:30:00 25/10/2016] tf: [08:00:00 31/10/2016] dt: 8490 id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 189 vo: 5 vu: ml t0: [10:30:00 25/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 120 vu: ml t0: [10:30:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 30 vu: ml
t0: [10:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [10:30:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 25/10/2016] dt: 24 id: PO/Gastric In Total el: 1 cu: CCU cg: RN cv: 120 ap: none
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: IV fr: Q1H:PRN m1: Lorazepam v1: 1-4 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: IV fr: Q2H fs: 15, 17, 19, 21, 23, 1, 3, 5, 7, 9, 11, 13 dn: 12 m1: Lorazepam v1: 2 u1: mg
t0: [05:20:00 25/10/2016] id: CPK Enzymes el: 0 cu: CCU cg: 140 v1: 72 rs: Final st: NotStopd
t0: [18:45:00 25/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.37 rs: Final st: NotStopd t0: [18:45:00 25/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 0 rs: Final st: NotStopd t0: [18:45:00 25/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 27 rs: Final st: NotStopd t0: [18:45:00 25/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 45 u1: mmHg rs: Final st: NotStopd t0: [18:45:00 25/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 58 u1: mmHg rs: Final st: NotStopd t0: [18:45:00 25/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.37 rs: Final st: NotStopd
pt: Miscellaneous Charges m1: LIDOCAINE 1% (W/Presv.)
t0: [21:43:00 25/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.37 rs: Final st: NotStopd t0: [21:43:00 25/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [21:43:00 25/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 28 rs: Final st: NotStopd t0: [21:43:00 25/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 46 u1: mmHg rs: Final st: NotStopd t0: [21:43:00 25/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 162 u1: mmHg rs: Final st: NotStopd t0: [21:43:00 25/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.37 rs: Final st: NotStopd
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: QID fs: 10, 14, 18, 22 dn: 4 m1: Neutra-Phos v1: 1 u1: PKT
t0: [23:00:00 25/10/2016] id: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: -1 ai: 115 vo: 0 st: D/C'd
tf: [23:00:00 26/10/2016] pt: Unit Dose rt: IV fr: ONCE fs: 0 dn: 1 m1: Calcium Gluconate v1: 2 u1: gm
t0: [13:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [13:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 109 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [13:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 73.6667 u1: mmHg st: NotStopd t0: [13:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [13:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [13:00:00 25/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.8889 u1: Deg. C st: NotStopd t0: [13:00:00 25/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.2 u1: Deg. F st: NotStopd t0: [13:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [14:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [14:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [14:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 111 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [14:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 75 u1: mmHg st: NotStopd t0: [14:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [14:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [14:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [15:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 73 u1: BPM st: NotStopd t0: [15:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [15:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 101 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [15:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 68.3333 u1: mmHg st: NotStopd t0: [15:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [15:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [15:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [16:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [16:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 102 u1: mmHg v2: 53 u2: mmHg st: NotStopd t0: [16:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 69.3333 u1: mmHg st: NotStopd t0: [16:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [16:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [16:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [17:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 73 u1: BPM st: NotStopd t0: [17:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [17:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 100 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [17:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 67.3333 u1: mmHg st: NotStopd t0: [17:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [17:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [17:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [18:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [18:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 107 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [18:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 73.6667 u1: mmHg st: NotStopd t0: [18:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 26 u1: BPM st: NotStopd t0: [18:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [18:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:00:00 25/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [19:00:00 25/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [19:00:00 25/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [19:00:00 25/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 25/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [19:00:00 25/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [19:00:00 25/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [19:00:00 25/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [19:00:00 25/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [19:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 25/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [19:00:00 25/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [19:00:00 25/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [19:00:00 25/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [19:00:00 25/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [19:00:00 25/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [19:00:00 25/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [19:00:00 25/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [19:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [19:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:00:00 25/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [19:00:00 25/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [19:00:00 25/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [19:00:00 25/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Other/Remarks v2: Ecchymotic st: NotStopd t0: [19:00:00 25/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 25/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 25/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [19:00:00 25/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [19:00:00 25/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [19:00:00 25/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [19:00:00 25/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [19:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 103 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [19:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 74.3333 u1: mmHg st: NotStopd t0: [19:00:00 25/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [19:00:00 25/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [19:00:00 25/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [19:00:00 25/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [19:00:00 25/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [19:00:00 25/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [19:00:00 25/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [19:00:00 25/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [19:00:00 25/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [19:00:00 25/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [19:00:00 25/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [19:00:00 25/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [19:00:00 25/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [19:00:00 25/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [19:00:00 25/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [19:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 31 u1: BPM st: NotStopd t0: [19:00:00 25/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Withdraws st: NotStopd t0: [19:00:00 25/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [19:00:00 25/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [19:00:00 25/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [19:00:00 25/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 25/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [19:00:00 25/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [19:00:00 25/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [19:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [19:00:00 25/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 25/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [19:00:00 25/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 25/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [19:00:00 25/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [19:00:00 25/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [19:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:00:00 25/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Absent st: NotStopd t0: [19:00:00 25/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [19:00:00 25/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [19:00:00 25/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd t0: [19:00:00 25/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [19:00:00 25/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [19:00:00 25/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 14 u1: number st: NotStopd t0: [19:00:00 25/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd t0: [20:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 73 u1: BPM st: NotStopd t0: [20:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 113 u1: mmHg v2: 61 u2: mmHg st: NotStopd t0: [20:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 78.3333 u1: mmHg st: NotStopd t0: [20:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [20:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [20:00:00 25/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.0556 u1: Deg. C st: NotStopd t0: [20:00:00 25/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98.7 u1: Deg. F st: NotStopd t0: [20:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [21:00:00 25/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [21:00:00 25/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 25/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [21:00:00 25/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 25/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [21:00:00 25/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [21:00:00 25/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [21:00:00 25/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [21:00:00 25/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [21:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 25/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [21:00:00 25/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [21:00:00 25/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [21:00:00 25/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [21:00:00 25/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [21:00:00 25/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [21:00:00 25/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [21:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [21:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [21:00:00 25/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [21:00:00 25/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [21:00:00 25/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [21:00:00 25/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Other/Remarks v2: Ecchymotic st: NotStopd t0: [21:00:00 25/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 25/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 25/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [21:00:00 25/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [21:00:00 25/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [21:00:00 25/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [21:00:00 25/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 4 Flex-withdraws st: NotStopd t0: [21:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 118 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [21:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 77.3333 u1: mmHg st: NotStopd t0: [21:00:00 25/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [21:00:00 25/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [21:00:00 25/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [21:00:00 25/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [21:00:00 25/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [21:00:00 25/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 25/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [21:00:00 25/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [21:00:00 25/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [21:00:00 25/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [21:00:00 25/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [21:00:00 25/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [21:00:00 25/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [21:00:00 25/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 25/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [21:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 34 u1: BPM st: NotStopd t0: [21:00:00 25/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Withdraws st: NotStopd t0: [21:00:00 25/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [21:00:00 25/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [21:00:00 25/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [21:00:00 25/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 25/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [21:00:00 25/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [21:00:00 25/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [21:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [21:00:00 25/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 25/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [21:00:00 25/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 25/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [21:00:00 25/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [21:00:00 25/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [21:00:00 25/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [21:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [21:00:00 25/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Absent st: NotStopd t0: [22:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [22:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 137 u1: mmHg v2: 81 u2: mmHg st: NotStopd t0: [22:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 99.6667 u1: mmHg st: NotStopd t0: [22:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [22:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [22:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [23:00:00 25/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [23:00:00 25/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [23:00:00 25/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [23:00:00 25/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 25/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [23:00:00 25/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [23:00:00 25/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [23:00:00 25/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [23:00:00 25/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [23:00:00 25/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 25/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 25/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [23:00:00 25/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [23:00:00 25/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [23:00:00 25/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [23:00:00 25/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [23:00:00 25/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [23:00:00 25/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [23:00:00 25/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [23:00:00 25/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [23:00:00 25/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [23:00:00 25/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [23:00:00 25/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [23:00:00 25/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [23:00:00 25/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [23:00:00 25/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [23:00:00 25/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [23:00:00 25/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 4 Flex-withdraws st: NotStopd t0: [23:00:00 25/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 136 u1: mmHg v2: 80 u2: mmHg st: NotStopd t0: [23:00:00 25/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 98.6667 u1: mmHg st: NotStopd t0: [23:00:00 25/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [23:00:00 25/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [23:00:00 25/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [23:00:00 25/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [23:00:00 25/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [23:00:00 25/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [23:00:00 25/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [23:00:00 25/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [23:00:00 25/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [23:00:00 25/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [23:00:00 25/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [23:00:00 25/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [23:00:00 25/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [23:00:00 25/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [23:00:00 25/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [23:00:00 25/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [23:00:00 25/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Withdraws st: NotStopd t0: [23:00:00 25/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [23:00:00 25/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [23:00:00 25/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [23:00:00 25/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 25/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [23:00:00 25/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [23:00:00 25/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [23:00:00 25/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [23:00:00 25/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 25/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [23:00:00 25/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 25/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [23:00:00 25/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [23:00:00 25/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [23:00:00 25/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [23:00:00 25/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [23:00:00 25/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Absent st: NotStopd t0: [00:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [00:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 136 u1: mmHg v2: 75 u2: mmHg st: NotStopd t0: [00:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 95.3333 u1: mmHg st: NotStopd t0: [00:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [00:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [00:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 25/10/2016] id: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: RN ai: 115 vo: 500 vu: ml t0: [17:00:00 25/10/2016] tf: [18:45:00 27/10/2016] dt: 2985 id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [13:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 30 vu: ml t0: [14:00:00 25/10/2016] id: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: RN ai: 115 vo: 200 vu: ml t0: [14:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [14:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 30 vu: ml t0: [15:00:00 25/10/2016] id: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: RN ai: 115 vo: 200 vu: ml t0: [15:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [15:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 40 vu: ml t0: [16:00:00 25/10/2016] id: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: RN ai: 115 vu: ml nb: 1 t0: [16:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml nb: 1 t0: [16:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 40 vu: ml t0: [17:00:00 25/10/2016] id: .9% Normal Saline IV Infusions el: 1 cu: CCU cg: RN ai: 115 vu: ml st: Stopped t0: [17:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [17:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml t0: [18:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [18:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml t0: [19:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [19:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml t0: [20:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [20:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 280 vu: ml t0: [21:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [21:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 240 vu: ml t0: [22:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [22:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 45 vu: ml t0: [23:00:00 25/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [23:00:00 25/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 50 vu: ml
t0: [13:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [14:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [15:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [16:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [17:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [18:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [20:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [21:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [22:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [23:00:00 25/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [00:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 25/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: RN pv: 50 cv: 50 ap: none t0: [23:00:00 25/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: RN pv: 78.14 cv: 78.14 ap: none t0: [23:00:00 25/10/2016] dt: 24 id: IV Infusion In Total el: 1 cu: CCU cg: RN pv: 128.14 cv: 3066.39 ap: none t0: [23:00:00 25/10/2016] dt: 24 id: 24h Total In el: 1 cu: CCU cg: RN pv: 128.14 cv: 3186.39 ap: none t0: [23:00:00 25/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN pv: 50 cv: 1371 ap: none t0: [23:00:00 25/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: RN pv: 78.14 cv: 1815.39 ap: none t0: [23:00:00 25/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: RN pv: 50 cv: 1371 ap: none t0: [23:00:00 25/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: RN pv: 78.14 cv: 3842.99 ap: none
t0: [00:00:00 26/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 36.7222 u1: Deg. C st: NotStopd t0: [00:00:00 26/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98.1 u1: Deg. F st: NotStopd
t0: [00:00:00 26/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 150 vu: ml t0: [00:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [00:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 45 vu: ml
t0: [01:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [01:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [01:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [01:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 77.6667 u1: mmHg st: NotStopd t0: [01:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 11 u1: BPM st: NotStopd t0: [01:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [01:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [01:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 40 vu: ml
t0: [01:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [01:00:00 26/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [01:00:00 26/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [01:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [01:00:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [01:00:00 26/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [01:00:00 26/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [01:00:00 26/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [01:00:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [01:00:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [01:00:00 26/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [01:00:00 26/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [01:00:00 26/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [01:00:00 26/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [01:00:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [01:00:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [01:00:00 26/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [01:00:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [01:00:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [01:00:00 26/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Other/Remarks v2: Ecchymotic st: NotStopd t0: [01:00:00 26/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 26/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 26/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [01:00:00 26/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [01:00:00 26/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [01:00:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [01:00:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 4 Flex-withdraws st: NotStopd t0: [01:00:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [01:00:00 26/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [01:00:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [01:00:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [01:00:00 26/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [01:00:00 26/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [01:00:00 26/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [01:00:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 1 Person Assist st: NotStopd t0: [01:00:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [01:00:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [01:00:00 26/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [01:00:00 26/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [01:00:00 26/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [01:00:00 26/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [01:00:00 26/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [01:00:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Withdraws st: NotStopd t0: [01:00:00 26/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [01:00:00 26/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [01:00:00 26/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [01:00:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 26/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [01:00:00 26/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [01:00:00 26/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [01:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [01:00:00 26/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [01:00:00 26/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [01:00:00 26/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [01:00:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [01:00:00 26/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [02:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [02:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [02:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 122 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [02:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [02:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [02:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [02:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [02:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 50 vu: ml
t0: [02:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [01:59:00 26/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 8.2 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: WBC Hematology el: 0 cu: CCU cg: 140 v1: 8.2 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 39.1 u1: % rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 13.3 u1: gm/dl rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Platelets Hematology el: 0 cu: CCU cg: 140 v1: 145 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: RBC Hematology el: 0 cu: CCU cg: 140 v1: 4.08 u1: /mic l rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 8.2 rs: Final st: NotStopd
t0: [01:59:00 26/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 5 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Albumin Chemistry el: 0 cu: CCU cg: 140 v1: 3.3 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 8.7 u1: mg/dl rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 110 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.5 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 100 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 3.4 u1: mEq/L rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 4.1 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 141 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Albumin (>3.2) Chemistry el: 0 cu: CCU cg: 140 v1: 3.3 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: BUN (6-20) Chemistry el: 0 cu: CCU cg: 140 v1: 5 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 8.7 u1: mg/dl rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 26 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 110 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.5 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 100 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 3.4 u1: mEq/L rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 4.1 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 141 rs: Final st: NotStopd
t0: [03:00:00 26/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [03:00:00 26/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [03:00:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [03:00:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [03:00:00 26/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [03:00:00 26/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [03:00:00 26/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [03:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [03:00:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [03:00:00 26/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [03:00:00 26/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [03:00:00 26/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [03:00:00 26/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [03:00:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [03:00:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [03:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [03:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [03:00:00 26/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [03:00:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [03:00:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [03:00:00 26/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [03:00:00 26/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [03:00:00 26/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [03:00:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Pain st: NotStopd t0: [03:00:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [03:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 126 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [03:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [03:00:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [03:00:00 26/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [03:00:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [03:00:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [03:00:00 26/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [03:00:00 26/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [03:00:00 26/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [03:00:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 1 Person Assist st: NotStopd t0: [03:00:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [03:00:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 2 mm v2: 2 mm st: NotStopd t0: [03:00:00 26/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [03:00:00 26/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [03:00:00 26/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [03:00:00 26/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [03:00:00 26/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [03:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 11 u1: BPM st: NotStopd t0: [03:00:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Localizes st: NotStopd t0: [03:00:00 26/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [03:00:00 26/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [03:00:00 26/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [03:00:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 26/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [03:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [03:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [03:00:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [03:00:00 26/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [03:00:00 26/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [03:00:00 26/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [03:00:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1 No Response st: NotStopd t0: [03:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [03:00:00 26/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd
t0: [03:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [03:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 60 vu: ml
t0: [03:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [03:45:00 26/10/2016] id: RSBI Not Completed el: 0 cu: CCU cg: RRT v1: PEEP >10 st: NotStopd t0: [03:45:00 26/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [03:45:00 26/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [03:45:00 26/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [03:45:00 26/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 45 u1: BPM st: NotStopd t0: [03:45:00 26/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [03:45:00 26/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [03:45:00 26/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 13 u1: cmH2O st: NotStopd t0: [03:45:00 26/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 7.49 u1: L/min st: NotStopd t0: [03:45:00 26/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [03:45:00 26/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 10 u1: . st: NotStopd t0: [03:45:00 26/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 11 u1: BPM st: NotStopd t0: [03:45:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 99 u1: % st: NotStopd t0: [03:45:00 26/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 735 u1: ml/B st: NotStopd t0: [03:45:00 26/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [03:45:00 26/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [04:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [04:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [04:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 81 u1: mmHg st: NotStopd t0: [04:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 32 u1: BPM st: NotStopd t0: [04:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [04:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [04:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [04:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 400 vu: ml
t0: [04:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [03:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 26/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [05:00:00 26/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [05:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [05:00:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [05:00:00 26/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [05:00:00 26/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [05:00:00 26/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [05:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [05:00:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [05:00:00 26/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [05:00:00 26/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [05:00:00 26/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [05:00:00 26/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [05:00:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [05:00:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [05:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 74 u1: BPM st: NotStopd t0: [05:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [05:00:00 26/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [05:00:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [05:00:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [05:00:00 26/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [05:00:00 26/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [05:00:00 26/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [05:00:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Pain st: NotStopd t0: [05:00:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [05:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 120 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [05:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 78.6667 u1: mmHg st: NotStopd t0: [05:00:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [05:00:00 26/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [05:00:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [05:00:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [05:00:00 26/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [05:00:00 26/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [05:00:00 26/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [05:00:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 1 Person Assist st: NotStopd t0: [05:00:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [05:00:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [05:00:00 26/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [05:00:00 26/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [05:00:00 26/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [05:00:00 26/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [05:00:00 26/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [05:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [05:00:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Localizes st: NotStopd t0: [05:00:00 26/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [05:00:00 26/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [05:00:00 26/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [05:00:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 26/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [05:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [05:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [05:00:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [05:00:00 26/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [05:00:00 26/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [05:00:00 26/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [05:00:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [05:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [05:00:00 26/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [06:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 71 u1: BPM st: NotStopd t0: [06:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [06:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [06:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82 u1: mmHg st: NotStopd t0: [06:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [06:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [06:00:00 26/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [06:00:00 26/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 36.8889 u1: Deg. C st: NotStopd t0: [06:00:00 26/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98.4 u1: Deg. F st: NotStopd t0: [06:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [05:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [05:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 120 vu: ml t0: [06:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [06:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 30 vu: ml
t0: [05:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [06:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [06:40:00 26/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.34 rs: Final st: NotStopd t0: [06:40:00 26/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 0 rs: Final st: NotStopd t0: [06:40:00 26/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 29 rs: Final st: NotStopd t0: [06:40:00 26/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 51 u1: mmHg rs: Final st: NotStopd t0: [06:40:00 26/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 171 u1: mmHg rs: Final st: NotStopd t0: [06:40:00 26/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.34 rs: Final st: NotStopd
t0: [07:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [07:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [07:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [07:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [07:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 140 u1: mmHg v2: 78 u2: mmHg st: NotStopd t0: [07:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 98.6667 u1: mmHg st: NotStopd t0: [07:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 36 u1: BPM st: NotStopd t0: [07:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [07:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [07:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [07:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 30 vu: ml
t0: [07:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [08:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 70 u2: mmHg st: NotStopd t0: [08:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 90.6667 u1: mmHg st: NotStopd t0: [08:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 33 u1: BPM st: NotStopd t0: [08:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [08:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [08:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 290 vu: ml
t0: [08:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 26/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 58.3333 u1: ml/cmH st: NotStopd t0: [08:00:00 26/10/2016] id: RSBI Not Completed el: 0 cu: CCU cg: RRT v1: PEEP >10 st: NotStopd t0: [08:00:00 26/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [08:00:00 26/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [08:00:00 26/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [08:00:00 26/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 20 u1: BPM st: NotStopd t0: [08:00:00 26/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:2.3 st: NotStopd t0: [08:00:00 26/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [08:00:00 26/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [08:00:00 26/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [08:00:00 26/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 14 u1: cmH2O st: NotStopd t0: [08:00:00 26/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 10.7 u1: L/min st: NotStopd t0: [08:00:00 26/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [08:00:00 26/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 22 u1: cmH2O st: NotStopd t0: [08:00:00 26/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 19 u1: cmH2O st: NotStopd t0: [08:00:00 26/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 0 u1: . st: NotStopd t0: [08:00:00 26/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 3 u1: BPM st: NotStopd t0: [08:00:00 26/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 17 u1: BPM st: NotStopd t0: [08:00:00 26/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [08:00:00 26/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [08:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 97 u1: % st: NotStopd t0: [08:00:00 26/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: White v2: Thick st: NotStopd t0: [08:00:00 26/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Small st: NotStopd t0: [08:00:00 26/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 665 u1: ml/B st: NotStopd t0: [08:00:00 26/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [08:00:00 26/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [08:00:00 26/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [08:00:00 26/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [08:00:00 26/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 26/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [08:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 26/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [08:00:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [08:00:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 26/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [08:00:00 26/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [08:00:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [08:00:00 26/10/2016] tf: [12:00:00 30/10/2016] dt: 6000 id: GI Guaiac/ph el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [08:00:00 26/10/2016] id: GI Guaiac/ph el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [08:00:00 26/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [08:00:00 26/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 26/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped v2: Clear st: NotStopd t0: [08:00:00 26/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [08:00:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 26/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [08:00:00 26/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [08:00:00 26/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 26/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Pain st: NotStopd t0: [08:00:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [08:00:00 26/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [08:00:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 26/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 26/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 26/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 26/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [08:00:00 26/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 26/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [08:00:00 26/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [08:00:00 26/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [08:00:00 26/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [08:00:00 26/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [08:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [08:00:00 26/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 26/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [08:00:00 26/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.7778 u1: Deg. C st: NotStopd t0: [08:00:00 26/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100 u1: Deg. F st: NotStopd t0: [08:00:00 26/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [08:00:00 26/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [08:00:00 26/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Hypoactive st: NotStopd
t0: [08:00:00 26/10/2016] tf: [16:00:00 26/10/2016] dt: 480 id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 5 vu: ml t0: [08:00:00 26/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 60 vu: ml
io: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ra: 20 ru: ml/hr
id: Promote w/fiber el: 1 cu: CCU cg: RN io: Promote w/fiber Tube Feeding du: str rt: Gastric/Feeding Tube id: TF Residual el: 2 cu: CCU cg: RN io: TF Residual Gastric/TF Residual du: ml rt: Gastric/Feeding Tube
t0: [09:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [09:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [09:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 128 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [09:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 85.3333 u1: mmHg st: NotStopd t0: [09:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [09:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [09:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [09:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [09:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 140 vu: ml
t0: [09:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [10:00:00 26/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [10:00:00 26/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Calm/Cooperative st: NotStopd t0: [10:00:00 26/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: Yes st: NotStopd t0: [10:00:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [10:00:00 26/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [10:00:00 26/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [10:00:00 26/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [10:00:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [10:00:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [10:00:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [10:00:00 26/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [10:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [10:00:00 26/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [10:00:00 26/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [10:00:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd
t0: [10:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [10:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 130 u1: mmHg v2: 67 u2: mmHg st: NotStopd t0: [10:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [10:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [10:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 100 u1: % st: NotStopd t0: [10:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [10:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 0 vu: ml nb: 1 t0: [10:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 40 vu: ml
t0: [10:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
tf: [09:00:00 26/10/2016] pt: Unit Dose rt: NG fr: Q24H fs: 10 dn: 1 m1: Levofloxacin v1: 500 u1: mg tf: [18:00:00 03/11/2016] pt: IV Piggyback rt: IV fr: Q8H fs: 10, 18, 2 dn: 3 m1: Metronidazole v1: 500 u1: mg m2: NS v2: 100 u2: ml tf: [18:00:00 03/11/2016] pt: Unit Dose rt: NG fr: Q6H:PRN m1: Guaifenesin v1: 5-10 u1: ml
t0: [08:00:00 26/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [08:00:00 26/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [08:00:00 26/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [08:00:00 26/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [08:00:00 26/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [08:00:00 26/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [11:00:00 26/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [11:00:00 26/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [11:00:00 26/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd
t0: [11:00:00 26/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 100 vu: ml t0: [11:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [11:00:00 26/10/2016] tf: [16:00:00 27/10/2016] dt: 1740 id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 20 vu: ml t0: [11:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 190 vu: ml
t0: [01:59:00 26/10/2016] id: Total Bili Chemistry el: 0 cu: CCU cg: 140 v1: 0.3 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: ALT Enzymes el: 0 cu: CCU cg: 140 v1: 15 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: AST Enzymes el: 0 cu: CCU cg: 140 v1: 16 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Alk. Phosphate Enzymes el: 0 cu: CCU cg: 140 v1: 53 rs: Final st: NotStopd t0: [01:59:00 26/10/2016] id: Total Bili (0-1.5) Chemistry el: 0 cu: CCU cg: 140 v1: 0.3 rs: Final st: NotStopd
tf: [18:00:00 03/11/2016] pt: IV Piggyback rt: IV fr: Q24H fs: 11 dn: 1 m1: Levofloxacin v1: 500 u1: mg m2: Dextrose 5% v2: 100 u2: ml
t0: [12:00:00 26/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 58.3333 u1: ml/cmH st: NotStopd t0: [12:00:00 26/10/2016] id: RSBI Not Completed el: 0 cu: CCU cg: RRT v1: PEEP >10 st: NotStopd t0: [12:00:00 26/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [12:00:00 26/10/2016] tf: [13:44:00 31/10/2016] dt: 7304 id: ETT Position Change el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [12:00:00 26/10/2016] id: ETT Position Change el: 0 cu: CCU cg: RRT v1: Done st: NotStopd t0: [12:00:00 26/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [12:00:00 26/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [12:00:00 26/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 20 u1: BPM st: NotStopd t0: [12:00:00 26/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:2.3 st: NotStopd t0: [12:00:00 26/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [12:00:00 26/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [12:00:00 26/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [12:00:00 26/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [12:00:00 26/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [12:00:00 26/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [12:00:00 26/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 14 u1: cmH2O st: NotStopd t0: [12:00:00 26/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 10.8 u1: L/min st: NotStopd t0: [12:00:00 26/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [12:00:00 26/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 22 u1: cmH2O st: NotStopd t0: [12:00:00 26/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 20 u1: cmH2O st: NotStopd t0: [12:00:00 26/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 0 u1: . st: NotStopd t0: [12:00:00 26/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 2 u1: BPM st: NotStopd t0: [12:00:00 26/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 16 u1: BPM st: NotStopd t0: [12:00:00 26/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [12:00:00 26/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [12:00:00 26/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: Yellow v2: Thick st: NotStopd t0: [12:00:00 26/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Copious st: NotStopd t0: [12:00:00 26/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 671 u1: ml/B st: NotStopd t0: [12:00:00 26/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [12:00:00 26/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [12:00:00 26/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [12:00:00 26/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [11:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [11:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [11:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 122 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [11:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [11:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [11:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [11:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [12:00:00 26/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [12:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [12:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [12:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 80.3333 u1: mmHg st: NotStopd t0: [12:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [12:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [12:00:00 26/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [12:00:00 26/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38 u1: Deg. C st: NotStopd t0: [12:00:00 26/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.4 u1: Deg. F st: NotStopd t0: [12:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [12:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [12:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 20 vu: ml t0: [12:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 90 vu: ml
t0: [11:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [12:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [08:00:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [08:00:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [08:00:00 26/10/2016] id: Inc Cleansing #1 el: 0 cu: CCU cg: RN v1: Normal Saline st: NotStopd t0: [08:00:00 26/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [08:00:00 26/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 26/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [08:00:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [08:00:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [08:00:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [08:00:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [08:00:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Sternal Rub v2: Localizes st: NotStopd t0: [08:00:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 26/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [08:00:00 26/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [08:00:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [08:00:00 26/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [08:00:00 26/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [08:00:00 26/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [08:00:00 26/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Rarely Moist st: NotStopd t0: [08:00:00 26/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [08:00:00 26/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 13 u1: number st: NotStopd t0: [08:00:00 26/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [09:00:00 26/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [09:00:00 26/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [10:00:00 26/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 26/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [10:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [10:00:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [10:00:00 26/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [10:00:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [10:00:00 26/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 26/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Feeding v2: Clear st: NotStopd t0: [10:00:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [10:00:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 45 degrees st: NotStopd t0: [10:00:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [10:00:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [10:00:00 26/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [10:00:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [10:00:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: Off st: NotStopd t0: [10:00:00 26/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [10:00:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [10:00:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [10:00:00 26/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [10:00:00 26/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [10:00:00 26/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [10:00:00 26/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [10:00:00 26/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [10:00:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 26/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [10:00:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [10:00:00 26/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [12:00:00 26/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 26/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [12:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [12:00:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 26/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [12:00:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [12:00:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 26/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [12:00:00 26/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [12:00:00 26/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Feeding st: NotStopd t0: [12:00:00 26/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [12:00:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 45 degrees st: NotStopd t0: [12:00:00 26/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [12:00:00 26/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [12:00:00 26/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [12:00:00 26/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [12:00:00 26/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [12:00:00 26/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [12:00:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [12:00:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [12:00:00 26/10/2016] id: Inc Cleansing #1 el: 0 cu: CCU cg: RN v1: Normal Saline st: NotStopd t0: [12:00:00 26/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [12:00:00 26/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 26/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 26/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [12:00:00 26/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 26/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Pain st: NotStopd t0: [12:00:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [12:00:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [12:00:00 26/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [12:00:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [12:00:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [12:00:00 26/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [12:00:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [12:00:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [12:00:00 26/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 26/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 26/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [12:00:00 26/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 26/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [12:00:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Sternal Rub v2: Localizes st: NotStopd t0: [12:00:00 26/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [12:00:00 26/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [12:00:00 26/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [12:00:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 26/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [12:00:00 26/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [12:00:00 26/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [12:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [12:00:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [12:00:00 26/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Side to Side st: NotStopd t0: [12:00:00 26/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [12:00:00 26/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [12:00:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [12:00:00 26/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [12:00:00 26/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [12:00:00 26/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [12:00:00 26/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Rarely Moist st: NotStopd t0: [12:00:00 26/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [12:00:00 26/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 13 u1: number st: NotStopd t0: [12:00:00 26/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd
t0: [12:00:00 26/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 150 vu: ml t0: [12:00:00 26/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 1 vu: ml t0: [12:00:00 26/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 120 vu: ml
t0: [23:00:00 26/10/2016] dt: 24 id: PO/Gastric In Total el: 1 cu: CCU cg: RN cv: 180 ap: none
t0: [12:23:00 26/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.37 rs: Final st: NotStopd t0: [12:23:00 26/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 2 rs: Final st: NotStopd t0: [12:23:00 26/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 29 rs: Final st: NotStopd t0: [12:23:00 26/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 49 u1: mmHg rs: Final st: NotStopd t0: [12:23:00 26/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 129 u1: mmHg rs: Final st: NotStopd t0: [12:23:00 26/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.37 rs: Final st: NotStopd
t0: [13:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [13:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 126 u1: mmHg v2: 75 u2: mmHg st: NotStopd t0: [13:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 92 u1: mmHg st: NotStopd t0: [13:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [13:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [13:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [13:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 20 vu: ml t0: [13:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 140 vu: ml
t0: [13:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [01:59:00 26/10/2016] id: CPK Enzymes el: 0 cu: CCU cg: 140 v1: 50 rs: Final st: NotStopd
t0: [14:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 74 u1: BPM st: NotStopd t0: [14:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [14:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [14:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 76 u1: mmHg st: NotStopd t0: [14:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [14:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [14:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [14:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 20 vu: ml t0: [14:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 165 vu: ml
t0: [14:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [15:00:00 26/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [15:00:00 26/10/2016] tf: [13:44:00 31/10/2016] dt: 7124 id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [15:00:00 26/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [15:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 75 u1: BPM st: NotStopd t0: [15:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [15:00:00 26/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [15:00:00 26/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [15:00:00 26/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [15:00:00 26/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [15:00:00 26/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [15:00:00 26/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [15:00:00 26/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [15:00:00 26/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [15:00:00 26/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [15:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 110 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [15:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 76.6667 u1: mmHg st: NotStopd t0: [15:00:00 26/10/2016] tf: [13:44:00 31/10/2016] dt: 7124 id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [15:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [15:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [15:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [15:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [15:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 20 vu: ml
t0: [15:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:00:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [16:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [16:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [16:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 83 u1: mmHg st: NotStopd t0: [16:00:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [16:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [16:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [16:00:00 26/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [16:00:00 26/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 36.7222 u1: Deg. C st: NotStopd t0: [16:00:00 26/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98.1 u1: Deg. F st: NotStopd t0: [16:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [16:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [16:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 260 vu: ml
t0: [16:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:00:00 26/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [16:00:00 26/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 26/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [16:00:00 26/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [16:00:00 26/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [16:00:00 26/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 26/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Feeding st: NotStopd t0: [16:00:00 26/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [16:00:00 26/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [16:00:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [16:00:00 26/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [16:00:00 26/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 26/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [16:00:00 26/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 26/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [16:00:00 26/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [16:00:00 26/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [16:00:00 26/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [16:00:00 26/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [16:00:00 26/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 26/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [16:00:00 26/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd
tf: [09:00:00 26/10/2016] pt: Unit Dose rt: NG fr: TID fs: 08, 16, 22 dn: 3 m1: Metronidazole v1: 500 u1: mg
t0: [16:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [16:00:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 1 No Response st: NotStopd t0: [16:00:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [16:00:00 26/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 7 u1: points st: NotStopd t0: [16:00:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [16:00:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [16:00:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [16:00:00 26/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [16:00:00 26/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 26/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 26/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Bronchial st: NotStopd t0: [16:00:00 26/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [16:00:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [16:00:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [16:00:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [16:00:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [16:00:00 26/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [16:00:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [16:00:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [16:00:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [16:00:00 26/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 26/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [16:00:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [16:00:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 26/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [16:00:00 26/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [16:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [16:00:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [16:00:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [16:00:00 26/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [16:00:00 26/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [16:00:00 26/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [16:00:00 26/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [16:00:00 26/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [16:00:00 26/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 12 u1: number st: NotStopd t0: [16:00:00 26/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd
t0: [16:00:00 26/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 58.3333 u1: ml/cmH st: NotStopd t0: [16:00:00 26/10/2016] id: RSBI Not Completed el: 0 cu: CCU cg: RRT v1: PEEP >10 st: NotStopd t0: [16:00:00 26/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [16:00:00 26/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [16:00:00 26/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [16:00:00 26/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [16:00:00 26/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 20 u1: BPM st: NotStopd t0: [16:00:00 26/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:2.3 st: NotStopd t0: [16:00:00 26/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [16:00:00 26/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [16:00:00 26/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [16:00:00 26/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [16:00:00 26/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [16:00:00 26/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [16:00:00 26/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 14 u1: cmH2O st: NotStopd t0: [16:00:00 26/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 9.5 u1: L/min st: NotStopd t0: [16:00:00 26/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [16:00:00 26/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 22 u1: cmH2O st: NotStopd t0: [16:00:00 26/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 19 u1: cmH2O st: NotStopd t0: [16:00:00 26/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 0 u1: . st: NotStopd t0: [16:00:00 26/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 0 u1: BPM st: NotStopd t0: [16:00:00 26/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [16:00:00 26/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [16:00:00 26/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [16:00:00 26/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: White v2: Thick st: NotStopd t0: [16:00:00 26/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Small st: NotStopd t0: [16:00:00 26/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 681 u1: ml/B st: NotStopd t0: [16:00:00 26/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [16:00:00 26/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [16:00:00 26/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [16:00:00 26/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [17:00:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [17:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [17:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [17:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 123 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [17:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82.3333 u1: mmHg st: NotStopd t0: [17:00:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [17:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [17:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [17:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:00:00 26/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [17:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [17:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [17:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 180 vu: ml
t0: [17:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [17:30:00 26/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thick st: NotStopd t0: [17:30:00 26/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Small st: NotStopd
t0: [18:00:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [18:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [18:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 120 u1: mmHg v2: 81 u2: mmHg st: NotStopd t0: [18:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 94 u1: mmHg st: NotStopd t0: [18:00:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [18:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [18:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [18:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [18:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [18:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [18:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 400 vu: ml
t0: [18:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [18:30:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [18:30:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:30:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:30:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [18:30:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:30:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 157 u1: mmHg v2: 98 u2: mmHg st: NotStopd t0: [18:30:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 117.667 u1: mmHg st: NotStopd t0: [18:30:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [18:30:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 25 u1: BPM st: NotStopd t0: [18:30:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [18:30:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [18:30:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [19:00:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: RN v1: Nodding st: NotStopd t0: [19:00:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [19:00:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [19:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [19:00:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [19:00:00 26/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [19:00:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [19:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 91 u1: BPM st: NotStopd t0: [19:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:00:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [19:00:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [19:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 169 u1: mmHg v2: 95 u2: mmHg st: NotStopd t0: [19:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 119.667 u1: mmHg st: NotStopd t0: [19:00:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [19:00:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [19:00:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:00:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [19:00:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [19:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [19:00:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [19:00:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [19:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: RN v1: Intubated/trach st: NotStopd t0: [19:00:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [19:00:00 26/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [19:00:00 26/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.7778 u1: Deg. C st: NotStopd t0: [19:00:00 26/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100 u1: Deg. F st: NotStopd t0: [19:00:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [19:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [19:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [19:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [19:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 180 vu: ml
t0: [19:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [19:00:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [19:00:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [19:00:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [19:00:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [19:00:00 26/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [19:00:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [19:00:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [20:00:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [20:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 89 u1: BPM st: NotStopd t0: [20:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 137 u1: mmHg v2: 75 u2: mmHg st: NotStopd t0: [20:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 95.6667 u1: mmHg st: NotStopd t0: [20:00:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [20:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [20:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [20:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [20:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [20:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [20:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 140 vu: ml
t0: [20:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [21:00:00 26/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 46.6667 u1: ml/cmH st: NotStopd t0: [21:00:00 26/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [21:00:00 26/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [21:00:00 26/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [21:00:00 26/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [21:00:00 26/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [21:00:00 26/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:2.3 st: NotStopd t0: [21:00:00 26/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [21:00:00 26/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [21:00:00 26/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [21:00:00 26/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [21:00:00 26/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [21:00:00 26/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 17 u1: cmH2O st: NotStopd t0: [21:00:00 26/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 13.4 u1: L/min st: NotStopd t0: [21:00:00 26/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [21:00:00 26/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 25 u1: cmH2O st: NotStopd t0: [21:00:00 26/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 21 u1: cmH2O st: NotStopd t0: [21:00:00 26/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 8 u1: BPM st: NotStopd t0: [21:00:00 26/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 22 u1: BPM st: NotStopd t0: [21:00:00 26/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [21:00:00 26/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [21:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 97 u1: % st: NotStopd t0: [21:00:00 26/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 620 u1: ml/B st: NotStopd t0: [21:00:00 26/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [21:00:00 26/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [21:00:00 26/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [21:00:00 26/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [21:00:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [21:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 91 u1: BPM st: NotStopd t0: [21:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [21:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 136 u1: mmHg v2: 70 u2: mmHg st: NotStopd t0: [21:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 92 u1: mmHg st: NotStopd t0: [21:00:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [21:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [21:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [22:00:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [22:00:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 95 u1: BPM st: NotStopd t0: [22:00:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:00:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [22:00:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 83 u1: mmHg st: NotStopd t0: [22:00:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [22:00:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [22:00:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [22:00:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [22:00:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [22:00:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [22:00:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 180 vu: ml
t0: [21:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [22:00:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 26/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 26/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 26/10/2016] dt: 24 id: IV Infusion In Total el: 1 cu: CCU cg: RN cv: 2697.22 ap: none t0: [23:00:00 26/10/2016] dt: 24 id: 24h Total In el: 1 cu: CCU cg: RN cv: 3187.22 ap: none t0: [23:00:00 26/10/2016] dt: 24 id: Tube Feeds In Total el: 1 cu: CCU cg: RN cv: 310 ap: none t0: [23:00:00 26/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN cv: 3170 ap: none t0: [23:00:00 26/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: RN cv: 17.2202 ap: none t0: [23:00:00 26/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: RN cv: 3170 ap: none t0: [23:00:00 26/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: RN cv: 3860.21 ap: none
t0: [18:00:00 26/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [20:00:00 26/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd
t0: [19:00:00 26/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thick st: NotStopd t0: [19:00:00 26/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Small st: NotStopd t0: [21:00:00 26/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Tan v2: Thick st: NotStopd t0: [21:00:00 26/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd
t0: [22:30:00 26/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml
t0: [23:00:00 26/10/2016] id: Communication el: 0 cu: CCU cg: -1 st: D/C'd t0: [23:00:00 26/10/2016] id: Speech el: 0 cu: CCU cg: -1 st: D/C'd
t0: [23:00:00 26/10/2016] id: Pre-Admission Intake Pre-Admission Intake el: 1 cu: CCU cg: -1 ai: 189 vo: 0 st: D/C'd t0: [23:00:00 26/10/2016] id: Pre-Admission Output Pre-Admission Output el: 1 cu: CCU cg: -1 vo: 0 st: D/C'd
t0: [23:30:00 26/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [23:30:00 26/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [23:30:00 26/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [23:30:00 26/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [23:30:00 26/10/2016] tf: [13:44:00 31/10/2016] dt: 6614 id: Ataxia el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [23:30:00 26/10/2016] tf: [13:44:00 31/10/2016] dt: 6614 id: Drowsiness el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [23:30:00 26/10/2016] id: Ataxia el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [23:30:00 26/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [23:30:00 26/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 0 u1: sum st: NotStopd t0: [23:30:00 26/10/2016] id: Drowsiness el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [23:30:00 26/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: Proton/Pump/Inhi st: NotStopd t0: [23:30:00 26/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [23:30:00 26/10/2016] id: Insomnia el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [23:30:00 26/10/2016] tf: [13:44:00 31/10/2016] dt: 6614 id: Slurred Speech el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [23:30:00 26/10/2016] tf: [13:44:00 31/10/2016] dt: 6614 id: Sustained Nystamus el: 0 cu: CCU cg: RN v1: Oriented st: NotStopd t0: [23:30:00 26/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [23:30:00 26/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [23:30:00 26/10/2016] id: Slurred Speech el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [23:30:00 26/10/2016] id: Sustained Nystamus el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [23:30:00 26/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:30:00 26/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [23:30:00 26/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:30:00 26/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [23:30:00 26/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RN v1: 21cm v2: Lip st: NotStopd t0: [23:30:00 26/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:30:00 26/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:30:00 26/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [23:30:00 26/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [23:30:00 26/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 9 u1: points st: NotStopd t0: [23:30:00 26/10/2016] id: GI Guaiac/ph el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [23:30:00 26/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [23:30:00 26/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [23:30:00 26/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped v2: Bilious st: NotStopd t0: [23:30:00 26/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [23:30:00 26/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [23:30:00 26/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [23:30:00 26/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 92 u1: BPM st: NotStopd t0: [23:30:00 26/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [23:30:00 26/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [23:30:00 26/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [23:30:00 26/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [23:30:00 26/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [23:30:00 26/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [23:30:00 26/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [23:30:00 26/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [23:30:00 26/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [23:30:00 26/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [23:30:00 26/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [23:30:00 26/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [23:30:00 26/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [23:30:00 26/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [23:30:00 26/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:30:00 26/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:30:00 26/10/2016] id: Airway Size el: 0 cu: CCU cg: RN v1: 7.5 mm st: NotStopd t0: [23:30:00 26/10/2016] id: Airway Type el: 0 cu: CCU cg: RN v1: Endotracheal st: NotStopd t0: [23:30:00 26/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [23:30:00 26/10/2016] id: Intubation Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [23:30:00 26/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Rhonchi st: NotStopd t0: [23:30:00 26/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [23:30:00 26/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [23:30:00 26/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [23:30:00 26/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 127 u1: mmHg v2: 82 u2: mmHg st: NotStopd t0: [23:30:00 26/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 97 u1: mmHg st: NotStopd t0: [23:30:00 26/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [23:30:00 26/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [23:30:00 26/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [23:30:00 26/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [23:30:00 26/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [23:30:00 26/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [23:30:00 26/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [23:30:00 26/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [23:30:00 26/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [23:30:00 26/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [23:30:00 26/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [23:30:00 26/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [23:30:00 26/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [23:30:00 26/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [23:30:00 26/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Withdraws st: NotStopd t0: [23:30:00 26/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [23:30:00 26/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [23:30:00 26/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:30:00 26/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [23:30:00 26/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [23:30:00 26/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [23:30:00 26/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [23:30:00 26/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [23:30:00 26/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:30:00 26/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [23:30:00 26/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.6667 u1: Deg. C st: NotStopd t0: [23:30:00 26/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 99.8 u1: Deg. F st: NotStopd t0: [23:30:00 26/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [23:30:00 26/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [23:30:00 26/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [23:30:00 26/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [23:30:00 26/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [23:30:00 26/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd
t0: [23:30:00 26/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 75 vu: ml t0: [23:30:00 26/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 60 vu: ml t0: [23:30:00 26/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [23:30:00 26/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 50 vu: ml
t0: [23:30:00 26/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:30:00 26/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 150 vu: ml
t0: [00:45:00 27/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 53.8462 u1: ml/cmH st: NotStopd t0: [00:45:00 27/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [00:45:00 27/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [00:45:00 27/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [00:45:00 27/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [00:45:00 27/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [00:45:00 27/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:2.3 st: NotStopd t0: [00:45:00 27/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [00:45:00 27/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [00:45:00 27/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [00:45:00 27/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [00:45:00 27/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [00:45:00 27/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [00:45:00 27/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 15 u1: cmH2O st: NotStopd t0: [00:45:00 27/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 11.8 u1: L/min st: NotStopd t0: [00:45:00 27/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [00:45:00 27/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 23 u1: cmH2O st: NotStopd t0: [00:45:00 27/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 20 u1: cmH2O st: NotStopd t0: [00:45:00 27/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 0 u1: . st: NotStopd t0: [00:45:00 27/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 3 u1: BPM st: NotStopd t0: [00:45:00 27/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 17 u1: BPM st: NotStopd t0: [00:45:00 27/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [00:45:00 27/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [00:45:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 97 u1: % st: NotStopd t0: [00:45:00 27/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: Yellow v2: Thick st: NotStopd t0: [00:45:00 27/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Small st: NotStopd t0: [00:45:00 27/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 706 u1: ml/B st: NotStopd t0: [00:45:00 27/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [00:45:00 27/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [00:45:00 27/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [00:45:00 27/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [00:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [00:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 97 u1: BPM st: NotStopd t0: [00:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 144 u1: mmHg v2: 81 u2: mmHg st: NotStopd t0: [00:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 102 u1: mmHg st: NotStopd t0: [00:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [00:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [00:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [00:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [00:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [01:00:00 27/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [01:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [01:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 97 u1: BPM st: NotStopd t0: [01:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [01:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 63 u2: mmHg st: NotStopd t0: [01:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 81.6667 u1: mmHg st: NotStopd t0: [01:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [01:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [01:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [01:00:00 27/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [01:00:00 27/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.3333 u1: Deg. C st: NotStopd t0: [01:00:00 27/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 101 u1: Deg. F st: NotStopd t0: [01:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [02:00:00 27/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [02:00:00 27/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [02:00:00 27/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [02:00:00 27/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [02:00:00 27/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [02:00:00 27/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [02:00:00 27/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Logroll st: NotStopd
t0: [01:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 75 vu: ml t0: [01:00:00 27/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 60 vu: ml t0: [01:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [01:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 100 vu: ml
t0: [01:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 50 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 27/10/2016] dt: 24 id: PO/Gastric In Total el: 1 cu: CCU cg: RN cv: 320 ap: none
t0: [02:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [02:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 100 u1: BPM st: NotStopd t0: [02:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [02:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 166 u1: mmHg v2: 86 u2: mmHg st: NotStopd t0: [02:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 112.667 u1: mmHg st: NotStopd t0: [02:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [02:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 34 u1: BPM st: NotStopd t0: [02:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [02:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [02:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 40 vu: ml t0: [02:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 50 vu: ml
t0: [02:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 27/10/2016] dt: 24 id: IV Infusion In Total el: 1 cu: CCU cg: 140 pv: 59.714 cv: 4043.07 ap: none t0: [23:00:00 27/10/2016] dt: 24 id: 24h Total In el: 1 cu: CCU cg: 140 pv: 59.714 cv: 5043.07 ap: none t0: [23:00:00 27/10/2016] dt: 24 id: Tube Feeds In Total el: 1 cu: CCU cg: RN cv: 680 ap: none
t0: [03:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: CoWkr v1: 90 u1: BPM st: NotStopd t0: [03:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: CoWkr v1: 158 u1: mmHg v2: 96 u2: mmHg st: NotStopd t0: [03:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: CoWkr v1: 116.667 u1: mmHg st: NotStopd t0: [03:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: CoWkr v1: 14 u1: BPM st: NotStopd t0: [03:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: CoWkr v1: 97 u1: % st: NotStopd t0: [03:00:00 27/10/2016] id: Temp. Site el: 0 cu: CCU cg: CoWkr v1: Axillary st: NotStopd t0: [03:00:00 27/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: CoWkr v1: 37.8333 u1: Deg. C st: NotStopd t0: [03:00:00 27/10/2016] id: Temperature F el: 0 cu: CCU cg: CoWkr v1: 100.1 u1: Deg. F st: NotStopd t0: [03:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: CoWkr v1: 1 u1: kg st: NotStopd
t0: [03:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: CoWkr vo: 35 vu: ml
t0: [23:00:00 27/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: 140 pv: 210 cv: 210 ap: none t0: [23:00:00 27/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: 140 pv: -150.286 cv: -150.286 ap: none t0: [23:00:00 27/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN pv: 200 cv: 2340 ap: none t0: [23:00:00 27/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: 140 pv: -150.286 cv: 2683.07 ap: none t0: [23:00:00 27/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: 140 pv: 210 cv: 2360 ap: none t0: [23:00:00 27/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: 140 pv: -150.286 cv: 6543.28 ap: none
t0: [04:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: CoWkr v1: 162 u1: mmHg v2: 76 u2: mmHg st: NotStopd t0: [04:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: CoWkr v1: 104.667 u1: mmHg st: NotStopd t0: [04:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: CoWkr v1: 17 u1: BPM st: NotStopd t0: [04:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: CoWkr v1: 97 u1: % st: NotStopd
t0: [04:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: CoWkr vo: 80 vu: ml
t0: [04:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [04:00:00 27/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [04:00:00 27/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [04:00:00 27/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [04:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 27/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [04:00:00 27/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [04:00:00 27/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [04:00:00 27/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [04:00:00 27/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [04:00:00 27/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [04:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 90 u1: BPM st: NotStopd t0: [04:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 27/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [04:00:00 27/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [04:00:00 27/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [04:00:00 27/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [04:00:00 27/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [04:00:00 27/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [04:00:00 27/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [04:00:00 27/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [04:00:00 27/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [04:00:00 27/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Crackles st: NotStopd t0: [04:00:00 27/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [04:00:00 27/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Stimul st: NotStopd t0: [04:00:00 27/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [04:00:00 27/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [04:00:00 27/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [04:00:00 27/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [04:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [04:00:00 27/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [04:00:00 27/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [04:00:00 27/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [04:00:00 27/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [04:00:00 27/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [04:00:00 27/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Withdraws st: NotStopd t0: [04:00:00 27/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 27/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Nonpurposeful st: NotStopd t0: [04:00:00 27/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [04:00:00 27/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [04:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [04:00:00 27/10/2016] tf: [16:00:00 28/10/2016] dt: 2160 id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 30 vu: ml t0: [04:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [04:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 80 vu: ml
t0: [04:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [03:00:00 27/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thick st: NotStopd t0: [03:00:00 27/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Small st: NotStopd t0: [05:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [05:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 27/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [05:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 92 u1: BPM st: NotStopd t0: [05:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [05:00:00 27/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [05:00:00 27/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [05:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 147 u1: mmHg v2: 82 u2: mmHg st: NotStopd t0: [05:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 103.667 u1: mmHg st: NotStopd t0: [05:00:00 27/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [05:00:00 27/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [05:00:00 27/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [05:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [05:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [05:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [05:00:00 27/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Logroll st: NotStopd t0: [05:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [05:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [05:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 40 vu: ml t0: [05:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 350 vu: ml
t0: [05:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [05:00:00 27/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 36.8421 u1: ml/cmH st: NotStopd t0: [05:00:00 27/10/2016] id: RSBI Not Completed el: 0 cu: CCU cg: RRT v1: PEEP >10 st: NotStopd t0: [05:00:00 27/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [05:00:00 27/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [05:00:00 27/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [05:00:00 27/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [05:00:00 27/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [05:00:00 27/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:3.3 st: NotStopd t0: [05:00:00 27/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [05:00:00 27/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [05:00:00 27/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [05:00:00 27/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [05:00:00 27/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [05:00:00 27/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 16 u1: cmH2O st: NotStopd t0: [05:00:00 27/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 13.1 u1: L/min st: NotStopd t0: [05:00:00 27/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [05:00:00 27/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 29 u1: cmH2O st: NotStopd t0: [05:00:00 27/10/2016] id: Plateau Pressure el: 0 cu: CCU cg: RRT v1: 21 u1: cmH2O st: NotStopd t0: [05:00:00 27/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 6 u1: BPM st: NotStopd t0: [05:00:00 27/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 20 u1: BPM st: NotStopd t0: [05:00:00 27/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [05:00:00 27/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [05:00:00 27/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: White v2: Thick st: NotStopd t0: [05:00:00 27/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Moderate st: NotStopd t0: [05:00:00 27/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 678 u1: ml/B st: NotStopd t0: [05:00:00 27/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [05:00:00 27/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [05:00:00 27/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [05:00:00 27/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [06:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 6224 id: Fingerstick Glucose Chemistry el: 0 cu: CCU cg: CoWkr v1: 138 rs: Manual st: NotStopd
t0: [06:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: CoWkr v1: 120 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [06:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: CoWkr v1: 85.3333 u1: mmHg st: NotStopd t0: [06:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: CoWkr v1: 20 u1: BPM st: NotStopd t0: [06:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: CoWkr v1: 98 u1: % st: NotStopd
t0: [06:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: CoWkr vo: 100 vu: ml
t0: [08:00:00 27/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 18cm st: NotStopd t0: [08:16:00 27/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 38.8889 u1: ml/cmH st: NotStopd t0: [08:16:00 27/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [08:16:00 27/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [08:16:00 27/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [08:16:00 27/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [08:16:00 27/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [08:16:00 27/10/2016] id: I:E Ratio el: 0 cu: CCU cg: RRT v1: 1:3. st: NotStopd t0: [08:16:00 27/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [08:16:00 27/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [08:16:00 27/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [08:16:00 27/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [08:16:00 27/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [08:16:00 27/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 15 u1: cmH2O st: NotStopd t0: [08:16:00 27/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 12 u1: L/min st: NotStopd t0: [08:16:00 27/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [08:16:00 27/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 28 u1: cmH2O st: NotStopd t0: [08:16:00 27/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 4 u1: BPM st: NotStopd t0: [08:16:00 27/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 18 u1: BPM st: NotStopd t0: [08:16:00 27/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 14 u1: BPM st: NotStopd t0: [08:16:00 27/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [08:16:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 93 u1: % st: NotStopd t0: [08:16:00 27/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: White v2: Thick st: NotStopd t0: [08:16:00 27/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Small st: NotStopd t0: [08:16:00 27/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 670 u1: ml/B st: NotStopd t0: [08:16:00 27/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [08:16:00 27/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CMV st: NotStopd t0: [08:16:00 27/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [08:16:00 27/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [08:00:00 27/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [08:00:00 27/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [08:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 99 u1: BPM st: NotStopd t0: [08:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [08:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 139 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [08:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 92.3333 u1: mmHg st: NotStopd t0: [08:00:00 27/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [08:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [08:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [08:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [08:00:00 27/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [08:00:00 27/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 39.1111 u1: Deg. C st: NotStopd t0: [08:00:00 27/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 102.4 u1: Deg. F st: NotStopd t0: [08:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [08:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 150 vu: ml t0: [08:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 120 vu: ml t0: [08:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 320 vu: ml
t0: [08:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 27/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 27/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [08:00:00 27/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 27/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [08:00:00 27/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [08:00:00 27/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [08:00:00 27/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [08:00:00 27/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [08:00:00 27/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 27/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [08:00:00 27/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [08:00:00 27/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [08:00:00 27/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [08:00:00 27/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [08:00:00 27/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [08:00:00 27/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [08:00:00 27/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [08:00:00 27/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 27/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [08:00:00 27/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Stimul st: NotStopd t0: [08:00:00 27/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [08:00:00 27/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [08:00:00 27/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 27/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 27/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [08:00:00 27/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 27/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [08:00:00 27/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 27/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [08:00:00 27/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [08:00:00 27/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [08:00:00 27/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [08:00:00 27/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [08:00:00 27/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [08:00:00 27/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [08:00:00 27/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 27/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [08:00:00 27/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 27/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [08:00:00 27/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Hypoactive st: NotStopd t0: [08:00:00 27/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [08:00:00 27/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [08:00:00 27/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [08:00:00 27/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [08:00:00 27/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [08:00:00 27/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 12 u1: number st: NotStopd t0: [08:00:00 27/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd
tf: [09:00:00 30/10/2016] pt: Unit Dose rt: IV fr: Q4H fs: 10, 14, 18, 22, 2, 6 dn: 6 m1: Lorazepam v1: 2 u1: mg tf: [11:00:00 30/10/2016] pt: IV Piggyback rt: IV fr: Q12H fs: 0, 12 dn: 2 m1: Vancomycin HCl v1: 1000 u1: mg m2: Iso-Osmotic Dextrose v2: 200 u2: ml tf: [17:00:00 31/10/2016] pt: Unit Dose rt: NG fr: Q6H fs: 10, 16, 22, 4 dn: 4 m1: Guaifenesin v1: 5-10 u1: ml
t0: [09:00:00 27/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thick st: NotStopd t0: [09:00:00 27/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Small st: NotStopd t0: [10:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [10:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 27/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [10:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 91 u1: BPM st: NotStopd t0: [10:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [10:00:00 27/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [10:00:00 27/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [10:00:00 27/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [10:00:00 27/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [10:00:00 27/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [10:00:00 27/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [10:00:00 27/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [10:00:00 27/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [10:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 152 u1: mmHg v2: 84 u2: mmHg st: NotStopd t0: [10:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 106.667 u1: mmHg st: NotStopd t0: [10:00:00 27/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [10:00:00 27/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [10:00:00 27/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [10:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [10:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [10:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [10:00:00 27/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [10:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [08:00:00 27/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 80 vu: ml t0: [10:00:00 27/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 10 vu: ml t0: [10:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [10:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 80 vu: ml t0: [10:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 160 vu: ml
t0: [10:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [10:00:00 27/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 27/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [10:00:00 27/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [10:00:00 27/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 27/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [10:00:00 27/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 27/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [10:00:00 27/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [10:00:00 27/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [10:00:00 27/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [10:00:00 27/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [11:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 90 u1: BPM st: NotStopd t0: [11:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [11:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 157 u1: mmHg v2: 81 u2: mmHg st: NotStopd t0: [11:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 106.333 u1: mmHg st: NotStopd t0: [11:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [11:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [11:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [11:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [12:00:00 27/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 27/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 27/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [12:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [12:00:00 27/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [12:00:00 27/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 27/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [12:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 27/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [12:00:00 27/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [12:00:00 27/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [12:00:00 27/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [12:00:00 27/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 87 u1: BPM st: NotStopd t0: [12:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:00:00 27/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [12:00:00 27/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [12:00:00 27/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [12:00:00 27/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [12:00:00 27/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [12:00:00 27/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [12:00:00 27/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [12:00:00 27/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [12:00:00 27/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 27/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [12:00:00 27/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [12:00:00 27/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [12:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [12:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 87.3333 u1: mmHg st: NotStopd t0: [12:00:00 27/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [12:00:00 27/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [12:00:00 27/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [12:00:00 27/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [12:00:00 27/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [12:00:00 27/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [12:00:00 27/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [12:00:00 27/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 27/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [12:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [12:00:00 27/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Sternal Rub v2: Localizes st: NotStopd t0: [12:00:00 27/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [12:00:00 27/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [12:00:00 27/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [12:00:00 27/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [12:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [12:00:00 27/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Nonpurposeful st: NotStopd t0: [12:00:00 27/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 27/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [12:00:00 27/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [12:00:00 27/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [12:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [12:00:00 27/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Hypoactive st: NotStopd t0: [12:00:00 27/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [12:00:00 27/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [12:00:00 27/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [12:00:00 27/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [12:00:00 27/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [12:00:00 27/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 12 u1: number st: NotStopd t0: [12:00:00 27/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd
t0: [10:00:00 27/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 100 vu: ml t0: [12:00:00 27/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 350 vu: ml t0: [12:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [12:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 80 vu: ml t0: [12:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 120 vu: ml
t0: [11:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [12:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [12:00:00 27/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [12:00:00 27/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.4444 u1: Deg. C st: NotStopd t0: [12:00:00 27/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 101.2 u1: Deg. F st: NotStopd
t0: [12:00:00 27/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 120 vu: ml
t0: [07:24:00 27/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.45 rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 137 rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 4 rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 2 rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 27 rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 38 u1: mmHg rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 87 u1: mmHg rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.45 rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 137 rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Ionized Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 1.23 rs: Final st: NotStopd t0: [07:24:00 27/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 4 rs: Final st: NotStopd
t0: [12:17:00 27/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 43.75 u1: ml/cmH st: NotStopd t0: [12:17:00 27/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [12:17:00 27/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [12:17:00 27/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [12:17:00 27/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [12:17:00 27/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [12:17:00 27/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [12:17:00 27/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [12:17:00 27/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [12:17:00 27/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [12:17:00 27/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [12:17:00 27/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 12 u1: cmH2O st: NotStopd t0: [12:17:00 27/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 10.5 u1: L/min st: NotStopd t0: [12:17:00 27/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 8 u1: cmH2O st: NotStopd t0: [12:17:00 27/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 24 u1: cmH2O st: NotStopd t0: [12:17:00 27/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 6 u1: BPM st: NotStopd t0: [12:17:00 27/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 16 u1: BPM st: NotStopd t0: [12:17:00 27/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [12:17:00 27/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [12:17:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 96 u1: % st: NotStopd t0: [12:17:00 27/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 680 u1: ml/B st: NotStopd t0: [12:17:00 27/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [12:17:00 27/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CMV st: NotStopd t0: [12:17:00 27/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [12:17:00 27/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [13:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [13:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [13:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [13:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 76 u1: mmHg st: NotStopd t0: [13:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [13:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [13:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [13:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [13:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 40 vu: ml t0: [13:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 85 vu: ml
t0: [13:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [15:11:00 27/10/2016] id: BSA el: 1033 cu: CCU cg: -1 t0: [15:11:00 27/10/2016] id: Admit Wt el: 1032 cu: CCU cg: -1 v1: 93.8 u1: kg t0: [15:11:00 27/10/2016] id: Allergy 1 el: 1020 cu: CCU cg: -1 v1: pcn t0: [15:11:00 27/10/2016] id: Diagnosis/op el: 1023 cu: CCU cg: -1 v1: HYPOXIA t0: [15:11:00 27/10/2016] id: Service el: 1026 cu: CCU cg: -1 v1: MED t0: [15:11:00 27/10/2016] id: Admit Ht el: 1034 cu: CCU cg: -1 t0: [15:11:00 27/10/2016] id: Readmission el: 1014 cu: CCU cg: -1 t0: [15:11:00 27/10/2016] id: Marital Status el: 1006 cu: CCU cg: -1 t0: [15:11:00 27/10/2016] id: Religion el: 1000 cu: CCU cg: -1 v1: OTR t0: [15:11:00 27/10/2016] id: Allergy 2 el: 1021 cu: CCU cg: -1 t0: [15:11:00 27/10/2016] id: Ext el: 1010 cu: CCU cg: -1 t0: [15:11:00 27/10/2016] id: PIN el: 1012 cu: CCU cg: -1 t0: [15:11:00 27/10/2016] id: Allergy 3 el: 1022 cu: CCU cg: -1
t0: [13:45:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [13:45:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:45:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:45:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 138 u1: BPM st: NotStopd t0: [13:45:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [13:45:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 129 u1: mmHg v2: 66 u2: mmHg st: NotStopd t0: [13:45:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 87 u1: mmHg st: NotStopd t0: [13:45:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [13:45:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [13:45:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [13:45:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [14:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [14:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [14:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [14:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 77 u2: mmHg st: NotStopd t0: [14:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 95.3333 u1: mmHg st: NotStopd t0: [14:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [14:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [14:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [14:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:45:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [14:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5774 id: Procedures el: 0 cu: CCU cg: RN v1: EKG st: NotStopd t0: [14:30:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [14:30:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:30:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:30:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 87 u1: BPM st: NotStopd t0: [14:30:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [14:30:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 82 u2: mmHg st: NotStopd t0: [14:30:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 98.6667 u1: mmHg st: NotStopd t0: [14:30:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [14:30:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [14:30:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [14:30:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:30:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [14:30:00 27/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [14:30:00 27/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.5556 u1: Deg. C st: NotStopd t0: [14:30:00 27/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 101.4 u1: Deg. F st: NotStopd t0: [15:00:00 27/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [15:00:00 27/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [15:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [15:00:00 27/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [15:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 27/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [15:00:00 27/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [15:00:00 27/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [15:00:00 27/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [15:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [15:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [15:00:00 27/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [15:00:00 27/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [15:00:00 27/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [15:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 126 u1: mmHg v2: 61 u2: mmHg st: NotStopd t0: [15:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82.6667 u1: mmHg st: NotStopd t0: [15:00:00 27/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [15:00:00 27/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [15:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [15:00:00 27/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [15:00:00 27/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [15:00:00 27/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [15:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [15:00:00 27/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [15:00:00 27/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [15:00:00 27/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [15:00:00 27/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [15:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [15:00:00 27/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 27/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [15:00:00 27/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [15:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [15:00:00 27/10/2016] id: Fingerstick Glucose Chemistry el: 0 cu: CCU cg: CoWker v1: 111 rs: Manual st: NotStopd
t0: [13:00:00 27/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vu: ml nb: 1 t0: [15:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [15:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 80 vu: ml t0: [15:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 260 vu: ml
t0: [15:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:00:00 27/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [16:00:00 27/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 27/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [16:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [16:00:00 27/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [16:00:00 27/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [16:00:00 27/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [16:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 27/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [16:00:00 27/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [16:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 92 u1: BPM st: NotStopd t0: [16:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Sinus Tachy st: NotStopd t0: [16:00:00 27/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [16:00:00 27/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [16:00:00 27/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [16:00:00 27/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [16:00:00 27/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [16:00:00 27/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [16:00:00 27/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [16:00:00 27/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [16:00:00 27/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [16:00:00 27/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [16:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 137 u1: mmHg v2: 78 u2: mmHg st: NotStopd t0: [16:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 97.6667 u1: mmHg st: NotStopd t0: [16:00:00 27/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [16:00:00 27/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [16:00:00 27/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [16:00:00 27/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [16:00:00 27/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [16:00:00 27/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [16:00:00 27/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 27/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [16:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [16:00:00 27/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [16:00:00 27/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [16:00:00 27/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [16:00:00 27/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [16:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [16:00:00 27/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 27/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [16:00:00 27/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [16:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [16:00:00 27/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Hypoactive st: NotStopd
t0: [16:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [16:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 0 vu: ml t0: [16:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 45 vu: ml
t0: [16:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:18:00 27/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 41.1765 u1: ml/cmH st: NotStopd t0: [16:18:00 27/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [16:18:00 27/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [16:18:00 27/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [16:18:00 27/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [16:18:00 27/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [16:18:00 27/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [16:18:00 27/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [16:18:00 27/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [16:18:00 27/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [16:18:00 27/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 13 u1: cmH2O st: NotStopd t0: [16:18:00 27/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 11.8 u1: L/min st: NotStopd t0: [16:18:00 27/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 8 u1: cmH2O st: NotStopd t0: [16:18:00 27/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 25 u1: cmH2O st: NotStopd t0: [16:18:00 27/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 11 u1: BPM st: NotStopd t0: [16:18:00 27/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 21 u1: BPM st: NotStopd t0: [16:18:00 27/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [16:18:00 27/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [16:18:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 96 u1: % st: NotStopd t0: [16:18:00 27/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 657 u1: ml/B st: NotStopd t0: [16:18:00 27/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [16:18:00 27/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CMV st: NotStopd t0: [16:18:00 27/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [16:18:00 27/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
tf: [16:00:00 28/10/2016] pt: IV Large Volume rt: IV fr: ONCE fs: 18 dn: 1 m1: Thiamine HCl v1: 100 u1: mg m2: D5 1/2NS v2: 1000 u2: ml m3: Folic Acid v3: 1 u3: mg m4: Multivitamin 12 v4: 10
t0: [17:00:00 27/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.44 rs: Final st: NotStopd t0: [17:00:00 27/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 6 rs: Final st: NotStopd t0: [17:00:00 27/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 32 rs: Final st: NotStopd t0: [17:00:00 27/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 45 u1: mmHg rs: Final st: NotStopd t0: [17:00:00 27/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 128 u1: mmHg rs: Final st: NotStopd t0: [17:00:00 27/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.44 rs: Final st: NotStopd t0: [17:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5564 id: SaO2 ABG's el: 0 cu: CCU cg: 140 v1: 98 u1: % rs: Final st: NotStopd
t0: [17:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [17:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 89 u1: BPM st: NotStopd t0: [17:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [17:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [17:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 85 u1: mmHg st: NotStopd t0: [17:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [17:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [17:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [17:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [17:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 70 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [17:36:00 27/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 6.2 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: WBC Hematology el: 0 cu: CCU cg: 140 v1: 6.2 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Differential-Basos Hematology el: 0 cu: CCU cg: 140 v1: 0.3 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Differential-Eos Hematology el: 0 cu: CCU cg: 140 v1: 4.5 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Differential-Lymphs Hematology el: 0 cu: CCU cg: 140 v1: 6.7 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Differential-Monos Hematology el: 0 cu: CCU cg: 140 v1: 5.4 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Differential-Polys Hematology el: 0 cu: CCU cg: 140 v1: 83.1 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 39.1 u1: % rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 13.6 u1: gm/dl rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Platelets Hematology el: 0 cu: CCU cg: 140 v1: 182 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: RBC Hematology el: 0 cu: CCU cg: 140 v1: 4.11 u1: /mic l rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 6.2 rs: Final st: NotStopd
id: .9% Normal Saline el: 3 cu: CCU cg: RN io: .9% Normal Saline 1000.0ml IV Infusions vo: 1000 du: ml rt: Intravenous Push
t0: [17:36:00 27/10/2016] id: PT el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: INR Coags el: 0 cu: CCU cg: 140 v1: 1.1 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: PTT Coags el: 0 cu: CCU cg: 140 v1: 26 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: INR (2-4 ref. range) Coags el: 0 cu: CCU cg: 140 v1: 1.1 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: PT(11-13.5) Coags el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: PTT(22-35) Coags el: 0 cu: CCU cg: 140 v1: 26 rs: Final st: NotStopd
t0: [18:25:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5479 id: Blood Products Hematology el: 0 cu: CCU cg: 140 v1: Y rs: Final st: NotStopd
t0: [18:31:00 27/10/2016] id: IV #1 Insert Date el: 0 cu: CCU cg: -1 st: D/C'd t0: [18:31:00 27/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: -1 st: D/C'd t0: [18:31:00 27/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: -1 st: D/C'd t0: [18:31:00 27/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: -1 st: D/C'd t0: [18:31:00 27/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: -1 st: D/C'd t0: [18:31:00 27/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: -1 st: D/C'd
t0: [18:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [18:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [18:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 108 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [18:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 75.3333 u1: mmHg st: NotStopd t0: [18:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [18:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [18:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [18:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [18:15:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [18:15:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:15:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:15:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [18:15:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:15:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 112 u1: mmHg v2: 61 u2: mmHg st: NotStopd t0: [18:15:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 78 u1: mmHg st: NotStopd t0: [18:15:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [18:15:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 28 u1: BPM st: NotStopd t0: [18:15:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [18:15:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [18:30:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [18:30:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:30:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:30:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [18:30:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: INV#1 WaveformAppear el: 0 cu: CCU cg: RN v1: Sharp st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: IV #1 D/C Date el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [18:30:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5474 id: IV #2 D/C Date el: 0 cu: CCU cg: RN v1: 9 v2: 1 st: NotStopd t0: [18:30:00 27/10/2016] id: IV #1 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 20 gauge st: NotStopd t0: [18:30:00 27/10/2016] id: IV #2 D/C Date el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [18:30:00 27/10/2016] id: IV #2 Insert Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [18:30:00 27/10/2016] id: IV #2 Site/Size el: 0 cu: CCU cg: RN v1: Right Hand v2: 20 gauge st: NotStopd t0: [18:30:00 27/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [18:30:00 27/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [18:30:00 27/10/2016] id: IV Site Appear #1 el: 0 cu: CCU cg: RN v1: Infiltrated st: NotStopd t0: [18:30:00 27/10/2016] id: IV Site Appear #2 el: 0 cu: CCU cg: RN v1: Redness st: NotStopd t0: [18:30:00 27/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [18:30:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 99 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [18:30:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 67.6667 u1: mmHg st: NotStopd t0: [18:30:00 27/10/2016] tf: [21:00:00 29/10/2016] dt: 3030 id: Arterial BP el: 0 cu: CCU cg: RN v1: 97 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [18:30:00 27/10/2016] tf: [21:00:00 29/10/2016] dt: 3030 id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 71 u1: mmHg st: NotStopd t0: [18:30:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [18:30:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 26 u1: BPM st: NotStopd t0: [18:30:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [18:30:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [18:30:00 27/10/2016] tf: [21:00:00 27/10/2016] dt: 150 id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 500 vu: ml t0: [18:45:00 27/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 500 vu: ml t0: [18:45:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [18:45:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 0 vu: ml t0: [18:45:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 45 vu: ml
t0: [18:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 70 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [18:15:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 70 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [18:30:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 70 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [17:36:00 27/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 10 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 9.4 u1: mg/dl rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 106 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.7 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 122 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 2 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 3.9 u1: mEq/L rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 4.1 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 141 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: BUN (6-20) Chemistry el: 0 cu: CCU cg: 140 v1: 10 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 9.4 u1: mg/dl rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 30 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 106 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.7 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 122 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 2 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 3.9 u1: mEq/L rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 4.1 rs: Final st: NotStopd t0: [17:36:00 27/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 141 rs: Final st: NotStopd
t0: [19:32:00 27/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd t0: [19:32:00 27/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [19:32:00 27/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 28 rs: Final st: NotStopd t0: [19:32:00 27/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 44 u1: mmHg rs: Final st: NotStopd t0: [19:32:00 27/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 85 u1: mmHg rs: Final st: NotStopd t0: [19:32:00 27/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd
t0: [19:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [19:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 110 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [19:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 75.3333 u1: mmHg st: NotStopd t0: [19:00:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 114 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [19:00:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 76 u1: mmHg st: NotStopd t0: [19:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 53 u1: BPM st: NotStopd t0: [19:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [19:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [19:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 60 vu: ml
t0: [19:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip
id: Neosynephrine-k el: 100 cu: CCU cg: RN io: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions am: 60 du: mcgkgmin rt: IV Drip
io: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ra: 11.725 ru: ml/hr
id: D5W el: 1 cu: CCU cg: RN io: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions vo: 250 du: ml rt: Intravenous Push
t0: [19:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5444 id: Significant Events el: 0 cu: CCU cg: RN v1: Pneumothorax st: NotStopd t0: [19:05:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:05:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:05:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:05:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [19:05:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:05:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 113 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [19:05:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 75.6667 u1: mmHg st: NotStopd t0: [19:05:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [19:05:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 78 u1: mmHg st: NotStopd t0: [19:05:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:05:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 38 u1: BPM st: NotStopd t0: [19:05:00 27/10/2016] id: Significant Events el: 0 cu: CCU cg: RN v1: Fluid Bolus st: NotStopd t0: [19:05:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:05:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:10:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:10:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:10:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:10:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [19:10:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:10:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [19:10:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 76.6667 u1: mmHg st: NotStopd t0: [19:10:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [19:10:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 79 u1: mmHg st: NotStopd t0: [19:10:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:10:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 40 u1: BPM st: NotStopd t0: [19:10:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:10:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:15:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:15:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:15:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:15:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [19:15:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:15:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [19:15:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82.3333 u1: mmHg st: NotStopd t0: [19:15:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [19:15:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 139 u1: mmHg st: NotStopd t0: [19:15:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:15:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 39 u1: BPM st: NotStopd t0: [19:15:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:15:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:20:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:20:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:20:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:20:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [19:20:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:20:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [19:20:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 80.3333 u1: mmHg st: NotStopd t0: [19:20:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 113 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [19:20:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 76 u1: mmHg st: NotStopd t0: [19:20:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:20:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 35 u1: BPM st: NotStopd t0: [19:20:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:20:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:25:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:25:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:25:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:25:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [19:25:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:25:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 118 u1: mmHg v2: 61 u2: mmHg st: NotStopd t0: [19:25:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 80 u1: mmHg st: NotStopd t0: [19:25:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 114 u1: mmHg v2: 61 u2: mmHg st: NotStopd t0: [19:25:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 78 u1: mmHg st: NotStopd t0: [19:25:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:25:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 27 u1: BPM st: NotStopd t0: [19:25:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [19:25:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:30:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:30:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:30:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:30:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [19:30:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:30:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 107 u1: mmHg v2: 54 u2: mmHg st: NotStopd t0: [19:30:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 71.6667 u1: mmHg st: NotStopd t0: [19:30:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 109 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [19:30:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 75 u1: mmHg st: NotStopd t0: [19:30:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:30:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 30 u1: BPM st: NotStopd t0: [19:30:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:30:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:35:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:35:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:35:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:35:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [19:35:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:35:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 110 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [19:35:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 74 u1: mmHg st: NotStopd t0: [19:35:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 107 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [19:35:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 74 u1: mmHg st: NotStopd t0: [19:35:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:35:00 27/10/2016] id: Procedures el: 0 cu: CCU cg: RN v1: Chest Tube In st: NotStopd t0: [19:35:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 27 u1: BPM st: NotStopd t0: [19:35:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:35:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:40:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:40:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:40:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:40:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [19:40:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:40:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 99 u1: mmHg v2: 53 u2: mmHg st: NotStopd t0: [19:40:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 68.3333 u1: mmHg st: NotStopd t0: [19:40:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 97 u1: mmHg v2: 54 u2: mmHg st: NotStopd t0: [19:40:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [19:40:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:40:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 30 u1: BPM st: NotStopd t0: [19:40:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:40:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:45:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:45:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:45:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:45:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [19:45:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:45:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 89 u1: mmHg v2: 53 u2: mmHg st: NotStopd t0: [19:45:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 65 u1: mmHg st: NotStopd t0: [19:45:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 88 u1: mmHg v2: 53 u2: mmHg st: NotStopd t0: [19:45:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 64 u1: mmHg st: NotStopd t0: [19:45:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:45:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [19:45:00 27/10/2016] id: Significant Events el: 0 cu: CCU cg: RN v1: Fluid Bolus st: NotStopd t0: [19:45:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:45:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:50:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:50:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:50:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:50:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 69 u1: BPM st: NotStopd t0: [19:50:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:50:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 114 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [19:50:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [19:50:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 144 u1: mmHg v2: 81 u2: mmHg st: NotStopd t0: [19:50:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 103 u1: mmHg st: NotStopd t0: [19:50:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:50:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [19:50:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [19:50:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:55:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:55:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:55:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:55:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 76 u1: BPM st: NotStopd t0: [19:55:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:55:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 113 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [19:55:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 75.6667 u1: mmHg st: NotStopd t0: [19:55:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 100 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [19:55:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 72 u1: mmHg st: NotStopd t0: [19:55:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:55:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [19:55:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [19:55:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [20:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [20:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 71 u1: BPM st: NotStopd t0: [20:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [20:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [20:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [20:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [19:05:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:10:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:15:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:20:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:25:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:30:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:35:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:40:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:45:00 27/10/2016] tf: [00:00:00 28/10/2016] dt: 255 id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 1 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [19:45:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:50:00 27/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [19:50:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:55:00 27/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [19:55:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [20:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [20:00:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 94 u1: mmHg v2: 54 u2: mmHg st: NotStopd t0: [20:00:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 67.3333 u1: mmHg st: NotStopd t0: [20:00:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 90 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [20:00:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 62 u1: mmHg st: NotStopd t0: [20:05:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [20:05:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:05:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:05:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 68 u1: BPM st: NotStopd t0: [20:05:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:05:00 27/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 124 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [20:05:00 27/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84.6667 u1: mmHg st: NotStopd t0: [20:05:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 126 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [20:05:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 90 u1: mmHg st: NotStopd t0: [20:05:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [20:05:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 23 u1: BPM st: NotStopd t0: [20:05:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [20:05:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [20:10:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [20:10:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:10:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 69 u1: BPM st: NotStopd t0: [20:10:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:10:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 125 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [20:10:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [20:10:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [20:10:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [20:10:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [20:10:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [20:00:00 27/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0.5 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [20:05:00 27/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0.5 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [20:05:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [20:10:00 27/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [20:10:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [19:45:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 0 vu: ml
t0: [17:36:00 27/10/2016] id: Dilantin Drug Level el: 0 cu: CCU cg: 140 v1: 1.4 rs: Final st: NotStopd
t0: [21:00:00 27/10/2016] id: Compliance (40-60ml) el: 0 cu: CCU cg: RRT v1: 38.4615 u1: ml/cmH st: NotStopd t0: [21:00:00 27/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [21:00:00 27/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 1 u1: torr st: NotStopd t0: [21:00:00 27/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [21:00:00 27/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [21:00:00 27/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [21:00:00 27/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [21:00:00 27/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [21:00:00 27/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [21:00:00 27/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [21:00:00 27/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [21:00:00 27/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [21:00:00 27/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 11 u1: L/min st: NotStopd t0: [21:00:00 27/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [21:00:00 27/10/2016] id: Peak Insp. Pressure el: 0 cu: CCU cg: RRT v1: 18 u1: cmH2O st: NotStopd t0: [21:00:00 27/10/2016] id: Resp Rate (Spont) el: 0 cu: CCU cg: RRT v1: 12 u1: BPM st: NotStopd t0: [21:00:00 27/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 22 u1: BPM st: NotStopd t0: [21:00:00 27/10/2016] id: Respiratory Rate Set el: 0 cu: CCU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [21:00:00 27/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [21:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 99 u1: % st: NotStopd t0: [21:00:00 27/10/2016] id: Tidal Volume (Obser) el: 0 cu: CCU cg: RRT v1: 511 u1: ml/B st: NotStopd t0: [21:00:00 27/10/2016] id: Tidal Volume (Set) el: 0 cu: CCU cg: RRT v1: 500 u1: ml/B st: NotStopd t0: [21:00:00 27/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: Assist Control st: NotStopd t0: [21:00:00 27/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd t0: [21:00:00 27/10/2016] id: Waveform-Vent el: 0 cu: CCU cg: RRT v1: RAMP st: NotStopd
t0: [20:58:00 27/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.36 rs: Final st: NotStopd t0: [20:58:00 27/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 3 rs: Final st: NotStopd t0: [20:58:00 27/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 31 rs: Final st: NotStopd t0: [20:58:00 27/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 52 u1: mmHg rs: Final st: NotStopd t0: [20:58:00 27/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 111 u1: mmHg rs: Final st: NotStopd t0: [20:58:00 27/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.36 rs: Final st: NotStopd
t0: [21:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [21:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 68 u1: BPM st: NotStopd t0: [21:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [21:00:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 106 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [21:00:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 73 u1: mmHg st: NotStopd t0: [21:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [21:00:00 27/10/2016] id: Radiologic Study el: 0 cu: CCU cg: RN v1: Chest Xray st: NotStopd t0: [21:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 23 u1: BPM st: NotStopd t0: [21:00:00 27/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thick st: NotStopd t0: [21:00:00 27/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Small st: NotStopd t0: [21:00:00 27/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [21:00:00 27/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.3333 u1: Deg. C st: NotStopd t0: [21:00:00 27/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 99.2 u1: Deg. F st: NotStopd t0: [21:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [22:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [22:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 68 u1: BPM st: NotStopd t0: [22:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:00:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 94 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [22:00:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 66 u1: mmHg st: NotStopd t0: [22:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [22:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [22:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [19:45:00 27/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vu: ml t0: [20:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml t0: [21:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 0 vu: ml t0: [21:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 100 vu: ml t0: [22:00:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 0 vu: ml t0: [22:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 100 vu: ml
t0: [21:00:00 27/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [21:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 100 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [22:00:00 27/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [22:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 80 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [22:01:00 27/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: -1 ai: 216 vo: 0 st: D/C'd
t0: [21:05:00 27/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 38.7 u1: % rs: Final st: NotStopd
t0: [22:00:00 27/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.8 u1: torr st: NotStopd
t0: [19:00:00 27/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [22:00:00 27/10/2016] tf: [15:00:00 30/10/2016] dt: 3900 id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [19:00:00 27/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [19:00:00 27/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [21:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5324 id: Eye Care el: 0 cu: CCU cg: RN v1: 1 No Response st: NotStopd t0: [19:00:00 27/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [19:00:00 27/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 5 u1: points st: NotStopd t0: [19:00:00 27/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [19:00:00 27/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [19:00:00 27/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [19:00:00 27/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Absent st: NotStopd t0: [19:00:00 27/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: Reverse T-Berg st: NotStopd t0: [19:00:00 27/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [19:00:00 27/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [19:00:00 27/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Good st: NotStopd t0: [19:00:00 27/10/2016] tf: [08:00:00 31/10/2016] dt: 5100 id: Imp Skin Cleanse #1 el: 0 cu: CCU cg: RN v1: Soap & H20 st: NotStopd t0: [19:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5444 id: ImpSkin Character #1 el: 0 cu: CCU cg: RN v1: Hematoma st: NotStopd t0: [19:00:00 27/10/2016] tf: [08:00:00 31/10/2016] dt: 5100 id: ImpSkin Treatment #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5444 id: ImpSkin Drain/Amt#1 el: 0 cu: CCU cg: RN v1: Open to Air st: NotStopd t0: [19:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5444 id: ImpSkin Wound Base#1 el: 0 cu: CCU cg: RN v1: Purple st: NotStopd t0: [19:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5444 id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Right st: NotStopd t0: [19:00:00 27/10/2016] id: Inc Cleansing #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [19:00:00 27/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [19:00:00 27/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 27/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [19:00:00 27/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [19:00:00 27/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [19:00:00 27/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [19:00:00 27/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 3 Abnorm flexion st: NotStopd t0: [21:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5324 id: Oral Care el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [19:00:00 27/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [19:00:00 27/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [19:00:00 27/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [19:00:00 27/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: Supervised st: NotStopd t0: [19:00:00 27/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Absent st: NotStopd t0: [19:00:00 27/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [19:00:00 27/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [19:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5444 id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [19:00:00 27/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Shallow st: NotStopd t0: [19:00:00 27/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Tachypneic st: NotStopd t0: [19:00:00 27/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 27/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [19:00:00 27/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: BehaviorSubsided st: NotStopd t0: [19:00:00 27/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 27/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [21:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5324 id: Skin Care el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [19:00:00 27/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [19:00:00 27/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 27/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 27/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [19:00:00 27/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [19:00:00 27/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [19:00:00 27/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [19:00:00 27/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [19:00:00 27/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [19:00:00 27/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Comp. Immobile st: NotStopd t0: [19:00:00 27/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Rarely Moist st: NotStopd t0: [19:00:00 27/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [19:00:00 27/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 11 u1: number st: NotStopd t0: [19:00:00 27/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Comp. Limited st: NotStopd t0: [20:00:00 27/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [20:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5384 id: Pain Assess Method el: 0 cu: CCU cg: RN v1: Grimace Scale st: NotStopd t0: [20:00:00 27/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [20:00:00 27/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [21:00:00 27/10/2016] id: Eye Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 27/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: Flat in Bed st: NotStopd t0: [21:00:00 27/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [21:00:00 27/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Good st: NotStopd t0: [21:00:00 27/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 27/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [21:00:00 27/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [21:00:00 27/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [21:00:00 27/10/2016] id: Skin Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 27/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Logroll st: NotStopd t0: [21:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5324 id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [22:00:00 27/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [22:00:00 27/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [22:00:00 27/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [22:00:00 27/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [22:00:00 27/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [22:00:00 27/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [22:00:00 27/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [22:00:00 27/10/2016] tf: [15:00:00 30/10/2016] dt: 3900 id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [22:00:00 27/10/2016] tf: [15:00:00 30/10/2016] dt: 3900 id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 27/10/2016] tf: [15:00:00 30/10/2016] dt: 3900 id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [22:00:00 27/10/2016] tf: [15:00:00 30/10/2016] dt: 3900 id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [22:30:00 27/10/2016] id: Radiologic Study el: 0 cu: CCU cg: RN v1: Chest Xray st: NotStopd
t0: [19:45:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vu: ml t0: [20:00:00 27/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 500 vu: ml t0: [21:00:00 27/10/2016] tf: [01:00:00 28/10/2016] dt: 240 id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml nb: 1 t0: [22:00:00 27/10/2016] tf: [01:00:00 28/10/2016] dt: 180 id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 0 vu: ml nb: 1 t0: [21:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vu: ml t0: [21:00:00 27/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 1.95417 vu: ml t0: [21:00:00 27/10/2016] tf: [13:30:00 28/10/2016] dt: 990 id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 10 vu: ml t0: [22:00:00 27/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 100 vu: ml t0: [22:00:00 27/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [22:00:00 27/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vu: ml t0: [22:00:00 27/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 4.69 vu: ml t0: [23:00:00 27/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [23:00:00 27/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 4.69 vu: ml t0: [23:00:00 27/10/2016] id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 10 vu: ml t0: [23:00:00 27/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 200 vu: ml
t0: [23:00:00 27/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [23:00:00 27/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 27/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 27/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 72 u1: BPM st: NotStopd t0: [23:00:00 27/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [23:00:00 27/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 137 u1: mmHg v2: 73 u2: mmHg st: NotStopd t0: [23:00:00 27/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 93 u1: mmHg st: NotStopd t0: [23:00:00 27/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [23:00:00 27/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 25 u1: BPM st: NotStopd t0: [23:00:00 27/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [23:00:00 27/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [23:00:00 27/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [23:00:00 27/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 150 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [19:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5444 id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [19:00:00 27/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [20:00:00 27/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [20:00:00 27/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [20:00:00 27/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [20:00:00 27/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [20:00:00 27/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [20:00:00 27/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [20:00:00 27/10/2016] id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [20:00:00 27/10/2016] id: INV#1 WaveformAppear el: 0 cu: CCU cg: RN v1: Sharp st: NotStopd t0: [20:00:00 27/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [20:00:00 27/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [20:00:00 27/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [21:00:00 27/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [21:00:00 27/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [21:00:00 27/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 27/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [21:00:00 27/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: BehaviorSubsided st: NotStopd t0: [21:00:00 27/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [22:00:00 27/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [23:00:00 27/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [23:00:00 27/10/2016] id: Procedures el: 0 cu: CCU cg: RN v1: Chest Tube In st: NotStopd t0: [00:00:00 28/10/2016] tf: [15:00:00 30/10/2016] dt: 3780 id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [00:00:00 28/10/2016] tf: [15:00:00 30/10/2016] dt: 3780 id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Negative st: NotStopd t0: [00:00:00 28/10/2016] tf: [15:00:00 30/10/2016] dt: 3780 id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [00:00:00 28/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [00:00:00 28/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [00:00:00 28/10/2016] id: Pain Assess Method el: 0 cu: CCU cg: RN v1: Grimace Scale st: NotStopd t0: [00:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [00:00:00 28/10/2016] tf: [15:00:00 30/10/2016] dt: 3780 id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [00:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [00:00:00 28/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [00:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [00:00:00 28/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [00:00:00 28/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [00:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [00:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 28/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 1 No Response st: NotStopd t0: [00:00:00 28/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [00:00:00 28/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 3 u1: points st: NotStopd t0: [00:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [00:00:00 28/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [00:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [00:00:00 28/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Absent st: NotStopd t0: [00:00:00 28/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: Reverse T-Berg st: NotStopd t0: [00:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 73 u1: BPM st: NotStopd t0: [00:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 28/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [00:00:00 28/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [00:00:00 28/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [00:00:00 28/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [00:00:00 28/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [00:00:00 28/10/2016] id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [00:00:00 28/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [00:00:00 28/10/2016] id: INV#1 WaveformAppear el: 0 cu: CCU cg: RN v1: Sharp st: NotStopd t0: [00:00:00 28/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [00:00:00 28/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [00:00:00 28/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [00:00:00 28/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [00:00:00 28/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Good st: NotStopd t0: [00:00:00 28/10/2016] id: ImpSkin Character #1 el: 0 cu: CCU cg: RN v1: Hematoma st: NotStopd t0: [00:00:00 28/10/2016] id: ImpSkin Drain/Amt#1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 28/10/2016] id: ImpSkin Treatment #1 el: 0 cu: CCU cg: RN v1: Open to Air st: NotStopd t0: [00:00:00 28/10/2016] id: ImpSkin Wound Base#1 el: 0 cu: CCU cg: RN v1: Purple st: NotStopd t0: [00:00:00 28/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Right st: NotStopd t0: [00:00:00 28/10/2016] id: Inc Cleansing #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [00:00:00 28/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [00:00:00 28/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 28/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [00:00:00 28/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [00:00:00 28/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 1 No Response st: NotStopd t0: [00:00:00 28/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [00:00:00 28/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [00:00:00 28/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [00:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 118 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [00:00:00 28/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [00:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 83 u1: mmHg st: NotStopd t0: [00:00:00 28/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [00:00:00 28/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [00:00:00 28/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [00:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [00:00:00 28/10/2016] id: Radiologic Study el: 0 cu: CCU cg: RN v1: Chest Xray st: NotStopd t0: [00:00:00 28/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [00:00:00 28/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [00:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [00:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [00:00:00 28/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [00:00:00 28/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [00:00:00 28/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: BehaviorReturned st: NotStopd t0: [00:00:00 28/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 28/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [00:00:00 28/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [00:00:00 28/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [00:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [00:00:00 28/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 28/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 28/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [00:00:00 28/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.4444 u1: Deg. C st: NotStopd t0: [00:00:00 28/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 99.4 u1: Deg. F st: NotStopd t0: [00:00:00 28/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [00:00:00 28/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [00:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [00:00:00 28/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [00:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [00:00:00 28/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [00:00:00 28/10/2016] tf: [15:00:00 30/10/2016] dt: 3780 id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [00:00:00 28/10/2016] tf: [15:00:00 30/10/2016] dt: 3780 id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [00:00:00 28/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Changed st: NotStopd t0: [00:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [00:00:00 28/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [00:00:00 28/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [00:00:00 28/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [00:00:00 28/10/2016] id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 5 vu: ml t0: [00:00:00 28/10/2016] id: Chest Tubes Right Pleural 2 el: 1 cu: CCU cg: RN vo: 0 vu: ml t0: [00:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 110 vu: ml
t0: [00:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 150 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:10:00 28/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.35 rs: Final st: NotStopd t0: [00:10:00 28/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 0 rs: Final st: NotStopd t0: [00:10:00 28/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 27 rs: Final st: NotStopd t0: [00:10:00 28/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 47 u1: mmHg rs: Final st: NotStopd t0: [00:10:00 28/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 95 u1: mmHg rs: Final st: NotStopd t0: [00:10:00 28/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.35 rs: Final st: NotStopd
t0: [23:00:00 27/10/2016] dt: 24 id: Chest Tube Out Total el: 1 cu: CCU cg: 140 pv: 10 cv: 20 ap: none
t0: [00:00:00 28/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [00:00:00 28/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [00:00:00 28/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.6 u1: torr st: NotStopd t0: [00:00:00 28/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [00:00:00 28/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [00:00:00 28/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [00:00:00 28/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [00:00:00 28/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [00:00:00 28/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [00:00:00 28/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [00:00:00 28/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 11 u1: cmH2O st: NotStopd t0: [00:00:00 28/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 13 u1: L/min st: NotStopd t0: [00:00:00 28/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [00:00:00 28/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 15 u1: . st: NotStopd t0: [00:00:00 28/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 20 u1: BPM st: NotStopd t0: [00:00:00 28/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [00:00:00 28/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 680 u1: ml/B st: NotStopd t0: [00:00:00 28/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [00:00:00 28/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [00:00:00 28/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [00:00:00 28/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [00:00:00 28/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [00:00:00 28/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd
t0: [00:00:00 28/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Impaired v2: Impaired st: NotStopd t0: [00:00:00 28/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [00:00:00 28/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: Pinpoint v2: Pinpoint st: NotStopd t0: [00:30:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [00:30:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [00:30:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:30:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:30:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 79 u1: BPM st: NotStopd t0: [00:30:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:30:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 85 u1: mmHg v2: 45 u2: mmHg st: NotStopd t0: [00:30:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 58 u1: mmHg st: NotStopd t0: [00:30:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [00:30:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [00:30:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [00:30:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [00:30:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 75 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:23:00 28/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 36.7 u1: % rs: Final st: NotStopd
t0: [01:08:00 28/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd t0: [01:08:00 28/10/2016] tf: [13:44:00 31/10/2016] dt: 5076 id: CaO2 el: 0 cu: CCU cg: 140 v1: 17.9594 u1: ml/dl st: NotStopd t0: [01:08:00 28/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [01:08:00 28/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 28 rs: Final st: NotStopd t0: [01:08:00 28/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 44 u1: mmHg rs: Final st: NotStopd t0: [01:08:00 28/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 91 u1: mmHg rs: Final st: NotStopd t0: [01:08:00 28/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd t0: [01:08:00 28/10/2016] id: SaO2 ABG's el: 0 cu: CCU cg: 140 v1: 97 u1: % rs: Final st: NotStopd
t0: [21:00:00 27/10/2016] tf: [13:44:00 31/10/2016] dt: 5324 id: Right Carotid Site el: 0 cu: CCU cg: RN v1: Hem/Sft t0: [22:00:00 27/10/2016] id: Right Carotid Site el: 0 cu: CCU cg: RN v1: Hem/Sft t0: [23:00:00 27/10/2016] id: Right Carotid Site el: 0 cu: CCU cg: RN v1: Hem/Sft t0: [00:00:00 28/10/2016] id: Right Carotid Site el: 0 cu: CCU cg: RN v1: Hem/Sft t0: [01:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [01:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [01:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [01:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [01:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 131 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [01:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 86 u1: mmHg st: NotStopd t0: [01:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [01:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 11 u1: BPM st: NotStopd t0: [01:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [01:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 75 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [22:00:00 27/10/2016] tf: [15:00:00 30/10/2016] dt: 3900 id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [00:00:00 28/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [00:00:00 28/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [00:00:00 28/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd
t0: [02:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [02:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [02:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [02:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [02:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 143 u1: mmHg v2: 70 u2: mmHg st: NotStopd t0: [02:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 96 u1: mmHg st: NotStopd t0: [02:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [02:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [02:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:00:00 28/10/2016] id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 10 vu: ml t0: [02:00:00 28/10/2016] tf: [13:44:00 31/10/2016] dt: 5024 id: Chest Tubes Right Pleural 2 el: 1 cu: CCU cg: RN vo: 5 vu: ml t0: [02:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 120 vu: ml
t0: [23:00:00 28/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: 140 cv: 0 ap: none t0: [23:00:00 28/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN cv: 3590 ap: none t0: [23:00:00 28/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: 140 cv: 3702 ap: none t0: [23:00:00 28/10/2016] dt: 24 id: Chest Tube Out Total el: 1 cu: CCU cg: 140 cv: 112 ap: none
t0: [02:00:00 28/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [02:00:00 28/10/2016] id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Negative st: NotStopd t0: [02:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [02:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [02:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [02:00:00 28/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [02:00:00 28/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [02:00:00 28/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [02:00:00 28/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [02:00:00 28/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [02:00:00 28/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [02:00:00 28/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 4 Flex-withdraws st: NotStopd t0: [02:00:00 28/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [02:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [02:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [02:00:00 28/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Withdraws st: NotStopd t0: [02:00:00 28/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 28/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Nonpurposeful st: NotStopd t0: [02:00:00 28/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [02:00:00 28/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [02:00:00 28/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [02:00:00 28/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [02:00:00 28/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [02:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [02:00:00 28/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [02:00:00 28/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [02:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 85 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:00:00 28/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 200 vu: ml
t0: [23:00:00 28/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: 140 cv: 0 ap: none t0: [23:00:00 28/10/2016] dt: 24 id: IV Infusion In Total el: 1 cu: CCU cg: 140 cv: 4330.71 ap: none t0: [23:00:00 28/10/2016] dt: 24 id: 24h Total In el: 1 cu: CCU cg: 140 cv: 5060.71 ap: none t0: [23:00:00 28/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: 140 cv: 1358.71 ap: none t0: [23:00:00 28/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: 140 cv: 7902 ap: none
t0: [00:00:00 28/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [00:00:00 28/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd
id: MVI el: 200 cu: CCU cg: RN io: D5/.45NS 1000.0ml IV Infusions am: 10 du: ml rt: Intravenous Push id: Thiamine el: 200 cu: CCU cg: RN io: D5/.45NS 1000.0ml IV Infusions am: 100 du: mg rt: Intravenous Push id: Folate el: 200 cu: CCU cg: RN io: D5/.45NS 1000.0ml IV Infusions am: 1 du: mg rt: Intravenous Push
io: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ra: 250 ru: ml/hr
t0: [04:00:00 28/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: -1 ai: 107 vo: 0 st: D/C'd
id: D5/.45NS el: 2 cu: CCU cg: RN io: D5/.45NS 1000.0ml IV Infusions vo: 1000 du: ml rt: Intravenous Infusion
t0: [20:00:00 27/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [20:00:00 27/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [20:00:00 27/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: No/Hemodyn Issue st: NotStopd t0: [20:00:00 27/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [20:00:00 27/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [20:00:00 27/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [00:00:00 28/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [00:00:00 28/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [00:00:00 28/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: No/Hemodyn Issue st: NotStopd t0: [00:00:00 28/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [00:00:00 28/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [00:00:00 28/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [03:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [03:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [03:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [03:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [03:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 140 u1: mmHg v2: 71 u2: mmHg st: NotStopd t0: [03:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 96 u1: mmHg st: NotStopd t0: [03:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [03:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 13 u1: BPM st: NotStopd t0: [03:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [03:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [04:00:00 28/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [04:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [04:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [04:00:00 28/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [04:00:00 28/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: Normal activity st: NotStopd t0: [04:00:00 28/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: No anxiety st: NotStopd t0: [04:00:00 28/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: No/Hemodyn Issue st: NotStopd t0: [04:00:00 28/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [04:00:00 28/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: No sweat visible st: NotStopd t0: [04:00:00 28/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [04:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 87 u1: BPM st: NotStopd t0: [04:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 135 u1: mmHg v2: 67 u2: mmHg st: NotStopd t0: [04:00:00 28/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [04:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 91 u1: mmHg st: NotStopd t0: [04:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [04:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [04:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:00:00 28/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vu: ml t0: [01:00:00 28/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 10 vu: ml st: Stopped t0: [02:00:00 28/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vu: ml t0: [03:00:00 28/10/2016] tf: [06:00:00 28/10/2016] dt: 180 id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 0 vu: ml nb: 1 t0: [03:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 250 vu: ml t0: [04:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 250 vu: ml t0: [04:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 200 vu: ml
t0: [03:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 85 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [04:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 85 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [04:00:00 28/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [04:00:00 28/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [04:00:00 28/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.6 u1: torr st: NotStopd t0: [04:00:00 28/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [04:00:00 28/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [04:00:00 28/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [04:00:00 28/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [04:00:00 28/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [04:00:00 28/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [04:00:00 28/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 5 st: NotStopd t0: [04:00:00 28/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 11 u1: cmH2O st: NotStopd t0: [04:00:00 28/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 10.9 u1: L/min st: NotStopd t0: [04:00:00 28/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [04:00:00 28/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 15 u1: . st: NotStopd t0: [04:00:00 28/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 15 u1: BPM st: NotStopd t0: [04:00:00 28/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [04:00:00 28/10/2016] id: Spon RR (Mech.) el: 0 cu: CCU cg: RRT v1: 52 u1: BPM st: NotStopd t0: [04:00:00 28/10/2016] id: Spon. Vt (L) (Mech.) el: 0 cu: CCU cg: RRT v1: 0.214 u1: L st: NotStopd t0: [04:00:00 28/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 726 u1: ml/B st: NotStopd t0: [04:00:00 28/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [04:00:00 28/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [04:00:00 28/10/2016] id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 5 vu: ml t0: [04:00:00 28/10/2016] id: Chest Tubes Right Pleural 2 el: 1 cu: CCU cg: RN vo: 5 vu: ml
t0: [00:00:00 28/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 90 vu: ml
t0: [04:58:00 28/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 147 rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 29 rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 45 u1: mmHg rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 110 u1: mmHg rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 147 rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: SaO2 ABG's el: 0 cu: CCU cg: 140 v1: 97 u1: % rs: Final st: NotStopd
t0: [04:45:00 28/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 8.2 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: WBC Hematology el: 0 cu: CCU cg: 140 v1: 8.2 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 36.1 u1: % rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 12.4 u1: gm/dl rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Platelets Hematology el: 0 cu: CCU cg: 140 v1: 170 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: RBC Hematology el: 0 cu: CCU cg: 140 v1: 3.8 u1: /mic l rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 8.2 rs: Final st: NotStopd t0: [04:58:00 28/10/2016] id: CaO2 el: 0 cu: CCU cg: 140 v1: 16.4585 u1: ml/dl st: NotStopd
t0: [00:00:00 28/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [02:00:00 28/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Not Done st: NotStopd t0: [02:00:00 28/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [02:00:00 28/10/2016] id: Right Carotid Site el: 0 cu: CCU cg: RN v1: Hem/Sft t0: [02:00:00 28/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Not Done st: NotStopd t0: [02:00:00 28/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [02:00:00 28/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Not Done st: NotStopd t0: [02:00:00 28/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [02:00:00 28/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [02:00:00 28/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [02:00:00 28/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [03:00:00 28/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: Reverse T-Berg st: NotStopd t0: [03:00:00 28/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [03:00:00 28/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Good st: NotStopd t0: [03:00:00 28/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [03:00:00 28/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [03:00:00 28/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 1 Person Assist st: NotStopd t0: [03:00:00 28/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [04:00:00 28/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Changed st: NotStopd t0: [04:00:00 28/10/2016] id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Negative st: NotStopd t0: [04:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [04:00:00 28/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [04:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [04:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [04:00:00 28/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [04:00:00 28/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [04:00:00 28/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [04:00:00 28/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [04:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [04:00:00 28/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [04:00:00 28/10/2016] id: Right Carotid Site el: 0 cu: CCU cg: RN v1: Hem/Sft t0: [04:00:00 28/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [04:00:00 28/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [04:00:00 28/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 7 u1: points st: NotStopd t0: [04:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [04:00:00 28/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [04:00:00 28/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [04:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [04:00:00 28/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [04:00:00 28/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [04:00:00 28/10/2016] id: ImpSkin Character #1 el: 0 cu: CCU cg: RN v1: Hematoma st: NotStopd t0: [04:00:00 28/10/2016] id: ImpSkin Drain/Amt#1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 28/10/2016] id: ImpSkin Treatment #1 el: 0 cu: CCU cg: RN v1: Open to Air st: NotStopd t0: [04:00:00 28/10/2016] id: ImpSkin Wound Base#1 el: 0 cu: CCU cg: RN v1: Purple st: NotStopd t0: [04:00:00 28/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Right st: NotStopd t0: [04:00:00 28/10/2016] id: Inc Cleansing #1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [04:00:00 28/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [04:00:00 28/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 28/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [04:00:00 28/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [04:00:00 28/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [04:00:00 28/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Stimul st: NotStopd t0: [04:00:00 28/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 4 Flex-withdraws st: NotStopd t0: [04:00:00 28/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [04:00:00 28/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [04:00:00 28/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [04:00:00 28/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [04:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [04:00:00 28/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [04:00:00 28/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [04:00:00 28/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [04:00:00 28/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [04:00:00 28/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [04:00:00 28/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [04:00:00 28/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [04:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [04:00:00 28/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Nail Bed v2: Withdraws st: NotStopd t0: [04:00:00 28/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [04:00:00 28/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [04:00:00 28/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [04:00:00 28/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 28/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [04:00:00 28/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [04:00:00 28/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [04:00:00 28/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Nonpurposeful st: NotStopd t0: [04:00:00 28/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 28/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [04:00:00 28/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.1667 u1: Deg. C st: NotStopd t0: [04:00:00 28/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.7 u1: Deg. F st: NotStopd t0: [04:00:00 28/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [04:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [04:00:00 28/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [04:00:00 28/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [04:00:00 28/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [04:00:00 28/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Sanguinous st: NotStopd t0: [04:00:00 28/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Changed st: NotStopd t0: [04:00:00 28/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [04:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [04:00:00 28/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [04:00:00 28/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [05:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [05:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [05:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [05:00:00 28/10/2016] id: Eye Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [05:00:00 28/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: Reverse T-Berg st: NotStopd t0: [05:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [05:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [05:00:00 28/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [05:00:00 28/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Good st: NotStopd t0: [05:00:00 28/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [05:00:00 28/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [05:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 139 u1: mmHg v2: 67 u2: mmHg st: NotStopd t0: [05:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 91 u1: mmHg st: NotStopd t0: [05:00:00 28/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [05:00:00 28/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [05:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [05:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [05:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [05:00:00 28/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thick st: NotStopd t0: [05:00:00 28/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Scant st: NotStopd t0: [05:00:00 28/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [05:00:00 28/10/2016] id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [05:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [04:00:00 28/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 100 vu: ml t0: [05:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 250 vu: ml
t0: [05:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 85 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [04:45:00 28/10/2016] id: PT el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: INR Coags el: 0 cu: CCU cg: 140 v1: 1.1 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: PTT Coags el: 0 cu: CCU cg: 140 v1: 25.1 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: INR (2-4 ref. range) Coags el: 0 cu: CCU cg: 140 v1: 1.1 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: PT(11-13.5) Coags el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: PTT(22-35) Coags el: 0 cu: CCU cg: 140 v1: 25.1 rs: Final st: NotStopd
t0: [04:00:00 28/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [04:00:00 28/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [04:00:00 28/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [04:00:00 28/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [04:00:00 28/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [04:00:00 28/10/2016] id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [04:00:00 28/10/2016] id: INV#1 WaveformAppear el: 0 cu: CCU cg: RN v1: Sharp st: NotStopd t0: [04:00:00 28/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [04:00:00 28/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [04:00:00 28/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd
t0: [22:00:00 27/10/2016] id: ETT Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [06:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [06:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [06:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [06:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [06:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 122 u1: mmHg v2: 63 u2: mmHg st: NotStopd t0: [06:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 82 u1: mmHg st: NotStopd t0: [06:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [06:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 10 u1: BPM st: NotStopd t0: [06:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [06:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [06:00:00 28/10/2016] id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 5 vu: ml t0: [06:00:00 28/10/2016] id: Chest Tubes Right Pleural 2 el: 1 cu: CCU cg: RN vo: 3 vu: ml t0: [06:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 160 vu: ml
t0: [06:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 85 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [04:45:00 28/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 9 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 8.4 u1: mg/dl rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 105 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.5 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 138 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 1.7 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 2.6 u1: mEq/L rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 3.6 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 136 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: BUN (6-20) Chemistry el: 0 cu: CCU cg: 140 v1: 9 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 8.4 u1: mg/dl rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 28 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 105 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.5 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 138 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 1.7 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 2.6 u1: mEq/L rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 3.6 rs: Final st: NotStopd t0: [04:45:00 28/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 136 rs: Final st: NotStopd
t0: [06:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml nb: 1 t0: [06:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 250 vu: ml st: Stopped
t0: [06:00:00 28/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 140 vu: ml
t0: [01:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [02:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [03:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [04:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [05:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [06:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml
t0: [00:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 4.69 vu: ml st: Restart
t0: [00:00:00 28/10/2016] id: Neosynephrine-k el: 1 cu: CCU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip st: Stopped
tf: [07:00:00 29/10/2016] pt: IV Piggyback rt: IV fr: ONCE fs: 8 dn: 1 m1: Potassium Chloride v1: 40 u1: mEq m2: SW v2: 100 u2: ml tf: [07:00:00 29/10/2016] pt: Unit Dose rt: IV fr: ONCE fs: 8 dn: 1 m1: Magnesium Sulfate v1: 2 u1: gm
t0: [08:00:00 28/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 28/10/2016] id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [08:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [08:00:00 28/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 28/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [08:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [08:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [08:00:00 28/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [08:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [08:00:00 28/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [08:00:00 28/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [08:00:00 28/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [08:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [08:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 28/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [08:00:00 28/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 28/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 7 u1: points st: NotStopd t0: [08:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [08:00:00 28/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [08:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [08:00:00 28/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [08:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 79 u1: BPM st: NotStopd t0: [08:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:00:00 28/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [08:00:00 28/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [08:00:00 28/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [08:00:00 28/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [08:00:00 28/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [08:00:00 28/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [08:00:00 28/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [08:00:00 28/10/2016] id: ImpSkin Character #1 el: 0 cu: CCU cg: RN v1: Hematoma st: NotStopd t0: [08:00:00 28/10/2016] id: ImpSkin Drain/Amt#1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 28/10/2016] id: ImpSkin Treatment #1 el: 0 cu: CCU cg: RN v1: Open to Air st: NotStopd t0: [08:00:00 28/10/2016] id: ImpSkin Wound Base#1 el: 0 cu: CCU cg: RN v1: Purple st: NotStopd t0: [08:00:00 28/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Right st: NotStopd t0: [08:00:00 28/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [08:00:00 28/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 28/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [08:00:00 28/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 28/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 28/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Stimul st: NotStopd t0: [08:00:00 28/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 4 Flex-withdraws st: NotStopd t0: [08:00:00 28/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [08:00:00 28/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [08:00:00 28/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 125 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [08:00:00 28/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [08:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 89 u1: mmHg st: NotStopd t0: [08:00:00 28/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [08:00:00 28/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 28/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [08:00:00 28/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [08:00:00 28/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 28/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [08:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [08:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [08:00:00 28/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [08:00:00 28/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [08:00:00 28/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [08:00:00 28/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 28/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [08:00:00 28/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [08:00:00 28/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [08:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [08:00:00 28/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Nonpurposeful st: NotStopd t0: [08:00:00 28/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thick st: NotStopd t0: [08:00:00 28/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Scant st: NotStopd t0: [08:00:00 28/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 28/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [08:00:00 28/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.2222 u1: Deg. C st: NotStopd t0: [08:00:00 28/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.8 u1: Deg. F st: NotStopd t0: [08:00:00 28/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [08:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 28/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [08:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [08:00:00 28/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [08:00:00 28/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [08:00:00 28/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [08:00:00 28/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [08:00:00 28/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [08:00:00 28/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [08:00:00 28/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 12 u1: number st: NotStopd t0: [08:00:00 28/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [08:00:00 28/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [08:00:00 28/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [08:00:00 28/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 28/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [08:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [08:00:00 28/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [08:00:00 28/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [08:00:00 28/10/2016] tf: [12:00:00 28/10/2016] dt: 240 id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [08:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [08:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 100 vu: ml
t0: [08:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 85 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [09:00:00 28/10/2016] id: RSBI (<100) el: 0 cu: CCU cg: RT v1: 146.667 u1: units st: NotStopd t0: [09:00:00 28/10/2016] id: RSBI (<200) el: 0 cu: CCU cg: RT v1: 146.667 u1: units st: NotStopd t0: [09:00:00 28/10/2016] id: Spon RR (Mech.) el: 0 cu: CCU cg: RT v1: 44 u1: BPM st: NotStopd t0: [09:00:00 28/10/2016] id: Spon. Vt (L) (Mech.) el: 0 cu: CCU cg: RT v1: 0.3 u1: L st: NotStopd
tf: [10:00:00 28/10/2016] pt: IV Large Volume rt: IV fr: ASDIR m1: Folic Acid v1: 1 u1: mg m2: NS v2: 1000 u2: ml m3: Multivitamin 12 v3: 10 u3: ml m4: Thiamine HCl v4: 100
t0: [08:00:00 28/10/2016] id: Radiologic Study el: 0 cu: CCU cg: RN v1: Chest Xray st: NotStopd t0: [08:45:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [08:45:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [08:45:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:45:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:45:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [08:45:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:45:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 130 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [08:45:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 89 u1: mmHg st: NotStopd t0: [08:45:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [08:45:00 28/10/2016] id: Procedures el: 0 cu: CCU cg: RN v1: EEG st: NotStopd t0: [08:45:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 10 u1: BPM st: NotStopd t0: [08:45:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [08:45:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [09:00:00 28/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [09:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [09:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [09:00:00 28/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [09:00:00 28/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: Yes st: NotStopd t0: [09:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [09:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [09:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 70 u2: mmHg st: NotStopd t0: [09:00:00 28/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [09:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 93 u1: mmHg st: NotStopd t0: [09:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [09:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [09:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [09:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [08:45:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 0 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [09:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 70 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [09:00:00 28/10/2016] id: high MV el: 0 cu: CCU cg: RT v1: 20 t0: [09:00:00 28/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RT v1: 21cm v2: Lip st: NotStopd t0: [09:00:00 28/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RT v1: 0.6 u1: torr st: NotStopd t0: [09:00:00 28/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RT v1: 40 u1: cmH2O st: NotStopd t0: [09:00:00 28/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RT v1: 35 u1: BPM st: NotStopd t0: [09:00:00 28/10/2016] id: Airway Size el: 0 cu: CCU cg: RT v1: 7.5 mm st: NotStopd t0: [09:00:00 28/10/2016] id: Airway Type el: 0 cu: CCU cg: RT v1: Endotracheal st: NotStopd t0: [09:00:00 28/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RT u1: Deg. C st: NotStopd t0: [09:00:00 28/10/2016] id: Intubation Date el: 0 cu: CCU cg: RT v1: 8 v2: 31 st: NotStopd t0: [09:00:00 28/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RT v1: 4 st: NotStopd t0: [09:00:00 28/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RT v1: 6 v2: Combivent st: NotStopd t0: [09:00:00 28/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RT v1: 11 u1: cmH2O st: NotStopd t0: [09:00:00 28/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RT v1: 7.9 u1: L/min st: NotStopd t0: [09:00:00 28/10/2016] id: PEEP Set el: 0 cu: CCU cg: RT v1: 5 u1: cmH2O st: NotStopd t0: [09:00:00 28/10/2016] id: Pressure Support el: 0 cu: CCU cg: RT v1: 15 u1: . st: NotStopd t0: [09:00:00 28/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RT v1: 8 u1: BPM st: NotStopd t0: [09:00:00 28/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RT v1: 3 u1: cmH2O st: NotStopd t0: [09:00:00 28/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RT v1: 980 u1: ml/B st: NotStopd t0: [09:00:00 28/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RT v1: CPAP+PS st: NotStopd t0: [09:00:00 28/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RT v1: Drager st: NotStopd
t0: [09:30:00 28/10/2016] id: PEEP Set el: 0 cu: CCU cg: RT v1: 3 u1: cmH2O st: NotStopd t0: [09:30:00 28/10/2016] id: Pressure Support el: 0 cu: CCU cg: RT v1: 12 u1: . st: NotStopd
t0: [10:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [10:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [10:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [10:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 125 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [10:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [10:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [10:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [10:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [10:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [10:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [10:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 400 vu: ml
t0: [10:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 70 du: mcgkgmin sv: 50 su: vl rt: IV Drip
tf: [07:00:00 01/11/2016] pt: Unit Dose rt: PO fr: QID fs: 10, 14, 18, 22 dn: 4 m1: Nystatin Oral Suspension v1: 5 u1: ml tf: [18:00:00 03/11/2016] pt: Unit Dose rt: NG fr: QD fs: 10 dn: 1 m1: Multivitamins v1: 1 u1: CAP tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Folic Acid v1: 1 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Thiamine HCl v1: 100 u1: mg
t0: [10:12:00 28/10/2016] id: Pressure Support el: 0 cu: CCU cg: RT v1: 15 u1: . st: NotStopd
t0: [10:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vu: ml nb: 1
t0: [10:00:00 28/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [10:00:00 28/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [10:00:00 28/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Good st: NotStopd t0: [10:00:00 28/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 28/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [10:00:00 28/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [10:00:00 28/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [10:00:00 28/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [10:00:00 28/10/2016] id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [11:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [11:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [11:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 63 u1: BPM st: NotStopd t0: [11:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [11:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 120 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [11:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 79 u1: mmHg st: NotStopd t0: [11:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [11:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 10 u1: BPM st: NotStopd t0: [11:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [11:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:00:00 28/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 100 vu: ml t0: [11:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [11:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 300 vu: ml
t0: [11:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 70 du: mcgkgmin sv: 50 su: vl rt: IV Drip
tf: [00:00:00 30/10/2016] pt: IV Piggyback rt: IV DRIP fr: INFUSION m1: Fentanyl Citrate v1: 2500 u1: mcg m2: D5W v2: 250 u2: ml tf: [18:00:00 03/11/2016] pt: Unit Dose rt: SC fr: Q8H fs: 11, 19, 3 dn: 3 m1: Heparin v1: 5000 u1: UNIT
id: Fentanyl el: 100 cu: CCU cg: RN io: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions am: 2500 du: mcghr rt: IV Drip
io: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ra: 2.5 ru: ml/hr
id: .9% Normal Saline el: 1 cu: CCU cg: RN io: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions vo: 250 du: ml rt: Intravenous Push
t0: [12:03:00 28/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd t0: [12:03:00 28/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 3 rs: Final st: NotStopd t0: [12:03:00 28/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 31 rs: Final st: NotStopd t0: [12:03:00 28/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 48 u1: mmHg rs: Final st: NotStopd t0: [12:03:00 28/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 118 u1: mmHg rs: Final st: NotStopd t0: [12:03:00 28/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd
t0: [12:00:00 28/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [12:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [12:00:00 28/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Sedated st: NotStopd t0: [12:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [12:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 127 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [12:00:00 28/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [12:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 82 u1: mmHg st: NotStopd t0: [12:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [12:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 11 u1: BPM st: NotStopd t0: [12:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [12:00:00 28/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [12:00:00 28/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.4444 u1: Deg. C st: NotStopd t0: [12:00:00 28/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 101.2 u1: Deg. F st: NotStopd t0: [12:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [11:00:00 28/10/2016] tf: [17:00:00 28/10/2016] dt: 360 id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vu: ml nb: 1 t0: [11:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vu: ml t0: [11:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 200 vu: ml
t0: [12:00:00 28/10/2016] tf: [13:44:00 31/10/2016] dt: 4424 id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [12:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [10:00:00 28/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 28/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [10:00:00 28/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Right st: NotStopd t0: [10:00:00 28/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [10:00:00 28/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 28/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [10:00:00 28/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 28/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [10:00:00 28/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [10:00:00 28/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [10:00:00 28/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [10:00:00 28/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 28/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [12:00:00 28/10/2016] id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [12:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [12:00:00 28/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [12:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [12:00:00 28/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [12:00:00 28/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [12:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [12:00:00 28/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [12:00:00 28/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 28/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 7 u1: points st: NotStopd t0: [12:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [12:00:00 28/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Feeding st: NotStopd t0: [12:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [12:00:00 28/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [12:00:00 28/10/2016] id: ImpSkin Character #1 el: 0 cu: CCU cg: RN v1: Hematoma st: NotStopd t0: [12:00:00 28/10/2016] id: ImpSkin Drain/Amt#1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 28/10/2016] id: ImpSkin Wound Base#1 el: 0 cu: CCU cg: RN v1: Purple st: NotStopd t0: [12:00:00 28/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Right st: NotStopd t0: [12:00:00 28/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [12:00:00 28/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Stimul st: NotStopd t0: [12:00:00 28/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 4 Flex-withdraws st: NotStopd t0: [12:00:00 28/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [12:00:00 28/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [12:00:00 28/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [12:00:00 28/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 28/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [12:00:00 28/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [12:00:00 28/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [12:00:00 28/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [12:00:00 28/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: RestraintReapply st: NotStopd t0: [12:00:00 28/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 28/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [12:00:00 28/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [12:00:00 28/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [12:00:00 28/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Nonpurposeful st: NotStopd t0: [12:00:00 28/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 28/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [12:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [12:00:00 28/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [12:00:00 28/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Hypoactive st: NotStopd t0: [12:00:00 28/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [12:00:00 28/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [12:00:00 28/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [12:00:00 28/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [12:00:00 28/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [12:00:00 28/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 12 u1: number st: NotStopd t0: [12:00:00 28/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [12:00:00 28/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [12:00:00 28/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [12:00:00 28/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [12:00:00 28/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Negative st: NotStopd t0: [12:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [12:00:00 28/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [12:00:00 28/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [12:00:00 28/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 120 vu: ml t0: [12:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [12:00:00 28/10/2016] tf: [16:00:00 29/10/2016] dt: 1680 id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 20 vu: ml t0: [12:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 260 vu: ml
t0: [12:00:00 28/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 350 vu: ml
t0: [12:35:00 28/10/2016] id: high MV el: 0 cu: CCU cg: RT v1: 20 t0: [12:35:00 28/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RT v1: 21cm v2: Lip st: NotStopd t0: [12:35:00 28/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RT v1: 0.5 u1: torr st: NotStopd t0: [12:35:00 28/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RT v1: 40 u1: cmH2O st: NotStopd t0: [12:35:00 28/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RT v1: 35 u1: BPM st: NotStopd t0: [12:35:00 28/10/2016] id: Airway Size el: 0 cu: CCU cg: RT v1: 7.5 mm st: NotStopd t0: [12:35:00 28/10/2016] id: Airway Type el: 0 cu: CCU cg: RT v1: Endotracheal st: NotStopd t0: [12:35:00 28/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RT u1: Deg. C st: NotStopd t0: [12:35:00 28/10/2016] id: Intubation Date el: 0 cu: CCU cg: RT v1: 8 v2: 31 st: NotStopd t0: [12:35:00 28/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RT v1: 4 st: NotStopd t0: [12:35:00 28/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RT v1: 6 v2: Combivent st: NotStopd t0: [12:35:00 28/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RT v1: 8 u1: cmH2O st: NotStopd t0: [12:35:00 28/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RT v1: 9.2 u1: L/min st: NotStopd t0: [12:35:00 28/10/2016] id: PEEP Set el: 0 cu: CCU cg: RT v1: 3 u1: cmH2O st: NotStopd t0: [12:35:00 28/10/2016] id: Pressure Support el: 0 cu: CCU cg: RT v1: 15 u1: . st: NotStopd t0: [12:35:00 28/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RT v1: 11 u1: BPM st: NotStopd t0: [12:35:00 28/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RT v1: 3 u1: cmH2O st: NotStopd t0: [12:35:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RT v1: 95 u1: % st: NotStopd t0: [12:35:00 28/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RT v1: 850 u1: ml/B st: NotStopd t0: [12:35:00 28/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RT v1: CPAP+PS st: NotStopd t0: [12:35:00 28/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RT v1: Drager st: NotStopd
t0: [12:30:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [12:30:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [12:30:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:30:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:30:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 80 u1: BPM st: NotStopd t0: [12:30:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:30:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 129 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [12:30:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 86 u1: mmHg st: NotStopd t0: [12:30:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [12:30:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [12:30:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [12:30:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [13:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [13:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [13:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [13:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 127 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [13:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 80 u1: mmHg st: NotStopd t0: [13:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [13:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [13:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [13:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [13:15:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [13:15:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [13:15:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:15:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:15:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 87 u1: BPM st: NotStopd t0: [13:15:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:15:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 144 u1: mmHg v2: 73 u2: mmHg st: NotStopd t0: [13:15:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 97 u1: mmHg st: NotStopd t0: [13:15:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [13:15:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 21 u1: BPM st: NotStopd t0: [13:15:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [13:15:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [12:30:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [12:30:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 60 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [13:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [13:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 55 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [13:15:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [13:15:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 55 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:30:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [13:30:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [13:30:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:30:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:30:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [13:30:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:30:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 84 u1: mmHg v2: 47 u2: mmHg st: NotStopd t0: [13:30:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 58 u1: mmHg st: NotStopd t0: [13:30:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [13:30:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 10 u1: BPM st: NotStopd t0: [13:30:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 90 u1: % st: NotStopd t0: [13:30:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:30:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [13:30:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 15 vu: ml t0: [13:30:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 160 vu: ml
t0: [13:30:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [13:30:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 55 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:37:00 28/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd t0: [13:37:00 28/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 2 rs: Final st: NotStopd t0: [13:37:00 28/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 30 rs: Final st: NotStopd t0: [13:37:00 28/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 47 u1: mmHg rs: Final st: NotStopd t0: [13:37:00 28/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 78 u1: mmHg rs: Final st: NotStopd t0: [13:37:00 28/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.4 rs: Final st: NotStopd
t0: [03:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [03:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [03:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [03:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [03:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [03:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [03:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [03:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [03:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [05:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [05:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [05:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [05:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NPO st: NotStopd t0: [05:00:00 28/10/2016] id: Right Carotid Site el: 0 cu: CCU cg: RN t0: [05:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [05:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [05:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [05:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [05:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [12:00:00 28/10/2016] id: Right Carotid Site el: 0 cu: CCU cg: RN v1: hem/sft t0: [13:30:00 28/10/2016] id: Eye Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [13:30:00 28/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [13:30:00 28/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [13:30:00 28/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [13:30:00 28/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [13:30:00 28/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [13:30:00 28/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [13:30:00 28/10/2016] id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [13:30:00 28/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [13:30:00 28/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [13:30:00 28/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [13:30:00 28/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [13:30:00 28/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Good st: NotStopd t0: [13:30:00 28/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [13:30:00 28/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [13:30:00 28/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [13:30:00 28/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [13:30:00 28/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Right Side st: NotStopd t0: [13:30:00 28/10/2016] id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [14:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [14:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [14:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 79 u1: BPM st: NotStopd t0: [14:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [14:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 105 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [14:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 72 u1: mmHg st: NotStopd t0: [14:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [14:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [14:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 92 u1: % st: NotStopd t0: [14:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip
t0: [12:00:00 28/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 28/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 28/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 28/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [14:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [14:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [14:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [14:00:00 28/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [14:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [14:00:00 28/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 2 To pain st: NotStopd t0: [14:00:00 28/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [14:00:00 28/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 8 u1: points st: NotStopd t0: [14:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [14:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [14:00:00 28/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [14:00:00 28/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [14:00:00 28/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [14:00:00 28/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [14:00:00 28/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [14:00:00 28/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [14:00:00 28/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [14:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [14:00:00 28/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Sternal Rub v2: Localizes st: NotStopd t0: [14:00:00 28/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 28/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Nonpurposeful st: NotStopd t0: [14:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [14:00:00 28/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [14:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd
t0: [14:00:00 28/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [14:00:00 28/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd
t0: [12:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [12:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 200 vu: ml t0: [13:30:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 200 vu: ml t0: [13:30:00 28/10/2016] id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 0 vu: ml t0: [13:30:00 28/10/2016] id: Chest Tubes Right Pleural 2 el: 1 cu: CCU cg: RN vo: 19 vu: ml t0: [14:00:00 28/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 5 vu: ml t0: [14:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [14:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [14:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 5 vu: ml
t0: [14:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 75 vu: ml
t0: [14:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [14:00:00 28/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [14:00:00 28/10/2016] id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [14:00:00 28/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [14:00:00 28/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [14:00:00 28/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [14:00:00 28/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Negative st: NotStopd t0: [14:00:00 28/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [14:00:00 28/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [15:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [15:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [15:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [15:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [15:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 142 u1: mmHg v2: 73 u2: mmHg st: NotStopd t0: [15:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 97 u1: mmHg st: NotStopd t0: [15:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [15:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 13 u1: BPM st: NotStopd t0: [15:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [15:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [15:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [15:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 250 vu: ml t0: [15:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [15:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 20 vu: ml
t0: [15:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [15:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:00:00 28/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [16:00:00 28/10/2016] id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [16:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [16:00:00 28/10/2016] id: Less Restrict Meas. el: 0 cu: CCU cg: RN v1: Medicated st: NotStopd t0: [16:00:00 28/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [16:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [16:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [16:00:00 28/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [16:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [16:00:00 28/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 28/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: H2 Blocker st: NotStopd t0: [16:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [16:00:00 28/10/2016] id: Dorsal PedPulse R/L el: 0 cu: CCU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [16:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 28/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [16:00:00 28/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [16:00:00 28/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [16:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [16:00:00 28/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 28/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Feeding st: NotStopd t0: [16:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [16:00:00 28/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 28/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [16:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [16:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:00:00 28/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [16:00:00 28/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [16:00:00 28/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [16:00:00 28/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [16:00:00 28/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [16:00:00 28/10/2016] id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [16:00:00 28/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [16:00:00 28/10/2016] id: INV#1 WaveformAppear el: 0 cu: CCU cg: RN v1: Sharp st: NotStopd t0: [16:00:00 28/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [16:00:00 28/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [16:00:00 28/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [16:00:00 28/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [16:00:00 28/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [16:00:00 28/10/2016] id: ImpSkin Character #1 el: 0 cu: CCU cg: RN v1: Hematoma st: NotStopd t0: [16:00:00 28/10/2016] id: ImpSkin Drain/Amt#1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 28/10/2016] id: ImpSkin Wound Base#1 el: 0 cu: CCU cg: RN v1: Purple st: NotStopd t0: [16:00:00 28/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Right st: NotStopd t0: [16:00:00 28/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [16:00:00 28/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 28/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [16:00:00 28/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [16:00:00 28/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [16:00:00 28/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [16:00:00 28/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [16:00:00 28/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [16:00:00 28/10/2016] id: AntiEmbDevice/Status el: 0 cu: CCU cg: RN v1: Compress Sleeves v2: On st: NotStopd t0: [16:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 144 u1: mmHg v2: 76 u2: mmHg st: NotStopd t0: [16:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 100 u1: mmHg st: NotStopd t0: [16:00:00 28/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [16:00:00 28/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 28/10/2016] id: PostTib. Pulses R/L el: 0 cu: CCU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [16:00:00 28/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [16:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [16:00:00 28/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [16:00:00 28/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [16:00:00 28/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [16:00:00 28/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [16:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [16:00:00 28/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [16:00:00 28/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [16:00:00 28/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [16:00:00 28/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [16:00:00 28/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 28/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [16:00:00 28/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [16:00:00 28/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [16:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 97 u1: % st: NotStopd t0: [16:00:00 28/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 28/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [16:00:00 28/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.5 u1: Deg. C st: NotStopd t0: [16:00:00 28/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 99.5 u1: Deg. F st: NotStopd t0: [16:00:00 28/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [16:00:00 28/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [16:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [16:00:00 28/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [16:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [16:00:00 28/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [16:00:00 28/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [16:00:00 28/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [16:00:00 28/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [16:00:00 28/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Occ. Moist st: NotStopd t0: [16:00:00 28/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [16:00:00 28/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 12 u1: number st: NotStopd t0: [16:00:00 28/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [16:00:00 28/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [16:00:00 28/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [16:00:00 28/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [16:00:00 28/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Negative st: NotStopd t0: [16:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [16:00:00 28/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [16:00:00 28/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [16:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [16:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vo: 250 vu: ml t0: [16:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [16:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 20 vu: ml t0: [16:00:00 28/10/2016] id: Gastric Nasogastric el: 1 cu: CCU cg: RN vo: 0 vu: ml t0: [16:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 400 vu: ml
t0: [16:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [16:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [10:45:00 23/10/2016] tf: [13:44:00 31/10/2016] dt: 11699 id: Dilantin Drug Level el: 0 cu: CCU cg: 140 v1: <0.6* rs: Final st: NotStopd
t0: [16:05:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [16:05:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [16:05:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:05:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:05:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [16:05:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:05:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 124 u1: mmHg v2: 66 u2: mmHg st: NotStopd t0: [16:05:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 86 u1: mmHg st: NotStopd t0: [16:05:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [16:05:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 10 u1: BPM st: NotStopd t0: [16:05:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [16:05:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [16:15:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [16:15:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [16:15:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:15:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:15:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [16:15:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:15:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 124 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [16:15:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [16:15:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [16:15:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [16:15:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [16:15:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [16:40:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [16:40:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [16:40:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:40:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:40:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [16:40:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:40:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 106 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [16:40:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [16:40:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [16:40:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [16:40:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 92 u1: % st: NotStopd t0: [16:40:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:05:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [16:05:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [16:15:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [16:15:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [16:40:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [16:40:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [17:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [17:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [17:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [17:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [17:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 135 u1: mmHg v2: 63 u2: mmHg st: NotStopd t0: [17:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 86 u1: mmHg st: NotStopd t0: [17:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [17:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 31 u1: BPM st: NotStopd t0: [17:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [17:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [17:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [17:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [17:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [17:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml
t0: [17:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [17:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:00:00 28/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Bronchial st: NotStopd t0: [16:00:00 28/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [16:00:00 28/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Bronchial st: NotStopd t0: [16:00:00 28/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd
t0: [17:00:00 28/10/2016] id: high MV el: 0 cu: CCU cg: RT v1: 20 t0: [17:00:00 28/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RT v1: 21cm v2: Lip st: NotStopd t0: [17:00:00 28/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RT v1: 0.5 u1: torr st: NotStopd t0: [17:00:00 28/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RT v1: 40 u1: cmH2O st: NotStopd t0: [17:00:00 28/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RT v1: 35 u1: BPM st: NotStopd t0: [17:00:00 28/10/2016] id: Airway Size el: 0 cu: CCU cg: RT v1: 7.5 mm st: NotStopd t0: [17:00:00 28/10/2016] id: Airway Type el: 0 cu: CCU cg: RT v1: Endotracheal st: NotStopd t0: [17:00:00 28/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RT u1: Deg. C st: NotStopd t0: [17:00:00 28/10/2016] id: Intubation Date el: 0 cu: CCU cg: RT v1: 8 v2: 31 st: NotStopd t0: [17:00:00 28/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RT v1: 4 st: NotStopd t0: [17:00:00 28/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RT v1: 6 v2: Combivent st: NotStopd t0: [17:00:00 28/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RT v1: 8 u1: cmH2O st: NotStopd t0: [17:00:00 28/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RT v1: 8.8 u1: L/min st: NotStopd t0: [17:00:00 28/10/2016] id: PEEP Set el: 0 cu: CCU cg: RT v1: 3 u1: cmH2O st: NotStopd t0: [17:00:00 28/10/2016] id: Pressure Support el: 0 cu: CCU cg: RT v1: 15 u1: . st: NotStopd t0: [17:00:00 28/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RT v1: 12 u1: BPM st: NotStopd t0: [17:00:00 28/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RT v1: 3 u1: cmH2O st: NotStopd t0: [17:00:00 28/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RT v1: 740 u1: ml/B st: NotStopd t0: [17:00:00 28/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RT v1: CPAP+PS st: NotStopd t0: [17:00:00 28/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RT v1: Drager st: NotStopd
t0: [18:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [18:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [18:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [18:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [18:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 77 u1: mmHg st: NotStopd t0: [18:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [18:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 11 u1: BPM st: NotStopd t0: [18:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [18:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [18:00:00 28/10/2016] id: Fingerstick Glucose Chemistry el: 0 cu: CCU cg: RN v1: 91 rs: Manual st: NotStopd
t0: [18:00:00 28/10/2016] tf: [12:01:00 29/10/2016] dt: 1081 id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [18:00:00 28/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 120 vu: ml t0: [18:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [18:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [18:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 280 vu: ml
t0: [18:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 28/10/2016] dt: 24 id: PO/Gastric In Total el: 1 cu: CCU cg: RN cv: 470 ap: none
t0: [18:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip
t0: [16:25:00 28/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thick st: NotStopd t0: [16:25:00 28/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd t0: [19:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [19:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [19:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 149 u1: mmHg v2: 75 u2: mmHg st: NotStopd t0: [19:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 100 u1: mmHg st: NotStopd t0: [19:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [19:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [19:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [19:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [19:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [19:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [19:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 380 vu: ml
t0: [19:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [19:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [19:00:00 28/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [19:00:00 28/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [19:00:00 28/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [19:00:00 28/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [19:00:00 28/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [19:00:00 28/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [19:00:00 28/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [19:00:00 28/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [19:00:00 28/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [19:00:00 28/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 4 st: NotStopd t0: [19:00:00 28/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [19:00:00 28/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 7 u1: cmH2O st: NotStopd t0: [19:00:00 28/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 8.7 u1: L/min st: NotStopd t0: [19:00:00 28/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [19:00:00 28/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 15 u1: . st: NotStopd t0: [19:00:00 28/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [19:00:00 28/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [19:00:00 28/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 885 u1: ml/B st: NotStopd t0: [19:00:00 28/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [19:00:00 28/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [20:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [20:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [20:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [20:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 121 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [20:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 78 u1: mmHg st: NotStopd t0: [20:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [20:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [20:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [20:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:00:00 28/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [19:00:00 28/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [19:00:00 28/10/2016] id: Gastric Nasogastric el: 1 cu: CCU cg: RN vo: 0 vu: ml t0: [20:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [20:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [20:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [20:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 180 vu: ml
t0: [20:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [20:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 28/10/2016] dt: 24 id: Gastric Out Total el: 1 cu: CCU cg: RN cv: 0 ap: none
t0: [21:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [21:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [21:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [21:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [21:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 109 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [21:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 75 u1: mmHg st: NotStopd t0: [21:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [21:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [21:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 92 u1: % st: NotStopd t0: [21:00:00 28/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [21:00:00 28/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.8889 u1: Deg. C st: NotStopd t0: [21:00:00 28/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.2 u1: Deg. F st: NotStopd t0: [21:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [21:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [21:00:00 28/10/2016] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml t0: [21:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [21:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 320 vu: ml
t0: [21:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [21:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [21:43:00 28/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.44 rs: Final st: NotStopd t0: [21:43:00 28/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 4 rs: Final st: NotStopd t0: [21:43:00 28/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 30 rs: Final st: NotStopd t0: [21:43:00 28/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 43 u1: mmHg rs: Final st: NotStopd t0: [21:43:00 28/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 67 u1: mmHg rs: Final st: NotStopd t0: [21:43:00 28/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.44 rs: Final st: NotStopd
t0: [20:00:00 28/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [20:00:00 28/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [20:00:00 28/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [20:00:00 28/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [20:00:00 28/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [20:00:00 28/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [20:00:00 28/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [20:00:00 28/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 11 u1: points st: NotStopd t0: [20:00:00 28/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [20:00:00 28/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [20:00:00 28/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [20:00:00 28/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [20:00:00 28/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [20:00:00 28/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [20:00:00 28/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [20:00:00 28/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [20:00:00 28/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [20:00:00 28/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [20:00:00 28/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [20:00:00 28/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 28/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [20:00:00 28/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [20:00:00 28/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [21:30:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [21:30:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [21:30:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:30:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:30:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [21:30:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [21:30:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 141 u1: mmHg v2: 76 u2: mmHg st: NotStopd t0: [21:30:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 98 u1: mmHg st: NotStopd t0: [21:30:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [21:30:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [21:30:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [21:30:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [22:00:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [22:00:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [22:00:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 83 u1: BPM st: NotStopd t0: [22:00:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:00:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 112 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [22:00:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 78 u1: mmHg st: NotStopd t0: [22:00:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [22:00:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 11 u1: BPM st: NotStopd t0: [22:00:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [22:00:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 28/10/2016] tf: [06:00:00 30/10/2016] dt: 2460 id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 0 vu: ml nb: 1 t0: [13:00:00 28/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 2.5 vu: ml t0: [16:00:00 28/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 9.375 vu: ml t0: [17:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: RN ai: 498 vu: ml st: Stopped t0: [20:00:00 28/10/2016] tf: [13:00:00 29/10/2016] dt: 1020 id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 15 vu: ml t0: [22:00:00 28/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 50 vu: ml t0: [22:00:00 28/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 25 vu: ml t0: [22:00:00 28/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 30 vu: ml t0: [22:00:00 28/10/2016] id: Chest Tubes Right Pleural 2 el: 1 cu: CCU cg: RN vo: 40 vu: ml t0: [22:00:00 28/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 140 vu: ml
t0: [21:30:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [21:30:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 30 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [22:00:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [22:00:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 30 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 28/10/2016] dt: 24 id: Tube Feeds In Total el: 1 cu: CCU cg: RN cv: 260 ap: none
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: NG fr: BID fs: 10, 22 dn: 2 m1: Docusate Sodium (Liquid) v1: 100 u1: mg
t0: [18:00:00 28/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thin st: NotStopd t0: [18:00:00 28/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd t0: [20:00:00 28/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thin st: NotStopd t0: [20:00:00 28/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd t0: [22:00:00 28/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thin st: NotStopd t0: [22:00:00 28/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd
t0: [22:05:00 28/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [22:05:00 28/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [22:05:00 28/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:05:00 28/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:05:00 28/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [22:05:00 28/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:05:00 28/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 112 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [22:05:00 28/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 77 u1: mmHg st: NotStopd t0: [22:05:00 28/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [22:05:00 28/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [22:05:00 28/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 98 u1: % st: NotStopd t0: [22:05:00 28/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [22:05:00 28/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [22:05:00 28/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:00:00 29/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [00:00:00 29/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [00:00:00 29/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [00:00:00 29/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [00:00:00 29/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [00:00:00 29/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [00:00:00 29/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [00:00:00 29/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [00:00:00 29/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [00:00:00 29/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 4 st: NotStopd t0: [00:00:00 29/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [00:00:00 29/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 7 u1: cmH2O st: NotStopd t0: [00:00:00 29/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 9.2 u1: L/min st: NotStopd t0: [00:00:00 29/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [00:00:00 29/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 15 u1: . st: NotStopd t0: [00:00:00 29/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [00:00:00 29/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [00:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 94 u1: % st: NotStopd t0: [00:00:00 29/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 920 u1: ml/B st: NotStopd t0: [00:00:00 29/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [00:00:00 29/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [00:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [00:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [00:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 89 u1: BPM st: NotStopd t0: [00:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 134 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [00:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [00:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [00:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 23 u1: BPM st: NotStopd t0: [00:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [00:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [00:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:00:00 29/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 250 vu: ml t0: [00:00:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [00:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 10 vu: ml t0: [00:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [00:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 400 vu: ml
t0: [00:00:00 29/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [00:00:00 29/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.7778 u1: Deg. C st: NotStopd t0: [00:00:00 29/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100 u1: Deg. F st: NotStopd t0: [02:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [02:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [02:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [02:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [02:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [02:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 91 u1: mmHg v2: 43 u2: mmHg st: NotStopd t0: [02:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 59 u1: mmHg st: NotStopd t0: [02:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [02:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [02:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [02:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:00:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [02:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 10 vu: ml t0: [02:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [02:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 220 vu: ml
t0: [02:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [02:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 29/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 29/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 29/10/2016] dt: 24 id: IV Infusion In Total el: 1 cu: CCU cg: RN cv: 1847.09 ap: none t0: [23:00:00 29/10/2016] dt: 24 id: 24h Total In el: 1 cu: CCU cg: RN cv: 2777.09 ap: none t0: [23:00:00 29/10/2016] dt: 24 id: Tube Feeds In Total el: 1 cu: CCU cg: RN cv: 810 ap: none t0: [23:00:00 29/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN cv: 4040 ap: none t0: [23:00:00 29/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: RN cv: -1397.91 ap: none t0: [23:00:00 29/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: RN cv: 4175 ap: none t0: [23:00:00 29/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: RN cv: 6504.09 ap: none
t0: [01:00:00 29/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [01:00:00 29/10/2016] id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [01:00:00 29/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [01:00:00 29/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [01:00:00 29/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [01:00:00 29/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [01:00:00 29/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [01:00:00 29/10/2016] id: Eye Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [01:00:00 29/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [01:00:00 29/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [01:00:00 29/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [01:00:00 29/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [01:00:00 29/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [01:00:00 29/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [01:00:00 29/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [01:00:00 29/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [01:00:00 29/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [01:00:00 29/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [01:00:00 29/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [01:00:00 29/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [01:00:00 29/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [01:00:00 29/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [01:00:00 29/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Not Indicated st: NotStopd t0: [01:00:00 29/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [01:00:00 29/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [01:00:00 29/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [01:00:00 29/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [01:00:00 29/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [01:00:00 29/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [01:00:00 29/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [01:00:00 29/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [01:00:00 29/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [01:00:00 29/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [01:00:00 29/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [01:00:00 29/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 29/10/2016] id: Skin Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [01:00:00 29/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [01:00:00 29/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [01:00:00 29/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [01:00:00 29/10/2016] id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [01:00:00 29/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [01:00:00 29/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [01:00:00 29/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [01:00:00 29/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [01:00:00 29/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: RN v1: Positive v2: Positive st: NotStopd t0: [01:00:00 29/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [01:00:00 29/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [01:00:00 29/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [02:00:00 29/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [02:00:00 29/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [02:00:00 29/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [02:00:00 29/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [02:00:00 29/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [02:00:00 29/10/2016] id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [02:00:00 29/10/2016] id: INV#1 WaveformAppear el: 0 cu: CCU cg: RN v1: Sharp st: NotStopd t0: [02:00:00 29/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [02:00:00 29/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [02:00:00 29/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd
t0: [04:00:00 29/10/2016] id: RSBI (<100) el: 0 cu: CCU cg: RRT v1: 64.6552 u1: units st: NotStopd t0: [04:00:00 29/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [04:00:00 29/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [04:00:00 29/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [04:00:00 29/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [04:00:00 29/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [04:00:00 29/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [04:00:00 29/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [04:00:00 29/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [04:00:00 29/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [04:00:00 29/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 4 st: NotStopd t0: [04:00:00 29/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [04:00:00 29/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [04:00:00 29/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 13.3 u1: L/min st: NotStopd t0: [04:00:00 29/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [04:00:00 29/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 15 u1: . st: NotStopd t0: [04:00:00 29/10/2016] id: RSBI (<200) el: 0 cu: CCU cg: RRT v1: 64.6552 u1: units st: NotStopd t0: [04:00:00 29/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 19 u1: BPM st: NotStopd t0: [04:00:00 29/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [04:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RRT v1: 94 u1: % st: NotStopd t0: [04:00:00 29/10/2016] id: Spon RR (Mech.) el: 0 cu: CCU cg: RRT v1: 30 u1: BPM st: NotStopd t0: [04:00:00 29/10/2016] id: Spon. Vt (L) (Mech.) el: 0 cu: CCU cg: RRT v1: 0.464 u1: L st: NotStopd t0: [04:00:00 29/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 620 u1: ml/B st: NotStopd t0: [04:00:00 29/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [04:00:00 29/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [04:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [04:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [04:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [04:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 101 u1: mmHg v2: 46 u2: mmHg st: NotStopd t0: [04:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [04:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [04:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 16 u1: BPM st: NotStopd t0: [04:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [04:00:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [04:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 10 vu: ml t0: [04:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [04:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 240 vu: ml
t0: [04:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [04:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [00:00:00 29/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thin st: NotStopd t0: [00:00:00 29/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd t0: [03:00:00 29/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RN v1: 21cm v2: Lip st: NotStopd t0: [03:00:00 29/10/2016] id: Airway Size el: 0 cu: CCU cg: RN v1: 7.5 mm st: NotStopd t0: [03:00:00 29/10/2016] id: Airway Type el: 0 cu: CCU cg: RN v1: Endotracheal st: NotStopd t0: [03:00:00 29/10/2016] id: Intubation Date el: 0 cu: CCU cg: RN v1: 8 v2: 31 st: NotStopd t0: [03:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [03:00:00 29/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Yellow v2: Thick st: NotStopd t0: [03:00:00 29/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd t0: [03:00:00 29/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RN v1: Drager st: NotStopd
t0: [06:38:00 29/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.39 rs: Final st: NotStopd t0: [06:38:00 29/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 4 rs: Final st: NotStopd t0: [06:38:00 29/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 32 rs: Final st: NotStopd t0: [06:38:00 29/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 51 u1: mmHg rs: Final st: NotStopd t0: [06:38:00 29/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 85 u1: mmHg rs: Final st: NotStopd t0: [06:38:00 29/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.39 rs: Final st: NotStopd
t0: [06:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [06:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [06:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [06:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [06:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 91 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [06:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [06:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [06:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [06:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [06:00:00 29/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [06:00:00 29/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.8889 u1: Deg. C st: NotStopd t0: [06:00:00 29/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.2 u1: Deg. F st: NotStopd t0: [06:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [06:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [06:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [06:00:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [06:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 10 vu: ml t0: [06:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [06:00:00 29/10/2016] id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 10 vu: ml t0: [06:00:00 29/10/2016] id: Chest Tubes Right Pleural 2 el: 1 cu: CCU cg: RN vo: 125 vu: ml t0: [06:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 200 vu: ml
t0: [06:00:00 29/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [06:00:00 29/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [06:00:00 29/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [06:00:00 29/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [06:00:00 29/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [06:00:00 29/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [06:00:00 29/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [06:00:00 29/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [06:00:00 29/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [06:00:00 29/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [06:00:00 29/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [06:00:00 29/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [06:00:00 29/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [06:00:00 29/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [06:00:00 29/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [06:00:00 29/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [06:00:00 29/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [06:00:00 29/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [06:00:00 29/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [06:00:00 29/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [06:00:00 29/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [06:00:00 29/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [06:00:00 29/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 29/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [06:00:00 29/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [06:00:00 29/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd
t0: [06:30:00 29/10/2016] id: PT el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: INR Coags el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: PTT Coags el: 0 cu: CCU cg: 140 v1: 28 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: INR (2-4 ref. range) Coags el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: PT(11-13.5) Coags el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: PTT(22-35) Coags el: 0 cu: CCU cg: 140 v1: 28 rs: Final st: NotStopd
t0: [06:30:00 29/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 6.9 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: WBC Hematology el: 0 cu: CCU cg: 140 v1: 6.9 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 36.6 u1: % rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 12.2 u1: gm/dl rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Platelets Hematology el: 0 cu: CCU cg: 140 v1: 177 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: RBC Hematology el: 0 cu: CCU cg: 140 v1: 3.82 u1: /mic l rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 6.9 rs: Final st: NotStopd t0: [07:21:00 29/10/2016] id: BSA el: 1033 cu: CCU cg: -1 t0: [07:21:00 29/10/2016] id: Admit Wt el: 1032 cu: CCU cg: -1 v1: 93.8 u1: kg t0: [07:21:00 29/10/2016] id: Allergy 1 el: 1020 cu: CCU cg: -1 v1: Penicillins t0: [07:21:00 29/10/2016] id: Diagnosis/op el: 1023 cu: CCU cg: -1 v1: HYPOXIA t0: [07:21:00 29/10/2016] id: Service el: 1026 cu: CCU cg: -1 v1: MED t0: [07:21:00 29/10/2016] id: Admit Ht el: 1034 cu: CCU cg: -1 t0: [07:21:00 29/10/2016] id: Readmission el: 1014 cu: CCU cg: -1 t0: [07:21:00 29/10/2016] id: Marital Status el: 1006 cu: CCU cg: -1 v1: S t0: [07:21:00 29/10/2016] id: Religion el: 1000 cu: CCU cg: -1 v1: PRO t0: [07:21:00 29/10/2016] id: Allergy 2 el: 1021 cu: CCU cg: -1 v1: Aspirin t0: [07:21:00 29/10/2016] id: Ext el: 1010 cu: CCU cg: -1 t0: [07:21:00 29/10/2016] id: PIN el: 1012 cu: CCU cg: -1 t0: [07:21:00 29/10/2016] id: Allergy 3 el: 1022 cu: CCU cg: -1
t0: [06:30:00 29/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 11 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 8.1 u1: mg/dl rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 108 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.4 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 105 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 3.4 u1: mEq/L rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 3.7 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 141 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: BUN (6-20) Chemistry el: 0 cu: CCU cg: 140 v1: 11 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 8.1 u1: mg/dl rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 30 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 108 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.4 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 105 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 3.4 u1: mEq/L rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 3.7 rs: Final st: NotStopd t0: [06:30:00 29/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 141 rs: Final st: NotStopd
t0: [08:00:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 2 cu: CCU cg: -1 ai: 498 vo: 0 st: D/C'd
t0: [08:00:00 29/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 29/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [08:00:00 29/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [08:00:00 29/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [08:00:00 29/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [08:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [08:00:00 29/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [08:00:00 29/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 29/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: Yes st: NotStopd t0: [08:00:00 29/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [08:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 29/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [08:00:00 29/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Inconsistently st: NotStopd t0: [08:00:00 29/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [08:00:00 29/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [08:00:00 29/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 29/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: RN v1: Clamped st: NotStopd t0: [08:00:00 29/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [08:00:00 29/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [08:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:00:00 29/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft Distended st: NotStopd t0: [08:00:00 29/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 29/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [08:00:00 29/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [08:00:00 29/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [08:00:00 29/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [08:00:00 29/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 92 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [08:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [08:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [08:00:00 29/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [08:00:00 29/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 4 mm v2: 4 mm st: NotStopd t0: [08:00:00 29/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 29/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [08:00:00 29/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [08:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 12 u1: BPM st: NotStopd t0: [08:00:00 29/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [08:00:00 29/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 91 u1: % st: NotStopd t0: [08:00:00 29/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [08:00:00 29/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 29/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [08:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [08:00:00 29/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [08:00:00 29/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [08:00:00 29/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd t0: [08:00:00 29/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 29/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [08:00:00 29/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [08:00:00 29/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [08:00:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [08:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 10 vu: ml t0: [08:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 120 vu: ml t0: [08:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 180 vu: ml
t0: [08:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [08:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 29/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [08:00:00 29/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [08:00:00 29/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [08:00:00 29/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [08:00:00 29/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [08:00:00 29/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [08:00:00 29/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [08:00:00 29/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [08:00:00 29/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [08:00:00 29/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 4 st: NotStopd t0: [08:00:00 29/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [08:00:00 29/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [08:00:00 29/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 8.6 u1: L/min st: NotStopd t0: [08:00:00 29/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [08:00:00 29/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 15 u1: . st: NotStopd t0: [08:00:00 29/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 12 u1: BPM st: NotStopd t0: [08:00:00 29/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [08:00:00 29/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 780 u1: ml/B st: NotStopd t0: [08:00:00 29/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [08:00:00 29/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [07:00:00 29/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thick st: NotStopd t0: [07:00:00 29/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Moderate st: NotStopd t0: [08:00:00 29/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 29/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [08:00:00 29/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [08:00:00 29/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [08:00:00 29/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [08:00:00 29/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [08:00:00 29/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [08:00:00 29/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [08:00:00 29/10/2016] id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [08:00:00 29/10/2016] id: INV#1 WaveformAppear el: 0 cu: CCU cg: RN v1: Sharp st: NotStopd t0: [08:00:00 29/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [08:00:00 29/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [08:00:00 29/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [08:00:00 29/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [08:00:00 29/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Fair st: NotStopd t0: [08:00:00 29/10/2016] id: ImpSkin Character #1 el: 0 cu: CCU cg: RN v1: Hematoma st: NotStopd t0: [08:00:00 29/10/2016] id: ImpSkin Drain/Amt#1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 29/10/2016] id: ImpSkin Wound Base#1 el: 0 cu: CCU cg: RN v1: Purple st: NotStopd t0: [08:00:00 29/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [08:00:00 29/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 29/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [08:00:00 29/10/2016] id: Position el: 0 cu: CCU cg: RN v1: Supine st: NotStopd t0: [08:00:00 29/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 29/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 2 Person Assist st: NotStopd t0: [08:00:00 29/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [08:00:00 29/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [08:00:00 29/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [08:00:00 29/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [08:00:00 29/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [08:00:00 29/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [08:00:00 29/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [08:00:00 29/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Impaired st: NotStopd t0: [08:00:00 29/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: White v2: Thick st: NotStopd t0: [08:00:00 29/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Copious st: NotStopd t0: [08:00:00 29/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 29/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [08:00:00 29/10/2016] id: Behavior el: 0 cu: CCU cg: RN v1: Anxious st: NotStopd t0: [08:00:00 29/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Bedfast st: NotStopd t0: [08:00:00 29/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [08:00:00 29/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [08:00:00 29/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Rarely Moist st: NotStopd t0: [08:00:00 29/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [08:00:00 29/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 13 u1: number st: NotStopd t0: [08:00:00 29/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Very Limited st: NotStopd t0: [08:30:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [08:30:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [08:30:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:30:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:30:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 80 u1: BPM st: NotStopd t0: [08:30:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:30:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 160 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [08:30:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 90 u1: mmHg st: NotStopd t0: [08:30:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [08:30:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 26 u1: BPM st: NotStopd t0: [08:30:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 85 u1: % st: NotStopd t0: [08:30:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [08:00:00 29/10/2016] tf: [12:00:00 29/10/2016] dt: 240 id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 5 vu: ml t0: [08:00:00 29/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 80 vu: ml
t0: [08:30:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [08:30:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [08:00:00 29/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Left st: NotStopd t0: [10:00:00 29/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [10:00:00 29/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [10:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [10:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [10:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:00:00 29/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Left st: NotStopd t0: [10:00:00 29/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [10:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 91 u1: mmHg v2: 44 u2: mmHg st: NotStopd t0: [10:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 59 u1: mmHg st: NotStopd t0: [10:00:00 29/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [10:00:00 29/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [10:00:00 29/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [10:00:00 29/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [10:00:00 29/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [10:00:00 29/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [10:00:00 29/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [10:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 91 u1: % st: NotStopd t0: [10:00:00 29/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Clear v2: Thick st: NotStopd t0: [10:00:00 29/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Copious st: NotStopd t0: [10:00:00 29/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 29/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [10:00:00 29/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38.7778 u1: Deg. C st: NotStopd t0: [10:00:00 29/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 101.8 u1: Deg. F st: NotStopd t0: [10:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [11:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [11:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [11:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [11:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [11:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 134 u1: mmHg v2: 63 u2: mmHg st: NotStopd t0: [11:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 87 u1: mmHg st: NotStopd t0: [11:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [11:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 15 u1: BPM st: NotStopd t0: [11:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 90 u1: % st: NotStopd t0: [11:00:00 29/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Left Side st: NotStopd t0: [11:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:00:00 29/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vu: ml t0: [10:00:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [10:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 8.75 vu: ml t0: [10:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 120 vu: ml t0: [10:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml
t0: [10:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 50 du: mcghr sv: 250 su: ml rt: IV Drip t0: [10:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [11:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 75 du: mcghr sv: 250 su: ml rt: IV Drip t0: [11:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [11:00:00 29/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RN v1: Clear v2: Thick st: NotStopd t0: [11:00:00 29/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RN v1: Suctioned v2: Copious st: NotStopd t0: [12:00:00 29/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [12:00:00 29/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [12:00:00 29/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [12:00:00 29/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [12:00:00 29/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [12:00:00 29/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [12:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [12:00:00 29/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 29/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [12:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 29/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 3 To speech st: NotStopd t0: [12:00:00 29/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [12:00:00 29/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 10 u1: points st: NotStopd t0: [12:00:00 29/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [12:00:00 29/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [12:00:00 29/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 89 u1: BPM st: NotStopd t0: [12:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:00:00 29/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Left st: NotStopd t0: [12:00:00 29/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [12:00:00 29/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 29/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [12:00:00 29/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Arouse to Voice st: NotStopd t0: [12:00:00 29/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [12:00:00 29/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Thrush st: NotStopd t0: [12:00:00 29/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [12:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 131 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [12:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 82 u1: mmHg st: NotStopd t0: [12:00:00 29/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [12:00:00 29/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [12:00:00 29/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [12:00:00 29/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 29/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [12:00:00 29/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [12:00:00 29/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [12:00:00 29/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [12:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [12:00:00 29/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [12:00:00 29/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [12:00:00 29/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [12:00:00 29/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [12:00:00 29/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 29/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [12:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 89 u1: % st: NotStopd t0: [12:00:00 29/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [12:00:00 29/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 29/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [12:00:00 29/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [12:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [12:00:00 29/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [12:00:00 29/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 29/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [12:00:00 29/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: 20 cm st: NotStopd t0: [12:00:00 29/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [12:00:00 29/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serosanguinous st: NotStopd
t0: [12:00:00 29/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: RN ai: 189 vo: 0 vu: ml t0: [12:00:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 189 vo: 100 vu: ml t0: [12:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 12.5 vu: ml t0: [12:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 120 vu: ml t0: [12:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 100 vu: ml
t0: [12:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 75 du: mcghr sv: 250 su: ml rt: IV Drip t0: [12:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
tf: [11:00:00 30/10/2016] pt: Unit Dose rt: IV fr: ONCE fs: 12 dn: 1 m1: Furosemide v1: 40 u1: mg tf: [11:00:00 30/10/2016] pt: Unit Dose rt: NG fr: ONCE fs: 12 dn: 1 m1: Potassium Chloride v1: 40 u1: mEq tf: [11:00:00 30/10/2016] pt: Unit Dose rt: PO fr: ONCE fs: 12 dn: 1 m1: Potassium Chloride v1: 40 u1: mEq
t0: [12:01:00 29/10/2016] id: D5/.45NS 1000.0ml IV Infusions el: 1 cu: CCU cg: -1 ai: 189 vo: 0 st: D/C'd
t0: [12:00:00 29/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [12:00:00 29/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [12:00:00 29/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [12:00:00 29/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [12:00:00 29/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [12:00:00 29/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [12:00:00 29/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [12:00:00 29/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [12:00:00 29/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [12:00:00 29/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 4 st: NotStopd t0: [12:00:00 29/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [12:00:00 29/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 11 u1: cmH2O st: NotStopd t0: [12:00:00 29/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 12.8 u1: L/min st: NotStopd t0: [12:00:00 29/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [12:00:00 29/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 15 u1: . st: NotStopd t0: [12:00:00 29/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 19 u1: BPM st: NotStopd t0: [12:00:00 29/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [12:00:00 29/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: Clear v2: Thick st: NotStopd t0: [12:00:00 29/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Copious st: NotStopd t0: [12:00:00 29/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 650 u1: ml/B st: NotStopd t0: [12:00:00 29/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [12:00:00 29/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [13:00:00 29/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [13:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: MICU st: NotStopd t0: [13:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [13:00:00 29/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [13:00:00 29/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: Yes st: NotStopd t0: [13:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 85 u1: BPM st: NotStopd t0: [13:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 97 u1: mmHg v2: 46 u2: mmHg st: NotStopd t0: [13:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [13:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [13:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 25 u1: BPM st: NotStopd t0: [13:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 89 u1: % st: NotStopd t0: [13:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 29/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: RN ai: 255 vo: 40 vu: ml t0: [13:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 7.5 vu: ml t0: [13:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [13:00:00 29/10/2016] id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 0 vu: ml t0: [13:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 400 vu: ml
t0: [13:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 75 du: mcghr sv: 250 su: ml rt: IV Drip t0: [13:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [23:00:00 29/10/2016] dt: 24 id: PO/Gastric In Total el: 1 cu: CCU cg: RN cv: 120 ap: none t0: [23:00:00 29/10/2016] dt: 24 id: Chest Tube Out Total el: 1 cu: CCU cg: RN cv: 135 ap: none
t0: [14:00:00 29/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [14:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [14:00:00 29/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [14:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [14:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [14:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [14:00:00 29/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Left st: NotStopd t0: [14:00:00 29/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [14:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 98 u1: mmHg v2: 47 u2: mmHg st: NotStopd t0: [14:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [14:00:00 29/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [14:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [14:00:00 29/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [14:00:00 29/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [14:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 14 u1: BPM st: NotStopd t0: [14:00:00 29/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [14:00:00 29/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [14:00:00 29/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [14:00:00 29/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [14:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 90 u1: % st: NotStopd t0: [14:00:00 29/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [12:00:00 29/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 200 vu: ml t0: [13:00:00 29/10/2016] id: D5W 100.0ml IV Infusions el: 1 cu: CCU cg: RN ai: 105 vo: 100 vu: ml t0: [14:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 7.5 vu: ml t0: [14:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 60 vu: ml t0: [14:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 900 vu: ml
t0: [14:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 75 du: mcghr sv: 250 su: ml rt: IV Drip t0: [14:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 45 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [14:15:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 1.875 vu: ml t0: [14:15:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 15 vu: ml t0: [14:15:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 340 vu: ml
t0: [14:00:00 29/10/2016] id: high MV el: 0 cu: CCU cg: RRT v1: 20 t0: [14:00:00 29/10/2016] id: ETT Mark/Location el: 0 cu: CCU cg: RRT v1: 21cm v2: Lip st: NotStopd t0: [14:00:00 29/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.5 u1: torr st: NotStopd t0: [14:00:00 29/10/2016] id: High Insp. Pressure el: 0 cu: CCU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [14:00:00 29/10/2016] id: High Resp. Rate el: 0 cu: CCU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [14:00:00 29/10/2016] id: Airway Size el: 0 cu: CCU cg: RRT v1: 7.5 mm st: NotStopd t0: [14:00:00 29/10/2016] id: Airway Type el: 0 cu: CCU cg: RRT v1: Endotracheal st: NotStopd t0: [14:00:00 29/10/2016] id: Inspired Gas Temp el: 0 cu: CCU cg: RRT u1: Deg. C st: NotStopd t0: [14:00:00 29/10/2016] id: Intubation Date el: 0 cu: CCU cg: RRT v1: 8 v2: 31 st: NotStopd t0: [14:00:00 29/10/2016] id: Low Exhaled Min Vol el: 0 cu: CCU cg: RRT v1: 4 st: NotStopd t0: [14:00:00 29/10/2016] id: MDI #1 (Puff/Drug) el: 0 cu: CCU cg: RRT v1: 6 v2: Combivent st: NotStopd t0: [14:00:00 29/10/2016] id: Mean Airway Pressure el: 0 cu: CCU cg: RRT v1: 7 u1: cmH2O st: NotStopd t0: [14:00:00 29/10/2016] id: Minute Volume(Obser) el: 0 cu: CCU cg: RRT v1: 12.8 u1: L/min st: NotStopd t0: [14:00:00 29/10/2016] id: PEEP Set el: 0 cu: CCU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [14:00:00 29/10/2016] id: Pressure Support el: 0 cu: CCU cg: RRT v1: 5 u1: . st: NotStopd t0: [14:00:00 29/10/2016] id: Resp Rate (Total) el: 0 cu: CCU cg: RRT v1: 27 u1: BPM st: NotStopd t0: [14:00:00 29/10/2016] id: Sensitivity-Vent el: 0 cu: CCU cg: RRT v1: 3 u1: cmH2O st: NotStopd t0: [14:00:00 29/10/2016] id: Sputum Color/Consist el: 0 cu: CCU cg: RRT v1: Clear v2: Thick st: NotStopd t0: [14:00:00 29/10/2016] id: Sputum Source/Amt el: 0 cu: CCU cg: RRT v1: Suctioned v2: Copious st: NotStopd t0: [14:00:00 29/10/2016] id: Tidal Volume (Spont) el: 0 cu: CCU cg: RRT v1: 450 u1: ml/B st: NotStopd t0: [14:00:00 29/10/2016] id: Ventilator Mode el: 0 cu: CCU cg: RRT v1: CPAP+PS st: NotStopd t0: [14:00:00 29/10/2016] id: Ventilator Type el: 0 cu: CCU cg: RRT v1: Drager st: NotStopd
t0: [15:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [15:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [15:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [15:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [15:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 100 u1: mmHg v2: 46 u2: mmHg st: NotStopd t0: [15:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [15:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [15:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [15:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [15:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [15:06:00 29/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.39 rs: Final st: NotStopd t0: [15:06:00 29/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 6 rs: Final st: NotStopd t0: [15:06:00 29/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 35 rs: Final st: NotStopd t0: [15:06:00 29/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 56 u1: mmHg rs: Final st: NotStopd t0: [15:06:00 29/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 73 u1: mmHg rs: Final st: NotStopd t0: [15:06:00 29/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.39 rs: Final st: NotStopd
t0: [15:00:00 29/10/2016] id: FiO2 Set el: 0 cu: CCU cg: RRT v1: 0.4 u1: torr st: NotStopd t0: [15:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2804 id: O2 Delivery Device el: 0 cu: CCU cg: RRT v1: Venti Mask st: NotStopd t0: [15:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2804 id: O2 Flow (lpm) el: 0 cu: CCU cg: RRT v1: 8 u1: lpm st: NotStopd
t0: [13:00:00 29/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [15:30:00 29/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [15:30:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [15:30:00 29/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [15:30:00 29/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [15:30:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [15:30:00 29/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [15:30:00 29/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [15:30:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:30:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:30:00 29/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [15:30:00 29/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [15:30:00 29/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 14 u1: points st: NotStopd t0: [15:30:00 29/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [15:30:00 29/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [15:30:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 87 u1: BPM st: NotStopd t0: [15:30:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [15:30:00 29/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [15:30:00 29/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [15:30:00 29/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [15:30:00 29/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [15:30:00 29/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [15:30:00 29/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [15:30:00 29/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 2 st: NotStopd t0: [15:30:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 126 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [15:30:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 80 u1: mmHg st: NotStopd t0: [15:30:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [15:30:00 29/10/2016] id: Pupil Response R/L el: 0 cu: CCU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [15:30:00 29/10/2016] id: Pupil Size R/L el: 0 cu: CCU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [15:30:00 29/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [15:30:00 29/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [15:30:00 29/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [15:30:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [15:30:00 29/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [15:30:00 29/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [15:30:00 29/10/2016] id: Significant Events el: 0 cu: CCU cg: RN v1: Extubated st: NotStopd t0: [15:30:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 91 u1: % st: NotStopd t0: [15:30:00 29/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [15:30:00 29/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [15:30:00 29/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [15:30:00 29/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 4 Confused st: NotStopd t0: [15:30:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [15:30:00 29/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [15:30:00 29/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [16:00:00 29/10/2016] id: Range of Motion el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 29/10/2016] id: Circulation/SkinInt el: 0 cu: CCU cg: RN v1: Circulation Adeq st: NotStopd t0: [16:00:00 29/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 90 degrees st: NotStopd t0: [16:00:00 29/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [16:00:00 29/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [16:00:00 29/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [16:00:00 29/10/2016] id: INV Line#2 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [16:00:00 29/10/2016] id: INV Line#2InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [16:00:00 29/10/2016] id: INV Line#2SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [16:00:00 29/10/2016] id: INV#1 WaveformAppear el: 0 cu: CCU cg: RN v1: Sharp st: NotStopd t0: [16:00:00 29/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [16:00:00 29/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [16:00:00 29/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bed as Chair st: NotStopd t0: [16:00:00 29/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [16:00:00 29/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Left st: NotStopd t0: [16:00:00 29/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [16:00:00 29/10/2016] id: Position Change el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 29/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 1 Person Assist st: NotStopd t0: [16:00:00 29/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [16:00:00 29/10/2016] id: Removed x 5 Mins el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 29/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: Both Arms st: NotStopd t0: [16:00:00 29/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [16:00:00 29/10/2016] id: Restraints Evaluated el: 0 cu: CCU cg: RN v1: Behavior Conts st: NotStopd t0: [16:00:00 29/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [16:00:00 29/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 29/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Side to Side st: NotStopd
t0: [15:30:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 6.875 vu: ml t0: [15:30:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vo: 75 vu: ml t0: [15:30:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 400 vu: ml
t0: [15:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [15:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 21.322 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [15:30:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [15:30:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 0 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [16:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [16:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [16:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [16:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 76 u1: mmHg st: NotStopd t0: [16:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [16:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [16:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 90 u1: % st: NotStopd t0: [16:00:00 29/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [16:00:00 29/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.3333 u1: Deg. C st: NotStopd t0: [16:00:00 29/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 99.2 u1: Deg. F st: NotStopd t0: [16:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [16:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 0 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [16:28:00 29/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.45 rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 106 rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 4.1 rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 6 rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 32 rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 45 u1: mmHg rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 60 u1: mmHg rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.45 rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 106 rs: Final st: NotStopd t0: [16:28:00 29/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 4.1 rs: Final st: NotStopd
t0: [17:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2684 id: Pain Level el: 0 cu: CCU cg: RN v1: 3-Mild to Mod st: NotStopd t0: [17:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2684 id: Pain Level/Response el: 0 cu: CCU cg: RN v1: 2-Mild st: NotStopd t0: [17:00:00 29/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [17:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [17:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [17:00:00 29/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Calm/Cooperative st: NotStopd t0: [17:00:00 29/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: > Norm activity st: NotStopd t0: [17:00:00 29/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mildly anxious st: NotStopd t0: [17:00:00 29/10/2016] id: Ataxia el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [17:00:00 29/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [17:00:00 29/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 11 u1: sum st: NotStopd t0: [17:00:00 29/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: No/Not Sedated st: NotStopd t0: [17:00:00 29/10/2016] id: Drowsiness el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [17:00:00 29/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [17:00:00 29/10/2016] id: Insomnia el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [17:00:00 29/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: No N/V st: NotStopd t0: [17:00:00 29/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: ? date < 2 days st: NotStopd t0: [17:00:00 29/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: Beads/ forehead st: NotStopd t0: [17:00:00 29/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [17:00:00 29/10/2016] id: Slurred Speech el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [17:00:00 29/10/2016] id: Sustained Nystamus el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [17:00:00 29/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 29/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: No Tremor st: NotStopd t0: [17:00:00 29/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: Moderate st: NotStopd t0: [17:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [17:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [17:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [17:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 140 u1: mmHg v2: 63 u2: mmHg st: NotStopd t0: [17:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2684 id: Pain Cause el: 0 cu: CCU cg: RN v1: Activity st: NotStopd t0: [17:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2684 id: Pain Level (Rest) el: 0 cu: CCU cg: RN v1: 3-Mild to Mod st: NotStopd t0: [17:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2684 id: Pain Management el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [17:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2684 id: Pain Type el: 1 cu: CCU cg: RN v1: IV Gtt v2: IV Gtt st: NotStopd t0: [17:00:00 29/10/2016] id: Pain Type el: 0 cu: CCU cg: RN v1: Constant st: NotStopd t0: [17:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [17:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [17:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 9 u1: BPM st: NotStopd t0: [17:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [17:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:00:00 29/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: RN ai: 216 vu: ml st: Stopped t0: [17:00:00 29/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 0 vu: ml nb: 1 t0: [17:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 3.75 vu: ml t0: [17:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 160 vu: ml
t0: [17:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [17:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 0 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [18:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [18:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [18:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 87 u1: BPM st: NotStopd t0: [18:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:00:00 29/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [18:00:00 29/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [18:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 142 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [18:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 93 u1: mmHg st: NotStopd t0: [18:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [18:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [18:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [18:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:00:00 29/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [19:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [19:00:00 29/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [19:00:00 29/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [19:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [19:00:00 29/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [19:00:00 29/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [19:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 29/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [19:00:00 29/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [19:00:00 29/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 14 u1: points st: NotStopd t0: [19:00:00 29/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [19:00:00 29/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [19:00:00 29/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [19:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [19:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [19:00:00 29/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Eye, Left st: NotStopd t0: [19:00:00 29/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [19:00:00 29/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [19:00:00 29/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 5 Localizes Pain st: NotStopd t0: [19:00:00 29/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 2 st: NotStopd t0: [19:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 117 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [19:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 120 u1: mmHg st: NotStopd t0: [19:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [19:00:00 29/10/2016] id: Reason For Restraint el: 0 cu: CCU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [19:00:00 29/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [19:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [19:00:00 29/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [19:00:00 29/10/2016] id: Restraint Location el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 29/10/2016] id: Restraint Type el: 0 cu: CCU cg: RN v1: Soft Limb st: NotStopd t0: [19:00:00 29/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 29/10/2016] id: Side Rails el: 0 cu: CCU cg: RN v1: Side Rails Up st: NotStopd t0: [19:00:00 29/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [19:00:00 29/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [19:00:00 29/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [19:00:00 29/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd t0: [19:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [19:00:00 29/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd
t0: [18:00:00 29/10/2016] tf: [13:44:00 31/10/2016] dt: 2624 id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [18:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 2.5 vu: ml t0: [19:00:00 29/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [19:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 2.5 vu: ml t0: [19:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 220 vu: ml
t0: [18:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [18:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 0 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [19:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [19:00:00 29/10/2016] id: Propofol el: 1 cu: CCU cg: RN so: N/A vo: 0 v1: 0 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [17:00:00 29/10/2016] id: Eye Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [17:00:00 29/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [17:00:00 29/10/2016] id: Skin Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [17:00:00 29/10/2016] id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd
t0: [21:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: -1 st: D/C'd t0: [21:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: -1 st: D/C'd
t0: [20:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [20:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [20:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [20:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:00:00 29/10/2016] id: Arterial BP el: 0 cu: CCU cg: RN v1: 147 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [20:00:00 29/10/2016] id: Arterial BP Mean el: 0 cu: CCU cg: RN v1: 95 u1: mmHg st: NotStopd t0: [20:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [20:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [20:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [21:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [21:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [21:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [21:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [21:00:00 29/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [21:00:00 29/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [21:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [21:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 23 u1: BPM st: NotStopd t0: [21:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [21:00:00 29/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Rectal st: NotStopd t0: [21:00:00 29/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.1111 u1: Deg. C st: NotStopd t0: [21:00:00 29/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98.8 u1: Deg. F st: NotStopd t0: [21:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [20:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [21:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip
t0: [22:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [22:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [22:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [22:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:00:00 29/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 126 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [22:00:00 29/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 83.3333 u1: mmHg st: NotStopd t0: [22:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [22:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [22:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [22:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [20:00:00 29/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 10 vu: ml t0: [20:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 2.5 vu: ml t0: [20:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml t0: [22:00:00 29/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 20 vu: ml t0: [22:00:00 29/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 5 vu: ml t0: [22:00:00 29/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 120 vu: ml
t0: [22:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip
tf: [18:00:00 30/10/2016] pt: Unit Dose rt: PO fr: Q4-6H:PRN m1: Oxycodone-Acetaminophen v1: 2 u1: TAB
t0: [23:00:00 29/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [23:00:00 29/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [23:00:00 29/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 29/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [23:00:00 29/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [23:00:00 29/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [23:00:00 29/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 118 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [23:00:00 29/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 78 u1: mmHg st: NotStopd t0: [23:00:00 29/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [23:00:00 29/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 26 u1: BPM st: NotStopd t0: [23:00:00 29/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [23:00:00 29/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [23:00:00 29/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip
t0: [00:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: CoWker v1: CCU st: NotStopd t0: [00:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: CoWker v1: Full Code st: NotStopd t0: [00:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: CoWker v1: 80 u1: BPM st: NotStopd t0: [00:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: CoWker v1: Universal st: NotStopd t0: [00:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: CoWker v1: 23 u1: BPM st: NotStopd t0: [00:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: CoWker v1: 94 u1: % st: NotStopd t0: [00:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: CoWker v1: 1 u1: kg st: NotStopd t0: [01:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: CoWker v1: CCU st: NotStopd t0: [01:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: CoWker v1: Full Code st: NotStopd t0: [01:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: CoWker v1: 84 u1: BPM st: NotStopd t0: [01:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: CoWker v1: Universal st: NotStopd t0: [01:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: CoWker v1: 15 u1: BPM st: NotStopd t0: [01:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: CoWker v1: 95 u1: % st: NotStopd t0: [01:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: CoWker v1: 1 u1: kg st: NotStopd t0: [02:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: CoWker v1: CCU st: NotStopd t0: [02:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: CoWker v1: Full Code st: NotStopd t0: [02:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: CoWker v1: None st: NotStopd t0: [02:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: CoWker v1: None st: NotStopd t0: [02:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: CoWker v1: 76 u1: BPM st: NotStopd t0: [02:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: CoWker v1: Normal Sinus st: NotStopd t0: [02:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: CoWker v1: 111 u1: mmHg v2: 53 u2: mmHg st: NotStopd t0: [02:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: CoWker v1: 72.3333 u1: mmHg st: NotStopd t0: [02:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: CoWker v1: Universal st: NotStopd t0: [02:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: CoWker v1: 28 u1: BPM st: NotStopd t0: [02:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: CoWker v1: 1 u1: kg st: NotStopd
t0: [02:00:00 30/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: CoWker ai: 107 vo: 40 vu: ml t0: [02:00:00 30/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: CoWker ai: 416 vo: 10 vu: ml t0: [02:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: CoWker vo: 120 vu: ml
t0: [00:00:00 30/10/2016] id: Fentanyl el: 1 cu: CCU cg: CoWker so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [01:00:00 30/10/2016] id: Fentanyl el: 1 cu: CCU cg: CoWker so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip t0: [02:00:00 30/10/2016] id: Fentanyl el: 1 cu: CCU cg: CoWker so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip
t0: [00:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 128 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [00:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [01:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [01:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [01:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 70 u2: mmHg st: NotStopd t0: [01:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 90.6667 u1: mmHg st: NotStopd t0: [02:00:00 30/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [02:00:00 30/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 38 u1: Deg. C st: NotStopd t0: [02:00:00 30/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.4 u1: Deg. F st: NotStopd
t0: [00:00:00 30/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 20 vu: ml t0: [00:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml
t0: [23:00:00 30/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 30/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 30/10/2016] dt: 24 id: IV Infusion In Total el: 1 cu: CCU cg: RN cv: 175 ap: none t0: [23:00:00 30/10/2016] dt: 24 id: 24h Total In el: 1 cu: CCU cg: RN cv: 675 ap: none t0: [23:00:00 30/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN cv: 1540 ap: none t0: [23:00:00 30/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: RN cv: -1165 ap: carryForward t0: [23:00:00 30/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: RN cv: 1840 ap: carryForward t0: [23:00:00 30/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: RN cv: 5339.09 ap: carryForward
t0: [00:00:00 30/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [00:00:00 30/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [00:00:00 30/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [00:00:00 30/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [00:00:00 30/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [00:00:00 30/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [00:00:00 30/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [00:00:00 30/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 15 u1: points st: NotStopd t0: [00:00:00 30/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [00:00:00 30/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [00:00:00 30/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [00:00:00 30/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [00:00:00 30/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [00:00:00 30/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [00:00:00 30/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [00:00:00 30/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 1 st: NotStopd t0: [00:00:00 30/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [00:00:00 30/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [00:00:00 30/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Shallow st: NotStopd t0: [00:00:00 30/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [00:00:00 30/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [00:00:00 30/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 30/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [00:00:00 30/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [00:00:00 30/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd t0: [00:00:00 30/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd
t0: [03:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [03:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [03:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [03:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [03:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [03:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 129 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [03:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 89 u1: mmHg st: NotStopd t0: [03:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [03:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [03:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [03:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [03:00:00 30/10/2016] id: Fentanyl el: 1 cu: CCU cg: RN so: .9% Normal Saline vo: 0 v1: 25 du: mcghr sv: 250 su: ml rt: IV Drip
t0: [06:00:00 30/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: -1 ai: 416 vo: 0 st: D/C'd
t0: [04:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [04:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [04:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 74 u1: BPM st: NotStopd t0: [04:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 115 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [04:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 76.3333 u1: mmHg st: NotStopd t0: [04:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [04:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [04:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [04:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [07:00:00 30/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: -1 st: D/C'd t0: [07:00:00 30/10/2016] id: GI#1 Tube Stat/Drain el: 0 cu: CCU cg: -1 st: D/C'd
t0: [06:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [06:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [06:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [06:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [06:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 119 u1: mmHg v2: 69 u2: mmHg st: NotStopd t0: [06:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 85.6667 u1: mmHg st: NotStopd t0: [06:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [06:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 19 u1: BPM st: NotStopd t0: [06:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [06:00:00 30/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [06:00:00 30/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.7778 u1: Deg. C st: NotStopd t0: [06:00:00 30/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100 u1: Deg. F st: NotStopd t0: [06:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [04:00:00 30/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 20 vu: ml t0: [04:00:00 30/10/2016] id: .9% Normal Saline 250.0ml + 2500mcghr Fentanyl IV Infusions el: 1 cu: CCU cg: RN ai: 416 vo: 5 vu: ml t0: [04:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml t0: [06:00:00 30/10/2016] tf: [13:44:00 31/10/2016] dt: 1904 id: Chest Tubes Right Pleural 1 el: 1 cu: CCU cg: RN vo: 10 vu: ml t0: [06:00:00 30/10/2016] id: Chest Tubes Right Pleural 2 el: 1 cu: CCU cg: RN vo: 90 vu: ml t0: [06:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 220 vu: ml
t0: [23:00:00 30/10/2016] dt: 24 id: Chest Tube Out Total el: 1 cu: CCU cg: RN cv: 100 ap: none
t0: [06:00:00 30/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [06:00:00 30/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [06:00:00 30/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [06:00:00 30/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [06:00:00 30/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [06:00:00 30/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [06:00:00 30/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [06:00:00 30/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 14 u1: points st: NotStopd t0: [06:00:00 30/10/2016] id: GI Intub #1/Site el: 0 cu: CCU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [06:00:00 30/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [06:00:00 30/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [06:00:00 30/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [06:00:00 30/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [06:00:00 30/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [06:00:00 30/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [06:00:00 30/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 1 st: NotStopd t0: [06:00:00 30/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [06:00:00 30/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [06:00:00 30/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [06:00:00 30/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [06:00:00 30/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [06:00:00 30/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 30/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [06:00:00 30/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [06:00:00 30/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 4 Confused st: NotStopd t0: [06:00:00 30/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd
t0: [06:45:00 30/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 9.8 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: WBC Hematology el: 0 cu: CCU cg: 140 v1: 9.8 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 40.4 u1: % rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 12.8 u1: gm/dl rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Platelets Hematology el: 0 cu: CCU cg: 140 v1: 202 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: RBC Hematology el: 0 cu: CCU cg: 140 v1: 4.2 u1: /mic l rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 9.8 rs: Final st: NotStopd
t0: [08:00:00 30/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 30/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [08:00:00 30/10/2016] id: Pain Level el: 0 cu: CCU cg: RN v1: 3-Mild to Mod st: NotStopd t0: [08:00:00 30/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [08:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [08:00:00 30/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [08:00:00 30/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [08:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [08:00:00 30/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [08:00:00 30/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 30/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: No/Not Sedated st: NotStopd t0: [08:00:00 30/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: Tube Feeding st: NotStopd t0: [08:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 30/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [08:00:00 30/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [08:00:00 30/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 15 u1: points st: NotStopd t0: [08:00:00 30/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [08:00:00 30/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 30/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [08:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [08:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:00:00 30/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [08:00:00 30/10/2016] id: INV Line#1InsertDate el: 0 cu: CCU cg: RN v1: 9 v2: 4 st: NotStopd t0: [08:00:00 30/10/2016] id: INV Line#1SiteAppear el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [08:00:00 30/10/2016] id: IV #3 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 3 st: NotStopd t0: [08:00:00 30/10/2016] id: IV #3 Site/Size el: 0 cu: CCU cg: RN v1: Left Antecub v2: 20 gauge st: NotStopd t0: [08:00:00 30/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [08:00:00 30/10/2016] id: IV Site Appear #3 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd t0: [08:00:00 30/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [08:00:00 30/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [08:00:00 30/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 30/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [08:00:00 30/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [08:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 137 u1: mmHg v2: 71 u2: mmHg st: NotStopd t0: [08:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 93 u1: mmHg st: NotStopd t0: [08:00:00 30/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [08:00:00 30/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [08:00:00 30/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 30/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 2 st: NotStopd t0: [08:00:00 30/10/2016] id: Pain Cause el: 0 cu: CCU cg: RN v1: At Rest st: NotStopd t0: [08:00:00 30/10/2016] id: Pain Level (Rest) el: 0 cu: CCU cg: RN v1: 3-Mild to Mod st: NotStopd t0: [08:00:00 30/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Headache st: NotStopd t0: [08:00:00 30/10/2016] id: Pain Type el: 0 cu: CCU cg: RN v1: Constant st: NotStopd t0: [08:00:00 30/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 1 Person Assist st: NotStopd t0: [08:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [08:00:00 30/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [08:00:00 30/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 30/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [08:00:00 30/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [08:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [08:00:00 30/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [08:00:00 30/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [08:00:00 30/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [08:00:00 30/10/2016] id: Support Systems el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 30/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [08:00:00 30/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 36.2222 u1: Deg. C st: NotStopd t0: [08:00:00 30/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 97.2 u1: Deg. F st: NotStopd t0: [08:00:00 30/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Turns by self st: NotStopd t0: [08:00:00 30/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [08:00:00 30/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 30/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd t0: [08:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [08:00:00 30/10/2016] id: Behavior el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [08:00:00 30/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Chairfast st: NotStopd t0: [08:00:00 30/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: No Apparent Prob st: NotStopd t0: [08:00:00 30/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd t0: [08:00:00 30/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Rarely Moist st: NotStopd t0: [08:00:00 30/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Adequate st: NotStopd t0: [08:00:00 30/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 18 u1: number st: NotStopd t0: [08:00:00 30/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd t0: [08:00:00 30/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [08:00:00 30/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 30/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [08:00:00 30/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd
t0: [08:00:00 30/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 40 vu: ml t0: [08:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 40 vu: ml
t0: [06:45:00 30/10/2016] id: PT el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: INR Coags el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: PTT Coags el: 0 cu: CCU cg: 140 v1: 25.5 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: INR (2-4 ref. range) Coags el: 0 cu: CCU cg: 140 v1: 1 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: PT(11-13.5) Coags el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: PTT(22-35) Coags el: 0 cu: CCU cg: 140 v1: 25.5 rs: Final st: NotStopd
t0: [06:45:00 30/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 15 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 9.1 u1: mg/dl rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 105 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.6 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 93 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 2.7 u1: mEq/L rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 3.8 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 144 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: BUN (6-20) Chemistry el: 0 cu: CCU cg: 140 v1: 15 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 9.1 u1: mg/dl rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 32 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 105 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.6 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 93 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 2.7 u1: mEq/L rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 3.8 rs: Final st: NotStopd t0: [06:45:00 30/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 144 rs: Final st: NotStopd
t0: [10:00:00 30/10/2016] id: TF Residual Gastric/TF Residual el: 1 cu: CCU cg: -1 ai: 189 vo: 0 st: D/C'd t0: [10:00:00 30/10/2016] id: Promote w/fiber Tube Feeding el: 1 cu: CCU cg: -1 ai: 216 vo: 0 st: D/C'd
tf: [18:00:00 30/10/2016] pt: Unit Dose rt: PO fr: Q4H fs: 10, 14, 18, 22, 2, 6 dn: 6 m1: Lorazepam v1: 2 u1: mg tf: [09:00:00 31/10/2016] pt: Unit Dose rt: PO fr: ONCE fs: 10 dn: 1 m1: Potassium Chloride v1: 40 u1: mEq tf: [16:00:00 01/11/2016] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Famotidine v1: 20 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: Q24H fs: 10 dn: 1 m1: Levofloxacin v1: 500 u1: mg
t0: [10:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [10:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [10:00:00 30/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Calm/Cooperative st: NotStopd t0: [10:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 30/10/2016] id: Eye Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [10:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 128 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [10:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [10:00:00 30/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [10:00:00 30/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [10:00:00 30/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [10:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 33 u1: BPM st: NotStopd t0: [10:00:00 30/10/2016] id: Skin Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [10:00:00 30/10/2016] id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [10:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [10:00:00 30/10/2016] id: Behavior el: 0 cu: CCU cg: RN v1: Sleeping st: NotStopd
t0: [12:00:00 30/10/2016] id: GI Guaiac/ph el: 0 cu: CCU cg: -1 st: D/C'd t0: [12:00:00 30/10/2016] id: GI#1 Tube PlaceCheck el: 0 cu: CCU cg: -1 st: D/C'd
t0: [12:00:00 30/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [12:00:00 30/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [12:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [12:00:00 30/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [12:00:00 30/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: RN v1: Right Posterior st: NotStopd t0: [12:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [12:00:00 30/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [12:00:00 30/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 30/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: No/Not Sedated st: NotStopd t0: [12:00:00 30/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: Proton/Pump/Inhi st: NotStopd t0: [12:00:00 30/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NAS/Low Cholest st: NotStopd t0: [12:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 30/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [12:00:00 30/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [12:00:00 30/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 15 u1: points st: NotStopd t0: [12:00:00 30/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [12:00:00 30/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [12:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:00:00 30/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [12:00:00 30/10/2016] id: Abdominal Assessment el: 0 cu: CCU cg: RN v1: Soft st: NotStopd t0: [12:00:00 30/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [12:00:00 30/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 30/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [12:00:00 30/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [12:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 128 u1: mmHg v2: 70 u2: mmHg st: NotStopd t0: [12:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 89.3333 u1: mmHg st: NotStopd t0: [12:00:00 30/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Headache st: NotStopd t0: [12:00:00 30/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [12:00:00 30/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [12:00:00 30/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 2 st: NotStopd t0: [12:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [12:00:00 30/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [12:00:00 30/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 30/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [12:00:00 30/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [12:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 17 u1: BPM st: NotStopd t0: [12:00:00 30/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [12:00:00 30/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [12:00:00 30/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [12:00:00 30/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [12:00:00 30/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.4444 u1: Deg. C st: NotStopd t0: [12:00:00 30/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 99.4 u1: Deg. F st: NotStopd t0: [12:00:00 30/10/2016] id: Urine Color/Appear el: 0 cu: CCU cg: RN v1: Brown v2: Clear st: NotStopd t0: [12:00:00 30/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [12:00:00 30/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd t0: [12:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [12:00:00 30/10/2016] id: Bowel Sounds el: 0 cu: CCU cg: RN v1: Present st: NotStopd t0: [12:00:00 30/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [12:00:00 30/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: RN v1: Serous st: NotStopd t0: [12:00:00 30/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: RN v1: Dry and Intact st: NotStopd t0: [12:00:00 30/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: RN v1: H2O Seal st: NotStopd t0: [12:00:00 30/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: RN v1: Negative st: NotStopd t0: [12:00:00 30/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: RN v1: Serous st: NotStopd
t0: [12:00:00 30/10/2016] id: .9% Normal Saline 1000.0ml IV Infusions el: 3 cu: CCU cg: RN ai: 107 vo: 40 vu: ml t0: [12:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 300 vu: ml
t0: [14:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [14:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [14:00:00 30/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Calm/Cooperative st: NotStopd t0: [14:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [14:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 79 u1: BPM st: NotStopd t0: [14:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [14:00:00 30/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Chair st: NotStopd t0: [14:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 134 u1: mmHg v2: 66 u2: mmHg st: NotStopd t0: [14:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 88.6667 u1: mmHg st: NotStopd t0: [14:00:00 30/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [14:00:00 30/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [14:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [14:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [14:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [14:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 30/10/2016] tf: [13:44:00 31/10/2016] dt: 1484 id: Po Intake PO/Gastric el: 1 cu: CCU cg: RN ai: 103 vo: 200 vu: ml t0: [14:00:00 30/10/2016] id: Po Intake PO/Gastric el: 1 cu: CCU cg: RN ai: 103 vo: 100 vu: ml
t0: [15:00:00 30/10/2016] id: CT #2 Dressing el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #2 Fluctuate/Leak el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #2 Suction Amount el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: Chest Tube Site #1 el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: Chest Tube Site #2 el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #1 Crepitus el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #1 Drainage el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #1 Dressing el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #1 Fluctuate/Leak el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #1 Suction Amount el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #2 Crepitus el: 0 cu: CCU cg: -1 st: D/C'd t0: [15:00:00 30/10/2016] id: CT #2 Drainage el: 0 cu: CCU cg: -1 st: D/C'd
t0: [16:00:00 30/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [16:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [16:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [16:00:00 30/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Agitated st: NotStopd t0: [16:00:00 30/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 30/10/2016] id: Daily Wake Up el: 1 cu: CCU cg: RN v1: No/Not Sedated st: NotStopd t0: [16:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 30/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [16:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 72 u1: BPM st: NotStopd t0: [16:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [16:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [16:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82 u1: mmHg st: NotStopd t0: [16:00:00 30/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Headache st: NotStopd t0: [16:00:00 30/10/2016] id: Pain Location el: 0 cu: CCU cg: RN v1: Headache st: NotStopd t0: [16:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [16:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [16:00:00 30/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [16:00:00 30/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 96 u1: % st: NotStopd t0: [16:00:00 30/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [16:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: TID fs: 08, 16, 22 dn: 3 m1: Metronidazole v1: 500 u1: mg
t0: [08:00:00 30/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [08:00:00 30/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [08:00:00 30/10/2016] id: Ataxia el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 30/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [08:00:00 30/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 18 u1: sum st: NotStopd t0: [08:00:00 30/10/2016] id: Drowsiness el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [08:00:00 30/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Moderate st: NotStopd t0: [08:00:00 30/10/2016] id: Insomnia el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [08:00:00 30/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: Mild Nau, No Vom st: NotStopd t0: [08:00:00 30/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: ? date < 2 days st: NotStopd t0: [08:00:00 30/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: Beads/ forehead st: NotStopd t0: [08:00:00 30/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 30/10/2016] id: Slurred Speech el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [08:00:00 30/10/2016] id: Sustained Nystamus el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 30/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 30/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [08:00:00 30/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: Mild st: NotStopd t0: [12:00:00 30/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: > Norm activity st: NotStopd t0: [12:00:00 30/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: Mildly anxious st: NotStopd t0: [12:00:00 30/10/2016] id: Ataxia el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 30/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [12:00:00 30/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 15 u1: sum st: NotStopd t0: [12:00:00 30/10/2016] id: Drowsiness el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [12:00:00 30/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Moderate st: NotStopd t0: [12:00:00 30/10/2016] id: Insomnia el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [12:00:00 30/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: Mild Nau, No Vom st: NotStopd t0: [12:00:00 30/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: ? date < 2 days st: NotStopd t0: [12:00:00 30/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: Beads/ forehead st: NotStopd t0: [12:00:00 30/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 30/10/2016] id: Slurred Speech el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [12:00:00 30/10/2016] id: Sustained Nystamus el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 30/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 30/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: Not visible st: NotStopd t0: [12:00:00 30/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: Mild st: NotStopd t0: [12:00:00 30/10/2016] id: Behavior el: 0 cu: CCU cg: RN v1: Anxious st: NotStopd t0: [16:00:00 30/10/2016] id: Aggitation el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [16:00:00 30/10/2016] id: Anxiety el: 0 cu: CCU cg: RN v1: .. st: NotStopd t0: [16:00:00 30/10/2016] id: Ataxia el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [16:00:00 30/10/2016] id: Auditory Disturbance el: 0 cu: CCU cg: RN v1: Not present st: NotStopd t0: [16:00:00 30/10/2016] id: CIWA Sum Total el: 0 cu: CCU cg: RN v1: 23 u1: sum st: NotStopd t0: [16:00:00 30/10/2016] id: Drowsiness el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [16:00:00 30/10/2016] id: GI Prophylaxis el: 0 cu: CCU cg: RN v1: Proton/Pump/Inhi st: NotStopd t0: [16:00:00 30/10/2016] id: Headache el: 0 cu: CCU cg: RN v1: Moderate st: NotStopd t0: [16:00:00 30/10/2016] id: Insomnia el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [16:00:00 30/10/2016] id: Nausea and Vomiting el: 0 cu: CCU cg: RN v1: ..... st: NotStopd t0: [16:00:00 30/10/2016] id: Orient/Clouding Sens el: 0 cu: CCU cg: RN v1: ? date < 2 days st: NotStopd t0: [16:00:00 30/10/2016] id: Paroxysmal Sweats el: 0 cu: CCU cg: RN v1: Beads/ forehead st: NotStopd t0: [16:00:00 30/10/2016] id: Seizure el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [16:00:00 30/10/2016] id: Slurred Speech el: 0 cu: CCU cg: RN v1: Yes st: NotStopd t0: [16:00:00 30/10/2016] id: Sustained Nystamus el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [16:00:00 30/10/2016] id: Tactile Disturbances el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [16:00:00 30/10/2016] id: Tremor el: 0 cu: CCU cg: RN v1: ... st: NotStopd t0: [16:00:00 30/10/2016] id: Visual Disturbances el: 0 cu: CCU cg: RN v1: Mild st: NotStopd t0: [16:00:00 30/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NAS/Low Cholest st: NotStopd t0: [16:00:00 30/10/2016] id: Eye Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 30/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [16:00:00 30/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 15 u1: points st: NotStopd t0: [16:00:00 30/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [16:00:00 30/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [16:00:00 30/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [16:00:00 30/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [16:00:00 30/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [16:00:00 30/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [16:00:00 30/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [16:00:00 30/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [16:00:00 30/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 30/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 2 st: NotStopd t0: [16:00:00 30/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [16:00:00 30/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [16:00:00 30/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [16:00:00 30/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [16:00:00 30/10/2016] id: Skin Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 30/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [16:00:00 30/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd t0: [16:00:00 30/10/2016] id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [16:00:00 30/10/2016] id: Behavior el: 0 cu: CCU cg: RN v1: Anxious st: NotStopd
t0: [15:00:00 30/10/2016] id: Stool Out (non-specific) el: 1 cu: CCU cg: RN vu: ml es: Small t0: [16:00:00 30/10/2016] id: Po Intake PO/Gastric el: 1 cu: CCU cg: RN ai: 103 vo: 200 vu: ml t0: [16:00:00 30/10/2016] tf: [13:44:00 31/10/2016] dt: 1304 id: Gastric Nasogastric el: 1 cu: CCU cg: RN vo: 200 vu: ml t0: [16:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 300 vu: ml
t0: [23:00:00 30/10/2016] dt: 24 id: Gastric Out Total el: 1 cu: CCU cg: RN cv: 200 ap: none t0: [23:00:00 30/10/2016] dt: 24 id: PO/Gastric In Total el: 1 cu: CCU cg: RN cv: 500 ap: none t0: [23:00:00 30/10/2016] dt: 24 id: Stool Out Total el: 1 cu: CCU cg: RN cv: 0 ap: carryForward
t0: [17:00:00 30/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [17:00:00 30/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.8333 u1: Deg. C st: NotStopd t0: [17:00:00 30/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100.1 u1: Deg. F st: NotStopd t0: [18:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [18:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [18:00:00 30/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Calm/Cooperative st: NotStopd t0: [18:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [18:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 77 u1: BPM st: NotStopd t0: [18:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [18:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 138 u1: mmHg v2: 71 u2: mmHg st: NotStopd t0: [18:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 93.3333 u1: mmHg st: NotStopd t0: [18:00:00 30/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [18:00:00 30/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [18:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [18:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [18:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 99 u1: % st: NotStopd t0: [18:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [18:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 180 vu: ml
tf: [22:00:00 30/10/2016] pt: Unit Dose rt: PO fr: Q2H fs: 19, 21, 23, 1, 3, 5, 7, 9, 11, 13, 15, 17 dn: 12 m1: Lorazepam v1: 2 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: Q4-6H:PRN m1: Oxycodone-Acetaminophen v1: 1-2 u1: TAB tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: Q6H:PRN m1: Haloperidol v1: 1-2 u1: mg
t0: [20:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [20:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [20:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [20:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 78 u1: BPM st: NotStopd t0: [20:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [20:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 136 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [20:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 90.6667 u1: mmHg st: NotStopd t0: [20:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [20:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [20:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 92 u1: % st: NotStopd t0: [20:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [22:00:00 30/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [22:00:00 30/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [22:00:00 30/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 30/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [22:00:00 30/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 81 u1: BPM st: NotStopd t0: [22:00:00 30/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [22:00:00 30/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 128 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [22:00:00 30/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 85.3333 u1: mmHg st: NotStopd t0: [22:00:00 30/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [22:00:00 30/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [22:00:00 30/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 94 u1: % st: NotStopd t0: [22:00:00 30/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [22:00:00 30/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.7778 u1: Deg. C st: NotStopd t0: [22:00:00 30/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 100 u1: Deg. F st: NotStopd t0: [22:00:00 30/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [21:00:00 30/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [21:00:00 30/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NAS/Low Cholest st: NotStopd t0: [21:00:00 30/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [21:00:00 30/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [21:00:00 30/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 15 u1: points st: NotStopd t0: [21:00:00 30/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [21:00:00 30/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [21:00:00 30/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [21:00:00 30/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [21:00:00 30/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [21:00:00 30/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [21:00:00 30/10/2016] id: Neuro Symptoms el: 0 cu: CCU cg: RN v1: Headache st: NotStopd t0: [21:00:00 30/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 2 st: NotStopd t0: [21:00:00 30/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [21:00:00 30/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [21:00:00 30/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [21:00:00 30/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [21:00:00 30/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [21:00:00 30/10/2016] id: Seizure Activity el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [21:00:00 30/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [21:00:00 30/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [21:00:00 30/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd
t0: [20:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml t0: [22:00:00 30/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 140 vu: ml
t0: [21:00:00 30/10/2016] id: Eye Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 30/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 30 degrees st: NotStopd t0: [21:00:00 30/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [21:00:00 30/10/2016] id: Oral Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 30/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: Independent st: NotStopd t0: [21:00:00 30/10/2016] id: Skin Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [21:00:00 30/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Back st: NotStopd t0: [21:00:00 30/10/2016] id: Back Care el: 0 cu: CCU cg: RN v1: Done st: NotStopd t0: [22:00:00 30/10/2016] id: INV Line#1 Type/Site el: 0 cu: CCU cg: RN v1: Multi-lumen v2: Right Femoral st: NotStopd t0: [22:00:00 30/10/2016] tf: [13:44:00 31/10/2016] dt: 944 id: IV #4 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 8 st: NotStopd t0: [22:00:00 30/10/2016] tf: [13:44:00 31/10/2016] dt: 944 id: IV #4 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 18 gauge st: NotStopd t0: [22:00:00 30/10/2016] tf: [13:44:00 31/10/2016] dt: 944 id: IV Site Appear #4 el: 0 cu: CCU cg: RN v1: WNL st: NotStopd
tf: [17:00:00 31/10/2016] pt: Unit Dose rt: IV fr: Q2H fs: 23, 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 21 dn: 12 m1: Lorazepam v1: 2 u1: mg
t0: [00:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [00:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [00:00:00 31/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [00:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 82 u1: BPM st: NotStopd t0: [00:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [00:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [00:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [00:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 22 u1: BPM st: NotStopd t0: [00:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 95 u1: % st: NotStopd t0: [00:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [00:00:00 31/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 80 vu: ml
t0: [23:00:00 31/10/2016] dt: 1 id: Total Hourly Output el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 31/10/2016] dt: 1 id: Net Hourly Balance el: 1 cu: CCU cg: RN cv: 0 ap: none t0: [23:00:00 31/10/2016] dt: 24 id: Urine Out Total el: 1 cu: CCU cg: RN cv: 300 ap: none t0: [23:00:00 31/10/2016] dt: 24 id: 24h Net Body Balance el: 1 cu: CCU cg: RN cv: -400 ap: carryForward t0: [23:00:00 31/10/2016] dt: 24 id: 24h Total Out el: 1 cu: CCU cg: RN cv: 700 ap: carryForward t0: [23:00:00 31/10/2016] dt: multiple days id: LOS Net Body Balance el: 1 cu: CCU cg: RN cv: 4939.09 ap: carryForward
tf: [01:00:00 31/10/2016] pt: Unit Dose rt: PO fr: QID:PRN m1: Diltiazem v1: 30 u1: mg
t0: [06:00:00 31/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: -1 vo: 0 st: D/C'd
t0: [04:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [04:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [04:00:00 31/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [04:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [04:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 118 u1: mmHg v2: 64 u2: mmHg st: NotStopd t0: [04:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 82 u1: mmHg st: NotStopd t0: [04:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [04:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 26 u1: BPM st: NotStopd t0: [04:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 88 u1: % st: NotStopd t0: [04:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [06:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [06:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [06:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [06:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 88 u1: BPM st: NotStopd t0: [06:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [06:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [06:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [06:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [06:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 32 u1: BPM st: NotStopd t0: [06:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 88 u1: % st: NotStopd t0: [06:00:00 31/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 36.6667 u1: Deg. C st: NotStopd t0: [06:00:00 31/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98 u1: Deg. F st: NotStopd t0: [06:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [00:00:00 31/10/2016] tf: [13:44:00 31/10/2016] dt: 824 id: Stool Out (non-specific) el: 1 cu: CCU cg: RN vo: 100 vu: ml t0: [04:00:00 31/10/2016] id: Stool Out (non-specific) el: 1 cu: CCU cg: RN vo: 200 vu: ml t0: [04:00:00 31/10/2016] id: Urine Out Foley el: 1 cu: CCU cg: RN vo: 220 vu: ml t0: [06:00:00 31/10/2016] id: Stool Out (non-specific) el: 1 cu: CCU cg: RN vo: 100 vu: ml
t0: [02:00:00 31/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [02:00:00 31/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NAS/Low Cholest st: NotStopd t0: [02:00:00 31/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [02:00:00 31/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [02:00:00 31/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 15 u1: points st: NotStopd t0: [02:00:00 31/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [02:00:00 31/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [02:00:00 31/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [02:00:00 31/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [02:00:00 31/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [02:00:00 31/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [02:00:00 31/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 3 st: NotStopd t0: [02:00:00 31/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Coarse st: NotStopd t0: [02:00:00 31/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [02:00:00 31/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [02:00:00 31/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [02:00:00 31/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [02:00:00 31/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [02:00:00 31/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd
t0: [07:00:00 31/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: WBC Hematology el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Hematocrit Hematology el: 0 cu: CCU cg: 140 v1: 41.4 u1: % rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Hemoglobin Hematology el: 0 cu: CCU cg: 140 v1: 13.8 u1: gm/dl rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Platelets Hematology el: 0 cu: CCU cg: 140 v1: 254 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: RBC Hematology el: 0 cu: CCU cg: 140 v1: 4.39 u1: /mic l rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: WBC (4-11,000) Hematology el: 0 cu: CCU cg: 140 v1: 12.6 rs: Final st: NotStopd
t0: [07:00:00 31/10/2016] id: Glucose Chemistry el: 0 cu: CCU cg: 140 v1: 107 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Potassium Chemistry el: 0 cu: CCU cg: 140 v1: 3.7 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Sodium Chemistry el: 0 cu: CCU cg: 140 v1: 141 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Glucose (70-105) Chemistry el: 0 cu: CCU cg: 140 v1: 107 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CCU cg: 140 v1: 3.7 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Sodium (135-148) Chemistry el: 0 cu: CCU cg: 140 v1: 141 rs: Final st: NotStopd
t0: [08:00:00 31/10/2016] id: Imp Skin Cleanse #1 el: 0 cu: CCU cg: -1 st: D/C'd t0: [08:00:00 31/10/2016] id: ImpSkin Treatment #1 el: 0 cu: CCU cg: -1 st: D/C'd t0: [08:00:00 31/10/2016] id: Inc Cleansing #1 el: 0 cu: CCU cg: -1 st: D/C'd t0: [08:00:00 31/10/2016] id: Inc Closure/Appear#1 el: 0 cu: CCU cg: -1 st: D/C'd t0: [08:00:00 31/10/2016] id: Inc Drainage/Amt #1 el: 0 cu: CCU cg: -1 st: D/C'd t0: [08:00:00 31/10/2016] id: Inc Dsg/Status #1 el: 0 cu: CCU cg: -1 st: D/C'd t0: [08:00:00 31/10/2016] id: Incision/Wound #1 el: 0 cu: CCU cg: -1 st: D/C'd
t0: [08:00:00 31/10/2016] id: Gastric Meds PO/Gastric el: 1 cu: CCU cg: -1 ai: 255 vo: 0 st: D/C'd
t0: [08:00:00 31/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [08:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [08:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [08:00:00 31/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Calm/Cooperative st: NotStopd t0: [08:00:00 31/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [08:00:00 31/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 31/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NAS/Low Cholest st: NotStopd t0: [08:00:00 31/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 31/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [08:00:00 31/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [08:00:00 31/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 15 u1: points st: NotStopd t0: [08:00:00 31/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [08:00:00 31/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 31/10/2016] id: HOB el: 0 cu: CCU cg: RN v1: 90 degrees st: NotStopd t0: [08:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 89 u1: BPM st: NotStopd t0: [08:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [08:00:00 31/10/2016] id: IV #4 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 8 st: NotStopd t0: [08:00:00 31/10/2016] id: IV #4 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 18 gauge st: NotStopd t0: [08:00:00 31/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Chair st: NotStopd t0: [08:00:00 31/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [08:00:00 31/10/2016] id: ImpSkin Character #1 el: 0 cu: CCU cg: RN v1: Abrasion st: NotStopd t0: [08:00:00 31/10/2016] id: ImpSkin Drain/Amt#1 el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [08:00:00 31/10/2016] id: ImpSkin Wound Base#1 el: 0 cu: CCU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 31/10/2016] id: Impaired Skin Site#1 el: 0 cu: CCU cg: RN v1: Facial st: NotStopd t0: [08:00:00 31/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Crackles st: NotStopd t0: [08:00:00 31/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 31/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [08:00:00 31/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [08:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [08:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 85.3333 u1: mmHg st: NotStopd t0: [08:00:00 31/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [08:00:00 31/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [08:00:00 31/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [08:00:00 31/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 2 st: NotStopd t0: [08:00:00 31/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: Supervised st: NotStopd t0: [08:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [08:00:00 31/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [08:00:00 31/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 31/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [08:00:00 31/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [08:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 25 u1: BPM st: NotStopd t0: [08:00:00 31/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [08:00:00 31/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [08:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 92 u1: % st: NotStopd t0: [08:00:00 31/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [08:00:00 31/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [08:00:00 31/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37.2222 u1: Deg. C st: NotStopd t0: [08:00:00 31/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 99 u1: Deg. F st: NotStopd t0: [08:00:00 31/10/2016] id: Turn el: 0 cu: CCU cg: RN v1: Turns by self st: NotStopd t0: [08:00:00 31/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 31/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd t0: [08:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [08:00:00 31/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Chairfast st: NotStopd t0: [08:00:00 31/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [08:00:00 31/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd t0: [08:00:00 31/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Rarely Moist st: NotStopd t0: [08:00:00 31/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Prob. Inadequate st: NotStopd t0: [08:00:00 31/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 16 u1: number st: NotStopd t0: [08:00:00 31/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd
t0: [07:00:00 31/10/2016] id: BUN el: 0 cu: CCU cg: 140 v1: 22 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Calcium Chemistry el: 0 cu: CCU cg: 140 v1: 9.5 u1: mg/dl rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Chloride Chemistry el: 0 cu: CCU cg: 140 v1: 103 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Creatinine Chemistry el: 0 cu: CCU cg: 140 v1: 0.6 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Magnesium Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Phosphorous Chemistry el: 0 cu: CCU cg: 140 v1: 2.9 u1: mEq/L rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: BUN (6-20) Chemistry el: 0 cu: CCU cg: 140 v1: 22 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Calcium (8.4-10.2) Chemistry el: 0 cu: CCU cg: 140 v1: 9.5 u1: mg/dl rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Carbon Dioxide Chemistry el: 0 cu: CCU cg: 140 v1: 26 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Chloride (100-112) Chemistry el: 0 cu: CCU cg: 140 v1: 103 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Creatinine (0-1.3) Chemistry el: 0 cu: CCU cg: 140 v1: 0.6 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CCU cg: 140 v1: 1.9 rs: Final st: NotStopd t0: [07:00:00 31/10/2016] id: Phosphorous(2.7-4.5) Chemistry el: 0 cu: CCU cg: 140 v1: 2.9 u1: mEq/L rs: Final st: NotStopd
t0: [09:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [09:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [09:00:00 31/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [09:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [09:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [09:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 132 u1: mmHg v2: 66 u2: mmHg st: NotStopd t0: [09:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 88 u1: mmHg st: NotStopd t0: [09:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [09:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 20 u1: BPM st: NotStopd t0: [09:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 91 u1: % st: NotStopd t0: [09:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd t0: [10:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [10:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [10:00:00 31/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [10:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 89 u1: BPM st: NotStopd t0: [10:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [10:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 130 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [10:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 86.6667 u1: mmHg st: NotStopd t0: [10:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [10:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 24 u1: BPM st: NotStopd t0: [10:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 92 u1: % st: NotStopd t0: [10:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [09:00:00 31/10/2016] id: Po Intake PO/Gastric el: 1 cu: CCU cg: RN ai: 103 vo: 150 vu: ml t0: [09:00:00 31/10/2016] id: Stool Out (non-specific) el: 1 cu: CCU cg: RN vu: ml es: Medium
t0: [23:00:00 31/10/2016] dt: 24 id: Stool Out Total el: 1 cu: -1 cg: RN cv: 400 ap: carryForward
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: TD fr: QD fs: 10 dn: 1 m1: Nicotine v1: 14 u1: mg
t0: [11:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [11:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [11:00:00 31/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [11:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 84 u1: BPM st: NotStopd t0: [11:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [11:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 127 u1: mmHg v2: 70 u2: mmHg st: NotStopd t0: [11:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 89 u1: mmHg st: NotStopd t0: [11:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [11:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 30 u1: BPM st: NotStopd t0: [11:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 87 u1: % st: NotStopd t0: [11:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [12:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [12:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [12:00:00 31/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [12:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [12:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [12:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 116 u1: mmHg v2: 68 u2: mmHg st: NotStopd t0: [12:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 84 u1: mmHg st: NotStopd t0: [12:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [12:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 18 u1: BPM st: NotStopd t0: [12:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 90 u1: % st: NotStopd t0: [12:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [12:03:00 31/10/2016] id: Art.pH ABG el: 0 cu: CCU cg: 140 v1: 7.5 rs: Final st: NotStopd t0: [12:03:00 31/10/2016] id: Arterial Base Excess ABG el: 0 cu: CCU cg: 140 v1: 4 rs: Final st: NotStopd t0: [12:03:00 31/10/2016] id: Arterial CO2(Calc) ABG el: 0 cu: CCU cg: 140 v1: 30 rs: Final st: NotStopd t0: [12:03:00 31/10/2016] id: Arterial PaCO2 ABG el: 0 cu: CCU cg: 140 v1: 37 u1: mmHg rs: Final st: NotStopd t0: [12:03:00 31/10/2016] id: Arterial PaO2 ABG el: 0 cu: CCU cg: 140 v1: 61 u1: mmHg rs: Final st: NotStopd t0: [12:03:00 31/10/2016] id: Arterial pH ABG el: 0 cu: CCU cg: 140 v1: 7.5 rs: Final st: NotStopd
t0: [10:00:00 31/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Bedrest st: NotStopd t0: [12:00:00 31/10/2016] id: Pain Present el: 0 cu: CCU cg: RN v1: No st: NotStopd t0: [12:00:00 31/10/2016] id: Riker-SAS Scale el: 0 cu: CCU cg: RN v1: Calm/Cooperative st: NotStopd t0: [12:00:00 31/10/2016] id: Corneal Reflex R/L el: 0 cu: CCU cg: RN v1: Intact v2: Intact st: NotStopd t0: [12:00:00 31/10/2016] id: Cough Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 31/10/2016] id: Diet Type el: 0 cu: CCU cg: RN v1: NAS/Low Cholest st: NotStopd t0: [12:00:00 31/10/2016] id: Eye Opening el: 0 cu: CCU cg: RN v1: 4 Spontaneously st: NotStopd t0: [12:00:00 31/10/2016] id: Follows Commands el: 0 cu: CCU cg: RN v1: Consistently st: NotStopd t0: [12:00:00 31/10/2016] id: GCS Total el: 0 cu: CCU cg: RN v1: 15 u1: points st: NotStopd t0: [12:00:00 31/10/2016] id: GU Catheter Size el: 0 cu: CCU cg: RN v1: 14 French st: NotStopd t0: [12:00:00 31/10/2016] id: Gag Reflex el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 31/10/2016] id: IV #4 Insert Date el: 0 cu: CCU cg: RN v1: 9 v2: 8 st: NotStopd t0: [12:00:00 31/10/2016] id: IV #4 Site/Size el: 0 cu: CCU cg: RN v1: Right Antecub v2: 18 gauge st: NotStopd t0: [12:00:00 31/10/2016] id: Activity el: 0 cu: CCU cg: RN v1: Chair st: NotStopd t0: [12:00:00 31/10/2016] id: Activity Tolerance el: 0 cu: CCU cg: RN v1: Tolerated Well st: NotStopd t0: [12:00:00 31/10/2016] id: LLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 31/10/2016] id: LUL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 31/10/2016] id: Level of Conscious el: 0 cu: CCU cg: RN v1: Alert st: NotStopd t0: [12:00:00 31/10/2016] id: Motor Response el: 0 cu: CCU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [12:00:00 31/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [12:00:00 31/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 4 u1: lpm st: NotStopd t0: [12:00:00 31/10/2016] id: Oral Cavity el: 0 cu: CCU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [12:00:00 31/10/2016] id: Orientation el: 0 cu: CCU cg: RN v1: Oriented x 3 st: NotStopd t0: [12:00:00 31/10/2016] id: Assistance Device el: 0 cu: CCU cg: RN v1: 1 Person Assist st: NotStopd t0: [12:00:00 31/10/2016] id: RLL Lung Sounds el: 0 cu: CCU cg: RN v1: Clear st: NotStopd t0: [12:00:00 31/10/2016] id: RUL Lung Sounds el: 0 cu: CCU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 31/10/2016] id: Respiratory Effort el: 0 cu: CCU cg: RN v1: Normal st: NotStopd t0: [12:00:00 31/10/2016] id: Respiratory Pattern el: 0 cu: CCU cg: RN v1: Regular st: NotStopd t0: [12:00:00 31/10/2016] id: Responds to Stimuli el: 0 cu: CCU cg: RN v1: Verbal v2: Localizes st: NotStopd t0: [12:00:00 31/10/2016] id: Skin Color el: 0 cu: CCU cg: RN v1: Normal for Race st: NotStopd t0: [12:00:00 31/10/2016] id: Skin Integrity el: 0 cu: CCU cg: RN v1: Intact st: NotStopd t0: [12:00:00 31/10/2016] id: Spontaneous Movement el: 0 cu: CCU cg: RN v1: Purposeful st: NotStopd t0: [12:00:00 31/10/2016] id: Urine Source el: 0 cu: CCU cg: RN v1: Indwelling Cath st: NotStopd t0: [12:00:00 31/10/2016] id: Verbal Response el: 0 cu: CCU cg: RN v1: 5 Oriented st: NotStopd t0: [12:00:00 31/10/2016] id: Braden Activity el: 0 cu: CCU cg: RN v1: Chairfast st: NotStopd t0: [12:00:00 31/10/2016] id: Braden Frict/Shear el: 0 cu: CCU cg: RN v1: Potential Prob st: NotStopd t0: [12:00:00 31/10/2016] id: Braden Mobility el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd t0: [12:00:00 31/10/2016] id: Braden Moisture el: 0 cu: CCU cg: RN v1: Rarely Moist st: NotStopd t0: [12:00:00 31/10/2016] id: Braden Nutrition el: 0 cu: CCU cg: RN v1: Adequate st: NotStopd t0: [12:00:00 31/10/2016] id: Braden Score el: 0 cu: CCU cg: RN v1: 17 u1: number st: NotStopd t0: [12:00:00 31/10/2016] id: Braden SensoryPercep el: 0 cu: CCU cg: RN v1: Sl. Limited st: NotStopd
t0: [12:00:00 31/10/2016] id: Temp. Site el: 0 cu: CCU cg: RN v1: Oral st: NotStopd t0: [12:00:00 31/10/2016] id: Temperature C (calc) el: 0 cu: CCU cg: RN v1: 37 u1: Deg. C st: NotStopd t0: [12:00:00 31/10/2016] id: Temperature F el: 0 cu: CCU cg: RN v1: 98.6 u1: Deg. F st: NotStopd t0: [13:00:00 31/10/2016] id: Service Type el: 0 cu: CCU cg: RN v1: CCU st: NotStopd t0: [13:00:00 31/10/2016] id: Code Status el: 0 cu: CCU cg: RN v1: Full Code st: NotStopd t0: [13:00:00 31/10/2016] id: Ectopy Frequency el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 31/10/2016] id: Ectopy Type el: 0 cu: CCU cg: RN v1: None st: NotStopd t0: [13:00:00 31/10/2016] id: Heart Rate el: 0 cu: CCU cg: RN v1: 86 u1: BPM st: NotStopd t0: [13:00:00 31/10/2016] id: Heart Rhythm el: 0 cu: CCU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 31/10/2016] id: NBP el: 0 cu: CCU cg: RN v1: 125 u1: mmHg v2: 55 u2: mmHg st: NotStopd t0: [13:00:00 31/10/2016] id: NBP Mean el: 0 cu: CCU cg: RN v1: 78.3333 u1: mmHg st: NotStopd t0: [13:00:00 31/10/2016] id: Precautions el: 0 cu: CCU cg: RN v1: Universal st: NotStopd t0: [13:00:00 31/10/2016] id: Respiratory Rate el: 0 cu: CCU cg: RN v1: 23 u1: BPM st: NotStopd t0: [13:00:00 31/10/2016] id: SpO2 el: 0 cu: CCU cg: RN v1: 93 u1: % st: NotStopd t0: [13:00:00 31/10/2016] id: calprevflg el: 0 cu: CCU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 31/10/2016] id: Po Intake PO/Gastric el: 1 cu: CCU cg: RN ai: 103 vo: 150 vu: ml
t0: [23:00:00 31/10/2016] dt: 24 id: 24h Total In el: 1 cu: -1 cg: RN cv: 300 ap: none t0: [23:00:00 31/10/2016] dt: 24 id: PO/Gastric In Total el: 1 cu: -1 cg: RN cv: 300 ap: none
t0: [13:00:00 31/10/2016] id: O2 Delivery Device el: 0 cu: CCU cg: RN v1: Nasal Cannula st: NotStopd t0: [13:00:00 31/10/2016] id: O2 Flow (lpm) el: 0 cu: CCU cg: RN v1: 5 u1: lpm st: NotStopd
tf: [17:00:00 31/10/2016] pt: Unit Dose rt: IV fr: Q1H:PRN m1: Lorazepam v1: 1-4 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: IH fr: Q4H:PRN m1: Albuterol-Ipratropium v1: 1-2 u1: PUFF tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: Q4-6H:PRN m1: Acetaminophen v1: 325-650 u1: mg
tf: [16:00:00 01/11/2016] pt: Unit Dose rt: IV fr: Q4H:PRN m1: Lorazepam v1: 1-4 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: IV fr: Q4H:PRN m1: Lorazepam v1: 2 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: Q6H:PRN m1: Guaifenesin v1: 5-10 u1: ml
tf: [16:00:00 01/11/2016] pt: Unit Dose rt: PO fr: TID fs: 08, 16, 22 dn: 3 m1: Clonazepam v1: 1.5 u1: mg
tf: [16:00:00 01/11/2016] pt: Unit Dose rt: PO fr: HS:PRN m1: traZODONE HCl v1: 150 u1: mg
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: QID fs: 10, 14, 18, 22 dn: 4 m1: Nystatin Oral Suspension v1: 5 u1: ml
tf: [16:00:00 01/11/2016] pt: Unit Dose rt: PO fr: ONCE fs: 12 dn: 1 m1: Oxcarbazepine v1: 150 u1: mg tf: [11:00:00 02/11/2016] pt: Unit Dose rt: PO fr: ONCE fs: 12 dn: 1 m1: Potassium Chloride v1: 60 u1: mEq
tf: [08:00:00 02/11/2016] pt: Unit Dose rt: PO fr: ONCE fs: 17 dn: 1 m1: Oxcarbazepine v1: 150 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: Q24H fs: 17 dn: 1 m1: Pantoprazole v1: 40 u1: mg
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: traZODONE HCl v1: 100 u1: mg tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: TID fs: 08, 16, 22 dn: 3 m1: Clonazepam v1: 0.5 u1: mg
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Oxcarbazepine v1: 150 u1: mg
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Quetiapine Fumarate v1: 25 u1: mg
tf: [18:00:00 03/11/2016] pt: Unit Dose rt: PO fr: ONCE fs: 23 dn: 1 m1: Lorazepam v1: 1 u1: mg
dd: 30000 ds: 1 ld: ANXIETY STATE NOS dd: 311 ds: 2 ld: DEPRESSIVE DISORDER NEC dd: 7862 ds: 3 ld: COUGH dd: V653 ds: 4 ld: DIETARY SURVEIL/COUNSEL dd: V6542 ds: 5 ld: COUNSEL SUBST USE/ABUSE
dd: 3004 ds: 4 ld: DYSTHYMIC DISORDER dd: 311 ds: 2 ld: DEPRESSIVE DISORDER NEC dd: 4549 ds: 6 ld: VARICOSE VEIN OF LEG NOS dd: 71690 ds: 1 ld: ARTHROPATHY NOS-UNSPEC dd: 71696 ds: 8 ld: ARTHROPATHY NOS-L/LEG dd: 71946 ds: 7 ld: JOINT PAIN-L/LEG dd: 78605 ds: 5 ld: SHORTNESS OF BREATH dd: V653 ds: 3 ld: DIETARY SURVEIL/COUNSEL
dd: 30500 ds: 1 ld: ALCOHOL ABUSE-UNSPEC
dd: 84200 ds: 1 ld: SPRAIN OF WRIST NOS dd: E8889 ds: 2 ld: OTHER UNSPECIFIED FALL
dd: 30500 ds: 1 ld: ALCOHOL ABUSE-UNSPEC dd: 9916 ds: 2 ld: HYPOTHERMIA dd: E9019 ds: 3 ld: EXCESSIVE COLD NOS
dd: 30390 ds: 2 ld: ALCOH DEP NEC/NOS-UNSPEC dd: 30500 ds: 1 ld: ALCOHOL ABUSE-UNSPEC dd: 3051 ds: 4 ld: TOBACCO USE DISORDER dd: 311 ds: 3 ld: DEPRESSIVE DISORDER NEC dd: 496 ds: 7 ld: CHR AIRWAY OBSTRUCT NEC dd: 71941 ds: 6 ld: JOINT PAIN-SHLDER dd: 71943 ds: 5 ld: JOINT PAIN-FOREARM dd: 78052 ds: 9 ld: INSOMNIA, UNSPECIFIED dd: 78609 ds: 8 ld: RESPIRATORY ABNORM NEC
dd: 2762 ds: 2 ld: ACIDOSIS dd: 30500 ds: 1 ld: ALCOHOL ABUSE-UNSPEC dd: 30500 ds: 4 ld: ALCOHOL ABUSE-UNSPEC dd: 51881 ds: 1 ld: RESPIRATORY FAILURE dd: 78009 ds: 2 ld: OTH ALTER OF CONSCIOUSNE dd: 7990 ds: 3 ld: ASPHYXIA
dd: 29570 ds: 1 ld: SCHIZOAFFECTIVE DISORDER
dd: 3004 ds: 3 ld: DYSTHYMIC DISORDER dd: 30390 ds: 2 ld: ALCOH DEP NEC/NOS-UNSPEC dd: 30500 ds: 1 ld: ALCOHOL ABUSE-UNSPEC dd: 311 ds: 4 ld: DEPRESSIVE DISORDER NEC dd: 4928 ds: 6 ld: EMPHYSEMA NEC dd: 71945 ds: 8 ld: JOINT PAIN-PELVIS dd: 78609 ds: 7 ld: RESPIRATORY ABNORM NEC dd: V6542 ds: 5 ld: COUNSEL SUBST USE/ABUSE
dd: 29570 ds: 1 ld: SCHIZOAFFECTIVE DISORDER
dd: 29570 ds: 1 ld: SCHIZOAFFECTIVE DISORDER
dd: 29530 ds: 1 ld: PARANOID SCHIZO-UNSPEC dd: 29570 ds: 2 ld: SCHIZOAFFECTIVE DISORDER
dd: 29530 ds: 1 ld: PARANOID SCHIZO-UNSPEC
dd: 29570 ds: 1 ld: SCHIZOAFFECTIVE DISORDER
dd: 29570 ds: 1 ld: SCHIZOAFFECTIVE DISORDER dd: 3009 ds: 1 ld: UNSPEC NONPSYCHOTIC MENT dd: 30500 ds: 4 ld: ALCOHOL ABUSE-UNSPEC dd: 311 ds: 2 ld: DEPRESSIVE DISORDER NEC dd: 37230 ds: 3 ld: CONJUNCTIVITIS NOS
dd: 29570 ds: 1 ld: SCHIZOAFFECTIVE DISORDER
dd: 29570 ds: 1 ld: SCHIZOAFFECTIVE DISORDER
dd: 3004 ds: 1 ld: DYSTHYMIC DISORDER dd: 30390 ds: 2 ld: ALCOH DEP NEC/NOS-UNSPEC dd: 3051 ds: 4 ld: TOBACCO USE DISORDER dd: 311 ds: 3 ld: DEPRESSIVE DISORDER NEC dd: 78050 ds: 6 ld: SLEEP DISTURBANCE NOS dd: 7831 ds: 7 ld: ABNORMAL WEIGHT GAIN dd: 78605 ds: 5 ld: SHORTNESS OF BREATH dd: 7862 ds: 9 ld: COUGH dd: V653 ds: 8 ld: DIETARY SURVEIL/COUNSEL
dd: 3004 ds: 3 ld: DYSTHYMIC DISORDER dd: 30390 ds: 2 ld: ALCOH DEP NEC/NOS-UNSPEC dd: 30500 ds: 1 ld: ALCOHOL ABUSE-UNSPEC dd: 3051 ds: 5 ld: TOBACCO USE DISORDER dd: 311 ds: 4 ld: DEPRESSIVE DISORDER NEC dd: 3689 ds: 6 ld: VISUAL DISTURBANCE NOS dd: 78605 ds: 8 ld: SHORTNESS OF BREATH dd: 7862 ds: 7 ld: COUGH dd: 9952 ds: 9 ld: ADV EFF MED/BIOL SUB NOS
dd: 30390 ds: 4 ld: ALCOH DEP NEC/NOS-UNSPEC dd: 311 ds: 5 ld: DEPRESSIVE DISORDER NEC dd: 412 ds: 2 ld: OLD MYOCARDIAL INFARCT dd: 7850 ds: 3 ld: TACHYCARDIA NOS dd: 7962 ds: 1 ld: ELEV BL PRES W/O HYPERTN
dd: 30500 ds: 1 ld: ALCOHOL ABUSE-UNSPEC
dd: 30500 ds: 3 ld: ALCOHOL ABUSE-UNSPEC dd: 78099 ds: 2 ld: OTH GENERAL SYMPTOMS dd: 95901 ds: 1 ld: HEAD INJURY UNSPECIFIED dd: E8889 ds: 4 ld: OTHER UNSPECIFIED FALL
dd: 30300 ds: 1 ld: AC ALCOHOL INTOX-UNSPEC
dd: 30391 ds: 1 ld: ALCOH DEP NEC/NOS-CONTIN
dd: 30390 ds: 1 ld: ALCOH DEP NEC/NOS-UNSPEC
dd: 30500 ds: 2 ld: ALCOHOL ABUSE-UNSPEC dd: 78099 ds: 1 ld: OTH GENERAL SYMPTOMS dd: V6284 ds: 3 ld: SUICIDAL IDEATION
dd: 30500 ds: 1 ld: ALCOHOL ABUSE-UNSPEC
dd: 29590 ds: 2 ld: SCHIZOPHRENIA NOS-UNSPEC dd: 30390 ds: 3 ld: ALCOH DEP NEC/NOS-UNSPEC dd: 7955 ds: 1 ld: REACT TUBERCULIN W/O TUB