This log is also available as text (s08779.txt) and as a (binary) annotation file (s08779.log).
Generated: Monday, 07-Jun-2010 13:20:27 EDT
(All dates below are surrogates.)
t0: [12:59:54 08/10/2014] tf: [10:35:26 10/10/2014] id: a40012 [view]
t0: [18:03:59 08/10/2014] tf: [10:33:59 13/10/2014] id: a40012n [view]
dd: 41401 ds: 1 ld: CORON ATHEROSCLER NATIVE dd: 78650 ds: 2 ld: CHEST PAIN NOS
dd: 25000 ds: 4 ld: DIABETES MELLITUS W/OUT dd: 2720 ds: 3 ld: PURE HYPERCHOLESTEROLEM dd: 41071 ds: 1 ld: AMI, SUBENDOCARD INFARCT dd: 41401 ds: 2 ld: CORON ATHEROSCLER NATIVE
tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Aspirin EC v1: 325 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Atorvastatin v1: 10 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Folic Acid v1: 1 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Moexipril HCl v1: 7.5 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Multivitamins v1: 1 u1: CAP
tf: [18:00:00 10/11/2014] pt: IV Piggyback rt: IV fr: ASDIR m1: Heparin Sodium v1: 25000 u1: UNIT m2: D5W v2: 250 u2: ml tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: Q24H fs: 17 dn: 1 m1: Pantoprazole v1: 40 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: Q4-6H:PRN m1: Acetaminophen v1: 325-650 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: Q6H fs: 17, 23, 5, 11 dn: 4 m1: Erythromycin v1: 250 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: QD:PRN m1: Bisacodyl v1: 10 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: QID:PRN m1: Aluminum-Magnesium Hydroxide v1: 15-30 u1: ml tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PR fr: QD:PRN m1: Bisacodyl (Rectal) v1: 10 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: SC fr: ASDIR m1: Insulin v1: 0 u1: UNIT
tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Docusate Sodium v1: 100 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Metoprolol v1: 25 u1: mg tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: HS fs: 22 dn: 1 m1: Nortriptyline v1: 25 u1: mg
tf: [18:00:00 10/11/2014] pt: Unit Dose rt: PO fr: Q4-6H:PRN m1: Lorazepam v1: 1-2 u1: mg
tf: [08:00:00 11/11/2014] pt: Unit Dose rt: NG fr: QD fs: 10 dn: 1 m1: Aspirin v1: 325 u1: mg tf: [09:00:00 12/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Isosorbide Mononitrate (Extended Release) v1: 60 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Aspirin EC v1: 325 u1: mg
id: Epinephrine-k el: 100 cu: CSRU cg: RN io: D5W 250.0ml + 2mcgkgmin Epinephrine-k IV Infusions am: 2 du: mcgkgmin rt: IV Drip id: Levophed-k el: 100 cu: CSRU cg: RN io: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions am: 4 du: mcgkgmin rt: IV Drip id: Nitroglycerine-k el: 100 cu: CSRU cg: RN io: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions am: 100 du: mcgkgmin rt: IV Drip id: Neosynephrine-k el: 100 cu: CSRU cg: RN io: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions am: 60 du: mg rt: IV Drip id: Propofol el: 100 cu: CSRU cg: RN io: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions am: 500 du: mcgkgmin rt: IV Drip id: KCL el: 100 cu: CSRU cg: RN io: D5W 50.0ml IV Infusions am: 20 du: mEq rt: Intravenous Push
io: D5W IV Infusions el: 1 cu: CSRU cg: RN ra: 10 ru: ml/hr
id: OR Crystalloid el: 1 cu: CSRU cg: RN io: OR Crystalloid OR Intake du: ml rt: Intravenous Push id: OR Colloid el: 1 cu: CSRU cg: RN io: OR Colloid OR Intake du: ml rt: Intravenous Push id: D5W el: 1 cu: CSRU cg: RN io: D5W 50.0ml IV Infusions vo: 50 du: ml rt: Intravenous Push id: D5W el: 1 cu: CSRU cg: RN io: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions vo: 250 du: ml rt: Intravenous Push id: D5W el: 1 cu: CSRU cg: RN io: D5W 250.0ml IV Infusions vo: 250 du: ml rt: Intravenous Push id: D5W el: 1 cu: CSRU cg: RN io: D5W IV Infusions du: ml rt: Intravenous Push id: D5W el: 1 cu: CSRU cg: RN io: D5W 250.0ml + 2mcgkgmin Epinephrine-k IV Infusions vo: 250 du: ml rt: Intravenous Push id: D5W el: 1 cu: CSRU cg: RN io: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions vo: 250 du: ml rt: Intravenous Push id: D5W el: 1 cu: CSRU cg: RN io: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions vo: 250 du: ml rt: Intravenous Push id: N/A el: 1 cu: CSRU cg: RN io: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions vo: 50 du: vl rt: Intravenous Push id: Lactated Ringers el: 1 cu: CSRU cg: RN io: Lactated Ringers IV Infusions du: ml rt: Intravenous Push
tf: [11:47:00 12/11/2014] dt: 2895 cu: CSRU de: FA2
id: D5W el: 1 cu: CSRU cg: -1 io: D5W 100.0ml IV Infusions vo: 100 du: ml rt: Intravenous Push id: Po Intake el: 1 cu: CSRU cg: -1 io: Po Intake PO/Gastric du: ml rt: Oral
t0: [10:42:00 10/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.4 rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 195 rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 5.3 rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: 1 rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 27 rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 42 u1: mmHg rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 384 u1: mmHg rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.4 rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 195 rs: Final st: NotStopd t0: [10:42:00 10/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 5.3 rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.44 rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 201 rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 5.9 rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: 2 rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 27 rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 39 u1: mmHg rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 338 u1: mmHg rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.44 rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 201 rs: Final st: NotStopd t0: [11:33:00 10/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 5.9 rs: Final st: NotStopd
t0: [11:52:00 10/11/2014] id: BSA el: 1033 cu: CSRU cg: -1 v1: 2.07379 u1: m2 t0: [11:52:00 10/11/2014] id: Admit Wt el: 1032 cu: CSRU cg: -1 v1: 94 u1: kg t0: [11:52:00 10/11/2014] id: Allergy 1 el: 1020 cu: CSRU cg: -1 v1: PCN,TETRACYCLINE t0: [11:52:00 10/11/2014] id: Diagnosis/op el: 1023 cu: CSRU cg: -1 v1: CORONARY ARTERY DISEASE t0: [11:52:00 10/11/2014] id: Service el: 1026 cu: CSRU cg: -1 v1: CSU t0: [11:52:00 10/11/2014] id: Admit Ht el: 1034 cu: CSRU cg: -1 v1: 59 u1: inches t0: [11:52:00 10/11/2014] id: Readmission el: 1014 cu: CSRU cg: -1 t0: [11:52:00 10/11/2014] id: Marital Status el: 1006 cu: CSRU cg: -1 v1: M t0: [11:52:00 10/11/2014] id: Religion el: 1000 cu: CSRU cg: -1 v1: JEW t0: [11:52:00 10/11/2014] id: Allergy 2 el: 1021 cu: CSRU cg: -1 t0: [11:52:00 10/11/2014] id: Ext el: 1010 cu: CSRU cg: -1 t0: [11:52:00 10/11/2014] id: PIN el: 1012 cu: CSRU cg: -1 t0: [11:52:00 10/11/2014] id: Allergy 3 el: 1022 cu: CSRU cg: -1
t0: [12:31:00 10/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.36 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: 0 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 27 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 46 u1: mmHg rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 80 u1: mmHg rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.36 rs: Final st: NotStopd
t0: [12:31:00 10/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 172 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.5 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Sodium Chemistry el: 0 cu: CSRU cg: 3161 v1: 133 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 172 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Hematocrit Hematology el: 0 cu: CSRU cg: 3161 v1: 35 u1: % rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.3 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.5 rs: Final st: NotStopd t0: [12:31:00 10/11/2014] id: Sodium (135-148) Chemistry el: 0 cu: CSRU cg: 3161 v1: 133 rs: Final st: NotStopd
t0: [13:00:00 10/11/2014] id: Compliance (40-60ml) el: 0 cu: CSRU cg: RRT v1: 35.8974 u1: ml/cmH st: NotStopd t0: [13:00:00 10/11/2014] id: ETT Mark/Location el: 0 cu: CSRU cg: RRT v1: 23cm v2: Lip st: NotStopd t0: [13:00:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RRT v1: 1 u1: torr st: NotStopd t0: [13:00:00 10/11/2014] id: High Insp. Pressure el: 0 cu: CSRU cg: RRT v1: 50 u1: cmH2O st: NotStopd t0: [13:00:00 10/11/2014] id: High Resp. Rate el: 0 cu: CSRU cg: RRT v1: 35 u1: BPM st: NotStopd t0: [13:00:00 10/11/2014] id: Airway Size el: 0 cu: CSRU cg: RRT v1: 7.5 mm st: NotStopd t0: [13:00:00 10/11/2014] id: Airway Type el: 0 cu: CSRU cg: RRT v1: Endotracheal st: NotStopd t0: [13:00:00 10/11/2014] id: Inspired Gas Temp el: 0 cu: CSRU cg: RRT u1: Deg. C st: NotStopd t0: [13:00:00 10/11/2014] id: Intubation Date el: 0 cu: CSRU cg: RRT v1: 9 v2: 29 st: NotStopd t0: [13:00:00 10/11/2014] id: Low Exhaled Min Vol el: 0 cu: CSRU cg: RRT v1: 4 st: NotStopd t0: [13:00:00 10/11/2014] id: Low Insp. Pressure el: 0 cu: CSRU cg: RRT v1: 10 u1: cmH2O st: NotStopd t0: [13:00:00 10/11/2014] id: Mean Airway Pressure el: 0 cu: CSRU cg: RRT v1: 12 u1: cmH2O st: NotStopd t0: [13:00:00 10/11/2014] id: Minute Volume(Obser) el: 0 cu: CSRU cg: RRT v1: 6.8 u1: L/min st: NotStopd t0: [13:00:00 10/11/2014] id: PEEP Set el: 0 cu: CSRU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [13:00:00 10/11/2014] id: Peak Flow el: 0 cu: CSRU cg: RRT v1: 60 u1: L/m st: NotStopd t0: [13:00:00 10/11/2014] id: Peak Insp. Pressure el: 0 cu: CSRU cg: RRT v1: 24.5 u1: cmH2O st: NotStopd t0: [13:00:00 10/11/2014] id: Plateau Pressure el: 0 cu: CSRU cg: RRT v1: 22 u1: cmH2O st: NotStopd t0: [13:00:00 10/11/2014] id: Plateau-Off el: 0 cu: CSRU cg: RRT v1: Yes st: NotStopd t0: [13:00:00 10/11/2014] id: Pressure Support el: 0 cu: CSRU cg: RRT v1: 5 u1: . st: NotStopd t0: [13:00:00 10/11/2014] id: Resp Rate (Spont) el: 0 cu: CSRU cg: RRT v1: 0 u1: BPM st: NotStopd t0: [13:00:00 10/11/2014] id: Resp Rate (Total) el: 0 cu: CSRU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [13:00:00 10/11/2014] id: Respiratory Rate Set el: 0 cu: CSRU cg: RRT v1: 10 u1: BPM st: NotStopd t0: [13:00:00 10/11/2014] id: Sensitivity-Vent el: 0 cu: CSRU cg: RRT v1: 2 u1: cmH2O st: NotStopd t0: [13:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RRT v1: 98 u1: % st: NotStopd t0: [13:00:00 10/11/2014] id: Tidal Volume (Obser) el: 0 cu: CSRU cg: RRT v1: 680 u1: ml/B st: NotStopd t0: [13:00:00 10/11/2014] id: Tidal Volume (Set) el: 0 cu: CSRU cg: RRT v1: 700 u1: ml/B st: NotStopd t0: [13:00:00 10/11/2014] id: Ventilator Mode el: 0 cu: CSRU cg: RRT v1: SIMV+PS st: NotStopd t0: [13:00:00 10/11/2014] id: Ventilator Type el: 0 cu: CSRU cg: RRT v1: 7200A st: NotStopd t0: [13:00:00 10/11/2014] id: Waveform-Vent el: 0 cu: CSRU cg: RRT v1: RAMP st: NotStopd
t0: [13:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [13:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [13:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Unarousable st: NotStopd t0: [13:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 94 u1: BPM st: NotStopd t0: [13:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [13:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 96 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [13:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 65 u1: mmHg st: NotStopd t0: [13:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [13:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 17 u1: BPM st: NotStopd t0: [13:00:00 10/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [13:00:00 10/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 35.5 u1: Deg. C st: NotStopd t0: [13:00:00 10/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 95.9 u1: Deg. F st: NotStopd t0: [13:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 10/11/2014] tf: [15:00:00 10/11/2014] dt: 120 id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.02 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [13:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2807 id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.3 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [13:00:00 10/11/2014] tf: [14:30:00 10/11/2014] dt: 90 id: Propofol el: 1 cu: CSRU cg: RN so: N/A vo: 0 v1: 10 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:00:00 10/11/2014] tf: [18:00:00 10/11/2014] dt: 300 id: OR Crystalloid OR Intake el: 1 cu: CSRU cg: RN ai: 124 vo: 3500 vu: ml t0: [13:00:00 10/11/2014] id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 0 vu: ml t0: [13:00:00 10/11/2014] id: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 0 vu: ml t0: [13:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 0 vu: ml t0: [13:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 0 vu: ml t0: [13:00:00 10/11/2014] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 116 vo: 0 vu: ml t0: [13:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2807 id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 800 vu: ml t0: [13:00:00 10/11/2014] tf: [18:00:00 10/11/2014] dt: 300 id: OR Out PACU Urine el: 1 cu: CSRU cg: RN vo: 1335 vu: ml t0: [13:00:00 10/11/2014] tf: [14:15:00 10/11/2014] dt: 75 id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 20 vu: ml t0: [13:00:00 10/11/2014] tf: [13:30:00 10/11/2014] dt: 30 id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 50 vu: ml
t0: [13:15:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [13:15:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [13:15:00 10/11/2014] id: Ectopy Frequency el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:15:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:15:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 98 u1: BPM st: NotStopd t0: [13:15:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [13:15:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 101 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [13:15:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 71 u1: mmHg st: NotStopd t0: [13:15:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [13:15:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 10 u1: BPM st: NotStopd t0: [13:15:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [13:15:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:15:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.02 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [13:15:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.3 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [13:15:00 10/11/2014] id: Propofol el: 1 cu: CSRU cg: RN so: N/A vo: 0 v1: 10 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:00:00 10/11/2014] id: Previous Weight el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [13:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [13:00:00 10/11/2014] id: Significant Events el: 0 cu: CSRU cg: RN v1: OR Received st: NotStopd t0: [13:00:00 10/11/2014] id: BSA - English el: 0 cu: CSRU cg: RN v1: 1.34629 u1: m2 st: NotStopd t0: [13:00:00 10/11/2014] id: BSA - Metric el: 0 cu: CSRU cg: RN v1: 1.56789 u1: m2 st: NotStopd t0: [13:00:00 10/11/2014] id: Weight Change el: 0 cu: CSRU cg: RN v1: 0 u1: kg st: NotStopd t0: [13:00:00 10/11/2014] id: Daily Weight el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [13:15:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd
t0: [13:15:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 3 vu: ml t0: [13:15:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 25 vu: ml
t0: [13:30:00 10/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.38 rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: 0 rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 27 rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 44 u1: mmHg rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 116 u1: mmHg rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.38 rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: SaO2 ABG's el: 0 cu: CSRU cg: 3161 v1: 97 u1: % rs: Final st: NotStopd
t0: [13:00:00 10/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [13:00:00 10/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [13:00:00 10/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [13:00:00 10/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [13:00:00 10/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [13:00:00 10/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: Carafate st: NotStopd t0: [13:00:00 10/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: NPO st: NotStopd t0: [13:00:00 10/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [13:00:00 10/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 1 No Response st: NotStopd t0: [13:00:00 10/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 3 u1: points st: NotStopd t0: [13:00:00 10/11/2014] id: GI Intub #1/Site el: 0 cu: CSRU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [13:00:00 10/11/2014] id: GI#1 Tube Stat/Drain el: 0 cu: CSRU cg: RN v1: Low Cont Suction v2: Bilious st: NotStopd t0: [13:00:00 10/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [13:00:00 10/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [13:00:00 10/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [13:00:00 10/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Unresponsive st: NotStopd t0: [13:00:00 10/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 1 No Response st: NotStopd t0: [13:00:00 10/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [13:00:00 10/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [13:00:00 10/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [13:00:00 10/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [13:00:00 10/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [13:00:00 10/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [13:00:00 10/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [13:00:00 10/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [13:00:00 10/11/2014] id: Pupil Response R/L el: 0 cu: CSRU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [13:00:00 10/11/2014] id: Pupil Size R/L el: 0 cu: CSRU cg: RN v1: 2 mm v2: 2 mm st: NotStopd t0: [13:00:00 10/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [13:00:00 10/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [13:00:00 10/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [13:00:00 10/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [13:00:00 10/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [13:00:00 10/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [13:00:00 10/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Absent st: NotStopd t0: [13:00:00 10/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd t0: [13:00:00 10/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [13:00:00 10/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [13:00:00 10/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [13:00:00 10/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd
t0: [13:00:00 10/11/2014] id: Circulation/SkinInt el: 0 cu: CSRU cg: RN v1: Circulation Adeq st: NotStopd t0: [13:00:00 10/11/2014] id: Education Barrier el: 0 cu: CSRU cg: RN v1: Medicated st: NotStopd t0: [13:00:00 10/11/2014] id: Education Learner el: 0 cu: CSRU cg: RN v1: Patient st: NotStopd t0: [13:00:00 10/11/2014] id: Education Method el: 0 cu: CSRU cg: RN v1: Explanation st: NotStopd t0: [13:00:00 10/11/2014] id: Education Readiness el: 0 cu: CSRU cg: RN v1: No st: NotStopd t0: [13:00:00 10/11/2014] id: Education Response el: 0 cu: CSRU cg: RN v1: Reinforced st: NotStopd t0: [13:00:00 10/11/2014] id: Education Topic #1 el: 0 cu: CSRU cg: RN v1: Plan of Care st: NotStopd t0: [13:00:00 10/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:00:00 10/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:00:00 10/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:00:00 10/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Transparent v2: Intact st: NotStopd t0: [13:00:00 10/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [13:00:00 10/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [13:00:00 10/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [13:00:00 10/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [13:00:00 10/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [13:00:00 10/11/2014] id: Reason For Restraint el: 0 cu: CSRU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [13:00:00 10/11/2014] id: Restraint Location el: 0 cu: CSRU cg: RN v1: Both Arms st: NotStopd t0: [13:00:00 10/11/2014] id: Restraint Type el: 0 cu: CSRU cg: RN v1: Soft Limb st: NotStopd t0: [13:00:00 10/11/2014] id: Restraints Evaluated el: 0 cu: CSRU cg: RN v1: Behavior Conts st: NotStopd t0: [13:00:00 10/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [13:00:00 10/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [13:00:00 10/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Bedfast st: NotStopd t0: [13:00:00 10/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: No Apparent Prob st: NotStopd t0: [13:00:00 10/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: Comp. Immobile st: NotStopd t0: [13:00:00 10/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Occ. Moist st: NotStopd t0: [13:00:00 10/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Prob. Inadequate st: NotStopd t0: [13:00:00 10/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 11 u1: number st: NotStopd t0: [13:00:00 10/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: Comp. Limited st: NotStopd
t0: [13:30:00 10/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 172 rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: RN v1: 3.7 rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: RN v1: 172 rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: RN v1: 1.13 rs: Final st: NotStopd t0: [13:30:00 10/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: RN v1: 3.7 rs: Final st: NotStopd
t0: [13:30:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [13:30:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [13:30:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Sedated st: NotStopd t0: [13:30:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:30:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 98 u1: BPM st: NotStopd t0: [13:30:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [13:30:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 90 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [13:30:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 67 u1: mmHg st: NotStopd t0: [13:30:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [13:30:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [13:30:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 20 u1: BPM st: NotStopd t0: [13:30:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [13:30:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [13:45:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [13:45:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [13:45:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Sedated st: NotStopd t0: [13:45:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:45:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 93 u1: BPM st: NotStopd t0: [13:45:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [13:45:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 103 u1: mmHg v2: 62 u2: mmHg st: NotStopd t0: [13:45:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 77 u1: mmHg st: NotStopd t0: [13:45:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [13:45:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [13:45:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 10 u1: BPM st: NotStopd t0: [13:45:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [13:45:00 10/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [13:45:00 10/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 35.8889 u1: Deg. C st: NotStopd t0: [13:45:00 10/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 96.6 u1: Deg. F st: NotStopd t0: [13:45:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:30:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.02 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [13:30:00 10/11/2014] id: Propofol el: 1 cu: CSRU cg: RN so: N/A vo: 0 v1: 25 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [13:45:00 10/11/2014] id: Propofol el: 1 cu: CSRU cg: RN so: N/A vo: 0 v1: 25 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [13:00:00 10/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: Flat in Bed st: NotStopd t0: [13:00:00 10/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [13:00:00 10/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Supine st: NotStopd t0: [13:00:00 10/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Back st: NotStopd t0: [13:00:00 10/11/2014] id: WarmingDevice/Status el: 0 cu: CSRU cg: RN v1: Blanket v2: On st: NotStopd
t0: [13:30:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [13:30:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 0 vu: ml
t0: [13:00:00 10/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [13:00:00 10/11/2014] id: INV Line#1 Zero/Cal el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [13:00:00 10/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [13:00:00 10/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [13:00:00 10/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [13:00:00 10/11/2014] id: INV Line#2 Zero/Cal el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [13:00:00 10/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [13:00:00 10/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [13:00:00 10/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [13:00:00 10/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [13:00:00 10/11/2014] id: IV #1 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [13:00:00 10/11/2014] id: IV #1 Site/Size el: 0 cu: CSRU cg: RN v1: Left Antecub v2: 16 gauge st: NotStopd t0: [13:00:00 10/11/2014] id: IV #2 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [13:00:00 10/11/2014] id: IV #2 Site/Size el: 0 cu: CSRU cg: RN v1: Right Antecub v2: 16 gauge st: NotStopd t0: [13:00:00 10/11/2014] id: IV Site Appear #1 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [13:00:00 10/11/2014] id: IV Site Appear #2 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd
id: Insulin el: 100 cu: CSRU cg: RN io: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions am: 100 du: Uhr rt: IV Drip
t0: [13:45:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RN v1: 0.8 u1: torr st: NotStopd t0: [13:45:00 10/11/2014] id: Sputum Color/Consist el: 0 cu: CSRU cg: RN v1: Clear v2: Thin st: NotStopd t0: [13:45:00 10/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v1: Suctioned v2: Scant st: NotStopd
io: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ra: 2 ru: ml/hr
tf: [08:00:00 11/11/2014] pt: IV Piggyback rt: IV DRIP fr: TITRATE TO m1: Nitroglycerin v1: 100 u1: mg m2: D5W v2: 250 u2: ml tf: [08:00:00 11/11/2014] pt: IV Piggyback rt: IV DRIP fr: TITRATE TO m1: Nitroprusside Sodium v1: 100 u1: mg m2: D5W v2: 250 u2: ml tf: [08:00:00 11/11/2014] pt: IV Piggyback rt: IV DRIP fr: TITRATE TO m1: Propofol (Generic) v1: 1000 u1: mg m2: Soln. v2: 100 u2: ml tf: [08:00:00 11/11/2014] pt: Unit Dose rt: IV fr: ONCE:PRN fs: 10 dn: 1 m1: Glycopyrrolate v1: 0.6 u1: mg tf: [08:00:00 11/11/2014] pt: Unit Dose rt: IV fr: ONCE:PRN fs: 10 dn: 1 m1: Neostigmine v1: 3 u1: mg tf: [08:00:00 11/11/2014] pt: Unit Dose rt: IV fr: PRN m1: Meperidine v1: 12.5 u1: mg tf: [08:00:00 11/11/2014] pt: Unit Dose rt: NG fr: Q6H fs: 14, 20, 2, 8 dn: 4 m1: Sucralfate v1: 1 u1: gm tf: [13:00:00 11/11/2014] pt: Unit Dose rt: IM fr: ONCE fs: 14 dn: 1 m1: Ketorolac v1: 30 u1: mg tf: [13:00:00 11/11/2014] pt: Unit Dose rt: IM fr: Q6H fs: 14, 20, 2, 8 dn: 4 m1: Ketorolac v1: 15 u1: mg tf: [09:00:00 12/11/2014] pt: IV Piggyback rt: IV DRIP fr: TITRATE TO m1: Phenylephrine HCl v1: 60 u1: mg m2: D5W v2: 250 u2: ml tf: [13:00:00 12/11/2014] pt: IV Piggyback rt: IV fr: Q12H fs: 14, 2 dn: 2 m1: Vancomycin HCl v1: 1000 u1: mg m2: Iso-Osmotic Dextrose v2: 200 u2: ml tf: [18:00:00 12/11/2014] pt: IV Piggyback rt: IV DRIP fr: INFUSION m1: Humulin-R Insulin v1: 100 u1: UNIT m2: NS v2: 100 u2: ml tf: [18:00:00 12/11/2014] pt: IV Piggyback rt: IV fr: PRN m1: Potassium Chloride v1: 20 u1: mEq m2: SW v2: 50 u2: ml tf: [18:00:00 12/11/2014] pt: Unit Dose rt: IV fr: PRN m1: Calcium Gluconate v1: 2 u1: gm tf: [18:00:00 12/11/2014] pt: Unit Dose rt: IV fr: PRN m1: Magnesium Sulfate v1: 2 u1: gm tf: [18:00:00 12/11/2014] pt: Unit Dose rt: IV fr: Q2H:PRN m1: Morphine Sulfate v1: 0.5-4.0 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: IV fr: Q6H:PRN m1: Metoclopramide v1: 10 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: Q4H:PRN m1: Acetaminophen v1: 650 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: Q4H:PRN m1: Oxycodone-Acetaminophen v1: 1-2 u1: TAB
id: .9% Normal Saline el: 1 cu: CSRU cg: RN io: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions vo: 100 du: ml rt: Intravenous Push
t0: [14:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [14:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [14:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Sedated st: NotStopd t0: [14:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [14:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 94 u1: BPM st: NotStopd t0: [14:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [14:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 108 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [14:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 80 u1: mmHg st: NotStopd t0: [14:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [14:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [14:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 10 u1: BPM st: NotStopd t0: [14:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [14:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:00:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.02 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:00:00 10/11/2014] id: Propofol el: 1 cu: CSRU cg: RN so: N/A vo: 0 v1: 25 du: mcgkgmin sv: 50 su: vl rt: IV Drip
t0: [14:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2747 id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 100 vu: ml nb: 1 t0: [14:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2747 id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vo: 500 vu: ml t0: [14:00:00 10/11/2014] tf: [23:00:00 10/11/2014] dt: 540 id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 3 vu: ml t0: [14:00:00 10/11/2014] tf: [15:00:00 10/11/2014] dt: 60 id: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 13 vu: ml t0: [14:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2747 id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [14:00:00 10/11/2014] tf: [05:00:00 12/11/2014] dt: 2340 id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 10 vu: ml t0: [14:00:00 10/11/2014] tf: [18:00:00 10/11/2014] dt: 240 id: Gastric Oral Gastric el: 1 cu: CSRU cg: RN vo: 400 vu: ml t0: [14:00:00 10/11/2014] id: Gastric Oral Gastric el: 1 cu: CSRU cg: RN vo: 25 vu: ml t0: [14:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 3 vu: ml t0: [14:00:00 10/11/2014] tf: [06:00:00 11/11/2014] dt: 960 id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 25 vu: ml
t0: [14:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2747 id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [23:00:00 10/11/2014] dt: 24 id: Gastric Out Total el: 3 cu: CSRU cg: RN cv: 25 ap: none
t0: [13:45:00 10/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Visited st: NotStopd t0: [13:45:00 10/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Children st: NotStopd t0: [13:45:00 10/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Sedated st: NotStopd
t0: [14:15:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [14:15:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [14:15:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Sedated st: NotStopd t0: [14:15:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [14:15:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 99 u1: BPM st: NotStopd t0: [14:15:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [14:15:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 101 u1: mmHg v2: 63 u2: mmHg st: NotStopd t0: [14:15:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 76 u1: mmHg st: NotStopd t0: [14:15:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [14:15:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [14:15:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 19 u1: BPM st: NotStopd t0: [14:15:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [14:15:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:15:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.02 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:15:00 10/11/2014] id: Propofol el: 1 cu: CSRU cg: RN so: N/A vo: 0 v1: 25 du: mcgkgmin sv: 50 su: vl rt: IV Drip t0: [14:15:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [14:15:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 0 vu: ml t0: [14:15:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 20 vu: ml
t0: [13:18:00 10/11/2014] id: Platelets Hematology el: 0 cu: CSRU cg: 3161 v1: 147 rs: Final st: NotStopd
t0: [13:18:00 10/11/2014] id: PT el: 0 cu: CSRU cg: 3161 v1: 14.5 rs: Final st: NotStopd t0: [13:18:00 10/11/2014] id: INR Coags el: 0 cu: CSRU cg: 3161 v1: 1.4 rs: Final st: NotStopd t0: [13:18:00 10/11/2014] id: PTT Coags el: 0 cu: CSRU cg: 3161 v1: 28.9 rs: Final st: NotStopd t0: [13:18:00 10/11/2014] id: INR (2-4 ref. range) Coags el: 0 cu: CSRU cg: 3161 v1: 1.4 rs: Final st: NotStopd t0: [13:18:00 10/11/2014] id: PT(11-13.5) Coags el: 0 cu: CSRU cg: 3161 v1: 14.5 rs: Final st: NotStopd t0: [13:18:00 10/11/2014] id: PTT(22-35) Coags el: 0 cu: CSRU cg: 3161 v1: 28.9 rs: Final st: NotStopd
t0: [13:18:00 10/11/2014] id: Hematocrit Hematology el: 0 cu: CSRU cg: 3161 v1: 32.5 u1: % rs: Final st: NotStopd
t0: [14:30:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [14:30:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [14:30:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [14:30:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [14:30:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 101 u1: BPM st: NotStopd t0: [14:30:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [14:30:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 100 u1: mmHg v2: 66 u2: mmHg st: NotStopd t0: [14:30:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 76 u1: mmHg st: NotStopd t0: [14:30:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [14:30:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [14:30:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 21 u1: BPM st: NotStopd t0: [14:30:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 97 u1: % st: NotStopd t0: [14:30:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:45:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:15:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:30:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:30:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:30:00 10/11/2014] id: Propofol el: 1 cu: CSRU cg: RN so: N/A vo: 0 v1: 25 du: mcgkgmin sv: 50 su: vl rt: IV Drip st: Stopped t0: [14:30:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [14:30:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RN v1: 0.6 u1: torr st: NotStopd
t0: [14:30:00 10/11/2014] tf: [18:00:00 10/11/2014] dt: 210 id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 15 vu: ml t0: [14:30:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 20 vu: ml
t0: [14:45:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [14:45:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [14:45:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [14:45:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [14:45:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 105 u1: BPM st: NotStopd t0: [14:45:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [14:45:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 98 u1: mmHg v2: 60 u2: mmHg st: NotStopd t0: [14:45:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 72 u1: mmHg st: NotStopd t0: [14:45:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [14:45:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [14:45:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 14 u1: BPM st: NotStopd t0: [14:45:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [14:45:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [15:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [15:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [15:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [15:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [15:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [15:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 97 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [15:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [15:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [15:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [15:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 12 u1: BPM st: NotStopd t0: [15:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [15:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:45:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:45:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [14:45:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip t0: [15:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [15:00:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip st: Stopped t0: [15:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [14:00:00 10/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IV Push st: NotStopd
t0: [15:00:00 10/11/2014] id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vo: 500 vu: ml t0: [15:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [15:00:00 10/11/2014] tf: [06:00:00 11/11/2014] dt: 900 id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 2 vu: ml t0: [15:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 10.575 vu: ml t0: [15:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 410 vu: ml t0: [15:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 2 vu: ml t0: [15:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 20 vu: ml
t0: [14:30:00 10/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 15 degrees st: NotStopd t0: [14:30:00 10/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [14:30:00 10/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Good st: NotStopd t0: [14:30:00 10/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [14:30:00 10/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [14:30:00 10/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Supine st: NotStopd t0: [14:30:00 10/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 2 Person Assist st: NotStopd t0: [14:30:00 10/11/2014] id: Skin Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [14:30:00 10/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Side to Side st: NotStopd t0: [14:30:00 10/11/2014] id: Back Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [14:30:00 10/11/2014] id: WarmingDevice/Status el: 0 cu: CSRU cg: RN v1: Blanket v2: On st: NotStopd
t0: [15:10:00 10/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.33 rs: Final st: NotStopd t0: [15:10:00 10/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: -1 rs: Final st: NotStopd t0: [15:10:00 10/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 25 rs: Final st: NotStopd t0: [15:10:00 10/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 46 u1: mmHg rs: Final st: NotStopd t0: [15:10:00 10/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 123 u1: mmHg rs: Final st: NotStopd t0: [15:10:00 10/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.33 rs: Final st: NotStopd t0: [15:10:00 10/11/2014] id: SaO2 ABG's el: 0 cu: CSRU cg: 3161 v1: 98 u1: % rs: Final st: NotStopd
t0: [15:15:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RN v1: 0.5 u1: torr st: NotStopd t0: [15:15:00 10/11/2014] id: Respiratory Rate Set el: 0 cu: CSRU cg: RN v1: 12 u1: BPM st: NotStopd
t0: [15:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 89 u1: BPM st: NotStopd t0: [15:15:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [15:15:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [15:15:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [15:15:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [15:15:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 103 u1: BPM st: NotStopd t0: [15:15:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [15:15:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 117 u1: mmHg v2: 74 u2: mmHg st: NotStopd t0: [15:15:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 87 u1: mmHg st: NotStopd t0: [15:15:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [15:15:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [15:15:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 15 u1: BPM st: NotStopd t0: [15:15:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [15:15:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [15:15:00 10/11/2014] tf: [17:00:00 10/11/2014] dt: 105 id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [15:15:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.3 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [15:15:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [15:00:00 10/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [15:00:00 10/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [15:00:00 10/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [15:00:00 10/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [15:00:00 10/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [15:00:00 10/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: Carafate st: NotStopd t0: [15:00:00 10/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: NPO st: NotStopd t0: [15:00:00 10/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [15:00:00 10/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 3 To speech st: NotStopd t0: [15:00:00 10/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 10 u1: points st: NotStopd t0: [15:00:00 10/11/2014] id: GI Intub #1/Site el: 0 cu: CSRU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [15:00:00 10/11/2014] id: GI#1 Tube Stat/Drain el: 0 cu: CSRU cg: RN v1: Clamped st: NotStopd t0: [15:00:00 10/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [15:00:00 10/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [15:00:00 10/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [15:00:00 10/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Arouse to Voice st: NotStopd t0: [15:00:00 10/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [15:00:00 10/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [15:00:00 10/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 1 st: NotStopd t0: [15:00:00 10/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [15:00:00 10/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [15:00:00 10/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [15:00:00 10/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [15:00:00 10/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [15:00:00 10/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [15:00:00 10/11/2014] id: Pupil Response R/L el: 0 cu: CSRU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [15:00:00 10/11/2014] id: Pupil Size R/L el: 0 cu: CSRU cg: RN v1: 2 mm v2: 2 mm st: NotStopd t0: [15:00:00 10/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [15:00:00 10/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [15:00:00 10/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [15:00:00 10/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [15:00:00 10/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [15:00:00 10/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [15:00:00 10/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Absent st: NotStopd t0: [15:00:00 10/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd t0: [15:00:00 10/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [15:00:00 10/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [15:00:00 10/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [15:00:00 10/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd
t0: [15:00:00 10/11/2014] id: Range of Motion el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [15:00:00 10/11/2014] id: Circulation/SkinInt el: 0 cu: CSRU cg: RN v1: Circulation Adeq st: NotStopd t0: [15:00:00 10/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 137 rs: Manual st: NotStopd t0: [15:00:00 10/11/2014] id: Education Barrier el: 0 cu: CSRU cg: RN v1: Medicated st: NotStopd t0: [15:00:00 10/11/2014] id: Education Learner el: 0 cu: CSRU cg: RN v1: Patient/Family st: NotStopd t0: [15:00:00 10/11/2014] id: Education Method el: 0 cu: CSRU cg: RN v1: Explanation st: NotStopd t0: [15:00:00 10/11/2014] id: Education Readiness el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [15:00:00 10/11/2014] id: Education Response el: 0 cu: CSRU cg: RN v1: Reinforced st: NotStopd t0: [15:00:00 10/11/2014] id: Education Topic #1 el: 0 cu: CSRU cg: RN v1: Plan of Care st: NotStopd t0: [15:00:00 10/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [15:00:00 10/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [15:00:00 10/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [15:00:00 10/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Transparent v2: Intact st: NotStopd t0: [15:00:00 10/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [15:00:00 10/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [15:00:00 10/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [15:00:00 10/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [15:00:00 10/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [15:00:00 10/11/2014] id: Position Change el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [15:00:00 10/11/2014] id: Reason For Restraint el: 0 cu: CSRU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [15:00:00 10/11/2014] id: Removed x 5 Mins el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [15:00:00 10/11/2014] id: Restraint Location el: 0 cu: CSRU cg: RN v1: Both Arms st: NotStopd t0: [15:00:00 10/11/2014] id: Restraint Type el: 0 cu: CSRU cg: RN v1: Soft Limb st: NotStopd t0: [15:00:00 10/11/2014] id: Restraints Evaluated el: 0 cu: CSRU cg: RN v1: Behavior Conts st: NotStopd t0: [15:00:00 10/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [15:00:00 10/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [15:00:00 10/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Children st: NotStopd t0: [15:00:00 10/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: RN v1: 137 rs: Manual st: NotStopd
t0: [15:00:00 10/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [15:00:00 10/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [15:00:00 10/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [15:00:00 10/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [15:00:00 10/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [15:00:00 10/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [15:00:00 10/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [15:00:00 10/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [15:00:00 10/11/2014] id: IV #1 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [15:00:00 10/11/2014] id: IV #1 Site/Size el: 0 cu: CSRU cg: RN v1: Left Antecub v2: 16 gauge st: NotStopd t0: [15:00:00 10/11/2014] id: IV #2 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [15:00:00 10/11/2014] id: IV #2 Site/Size el: 0 cu: CSRU cg: RN v1: Right Antecub v2: 16 gauge st: NotStopd t0: [15:00:00 10/11/2014] id: IV Site Appear #1 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [15:00:00 10/11/2014] id: IV Site Appear #2 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd
t0: [15:30:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [15:30:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [15:30:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [15:30:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [15:30:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 94 u1: BPM st: NotStopd t0: [15:30:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [15:30:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 107 u1: mmHg v2: 67 u2: mmHg st: NotStopd t0: [15:30:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 79 u1: mmHg st: NotStopd t0: [15:30:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [15:30:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [15:30:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 16 u1: BPM st: NotStopd t0: [15:30:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 99 u1: % st: NotStopd t0: [15:30:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [15:45:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [15:45:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [15:45:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [15:45:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [15:45:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 97 u1: BPM st: NotStopd t0: [15:45:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [15:45:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 105 u1: mmHg v2: 67 u2: mmHg st: NotStopd t0: [15:45:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 78 u1: mmHg st: NotStopd t0: [15:45:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [15:45:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [15:45:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 12 u1: BPM st: NotStopd t0: [15:45:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 99 u1: % st: NotStopd t0: [15:45:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [15:30:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [15:30:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.3 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [15:30:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip t0: [15:45:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [15:45:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.3 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [15:45:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [15:50:00 10/11/2014] id: High Insp. Pressure el: 0 cu: CSRU cg: RRT v1: 40 u1: cmH2O st: NotStopd t0: [15:50:00 10/11/2014] id: PEEP Set el: 0 cu: CSRU cg: RRT v1: 5 u1: cmH2O st: NotStopd t0: [15:50:00 10/11/2014] id: Pressure Support el: 0 cu: CSRU cg: RRT v1: 5 u1: . st: NotStopd t0: [15:50:00 10/11/2014] id: Resp Rate (Total) el: 0 cu: CSRU cg: RRT v1: 24 u1: BPM st: NotStopd t0: [15:50:00 10/11/2014] id: Tidal Volume (Spont) el: 0 cu: CSRU cg: RRT v1: 400 u1: ml/B st: NotStopd t0: [15:50:00 10/11/2014] id: Ventilator Mode el: 0 cu: CSRU cg: RRT v1: CPAP+PS st: NotStopd
t0: [16:00:00 10/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [16:00:00 10/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [16:00:00 10/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [16:00:00 10/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [16:00:00 10/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [16:00:00 10/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [16:00:00 10/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [16:00:00 10/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [16:00:00 10/11/2014] id: IV #1 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [16:00:00 10/11/2014] id: IV #1 Site/Size el: 0 cu: CSRU cg: RN v1: Left Antecub v2: 16 gauge st: NotStopd t0: [16:00:00 10/11/2014] id: IV #2 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [16:00:00 10/11/2014] id: IV #2 Site/Size el: 0 cu: CSRU cg: RN v1: Right Antecub v2: 16 gauge st: NotStopd t0: [16:00:00 10/11/2014] id: IV Site Appear #1 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [16:00:00 10/11/2014] id: IV Site Appear #2 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd
t0: [15:30:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 5 vu: ml t0: [15:30:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 15 vu: ml
t0: [16:00:00 10/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd
t0: [16:00:00 10/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [16:00:00 10/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [16:00:00 10/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [16:00:00 10/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [16:00:00 10/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [16:00:00 10/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: NPO st: NotStopd t0: [16:00:00 10/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [16:00:00 10/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 3 To speech st: NotStopd t0: [16:00:00 10/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 10 u1: points st: NotStopd t0: [16:00:00 10/11/2014] id: GI Intub #1/Site el: 0 cu: CSRU cg: RN v1: Salem Sump v2: Oral st: NotStopd t0: [16:00:00 10/11/2014] id: GI#1 Tube Stat/Drain el: 0 cu: CSRU cg: RN v1: Low Cont Suction v2: Bilious st: NotStopd t0: [16:00:00 10/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [16:00:00 10/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 10/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [16:00:00 10/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Arouse to Voice st: NotStopd t0: [16:00:00 10/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [16:00:00 10/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [16:00:00 10/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 1 st: NotStopd t0: [16:00:00 10/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [16:00:00 10/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [16:00:00 10/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [16:00:00 10/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [16:00:00 10/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [16:00:00 10/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [16:00:00 10/11/2014] id: Pupil Response R/L el: 0 cu: CSRU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [16:00:00 10/11/2014] id: Pupil Size R/L el: 0 cu: CSRU cg: RN v1: 2 mm v2: 2 mm st: NotStopd t0: [16:00:00 10/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 10/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [16:00:00 10/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [16:00:00 10/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [16:00:00 10/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [16:00:00 10/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 1.0 ET/Trach st: NotStopd t0: [16:00:00 10/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Absent st: NotStopd t0: [16:00:00 10/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd t0: [16:00:00 10/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [16:00:00 10/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [16:00:00 10/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [16:00:00 10/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd
t0: [15:00:00 10/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Visited st: NotStopd t0: [15:00:00 10/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Calm st: NotStopd t0: [16:00:00 10/11/2014] id: Circulation/SkinInt el: 0 cu: CSRU cg: RN v1: Circulation Adeq st: NotStopd t0: [16:00:00 10/11/2014] id: Education Barrier el: 0 cu: CSRU cg: RN v1: Medicated st: NotStopd t0: [16:00:00 10/11/2014] id: Education Learner el: 0 cu: CSRU cg: RN v1: Patient/Family st: NotStopd t0: [16:00:00 10/11/2014] id: Education Method el: 0 cu: CSRU cg: RN v1: Explanation st: NotStopd t0: [16:00:00 10/11/2014] id: Education Readiness el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [16:00:00 10/11/2014] id: Education Response el: 0 cu: CSRU cg: RN v1: Reinforced st: NotStopd t0: [16:00:00 10/11/2014] id: Education Topic #1 el: 0 cu: CSRU cg: RN v1: Plan of Care st: NotStopd t0: [16:00:00 10/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Visited st: NotStopd t0: [16:00:00 10/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: Sanguinous v2: Scant st: NotStopd t0: [16:00:00 10/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:00:00 10/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:00:00 10/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Transparent v2: Intact st: NotStopd t0: [16:00:00 10/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [16:00:00 10/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [16:00:00 10/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [16:00:00 10/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [16:00:00 10/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [16:00:00 10/11/2014] id: Reason For Restraint el: 0 cu: CSRU cg: RN v1: Ext/TXInterfere st: NotStopd t0: [16:00:00 10/11/2014] id: Restraint Location el: 0 cu: CSRU cg: RN v1: Both Arms st: NotStopd t0: [16:00:00 10/11/2014] id: Restraint Type el: 0 cu: CSRU cg: RN v1: Soft Limb st: NotStopd t0: [16:00:00 10/11/2014] id: Restraints Evaluated el: 0 cu: CSRU cg: RN v1: Behavior Conts st: NotStopd t0: [16:00:00 10/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [16:00:00 10/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [16:00:00 10/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [16:00:00 10/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Calm st: NotStopd
t0: [15:30:00 10/11/2014] id: Radiologic Study el: 0 cu: CSRU cg: RN v1: Chest Xray st: NotStopd t0: [16:00:00 10/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [16:00:00 10/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Non-verbal cues st: NotStopd t0: [16:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [16:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [16:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [16:00:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [16:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 99 u1: BPM st: NotStopd t0: [16:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [16:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 97 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [16:00:00 10/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [16:00:00 10/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IM Inject st: NotStopd t0: [16:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 69 u1: mmHg st: NotStopd t0: [16:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [16:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [16:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 21 u1: BPM st: NotStopd t0: [16:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 98 u1: % st: NotStopd t0: [16:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [16:00:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.3 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [16:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [16:00:00 10/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [16:00:00 10/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 35.7222 u1: Deg. C st: NotStopd t0: [16:00:00 10/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 96.3 u1: Deg. F st: NotStopd
t0: [16:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [16:00:00 10/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 4 vu: ml t0: [16:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 10.575 vu: ml t0: [16:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 310 vu: ml t0: [16:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 5 vu: ml t0: [16:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 20 vu: ml
t0: [16:27:00 10/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.34 rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: 0 rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 27 rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 48 u1: mmHg rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 92 u1: mmHg rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.34 rs: Final st: NotStopd
t0: [16:27:00 10/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 145 rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.2 rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 145 rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.16 rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.2 rs: Final st: NotStopd t0: [16:27:00 10/11/2014] id: SaO2 ABG's el: 0 cu: CSRU cg: 3161 v1: 96 u1: % rs: Final st: NotStopd
t0: [16:45:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RRT v1: 0.6 u1: torr st: NotStopd t0: [16:45:00 10/11/2014] id: O2 Delivery Device el: 0 cu: CSRU cg: RRT v1: Aerosol-Cool st: NotStopd t0: [16:45:00 10/11/2014] id: O2 Flow (lpm) el: 0 cu: CSRU cg: RRT v1: 12 u1: lpm st: NotStopd
t0: [16:30:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [16:30:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [16:30:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [16:30:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [16:30:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:30:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 98 u1: BPM st: NotStopd t0: [16:30:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [16:30:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 95 u1: mmHg v2: 59 u2: mmHg st: NotStopd t0: [16:30:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 69 u1: mmHg st: NotStopd t0: [16:30:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [16:30:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [16:30:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 20 u1: BPM st: NotStopd t0: [16:30:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 99 u1: % st: NotStopd t0: [16:30:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:30:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [16:30:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.3 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [16:30:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [16:00:00 10/11/2014] id: Creatinine Chemistry el: 0 cu: CSRU cg: RN v1: 134 rs: Manual st: NotStopd t0: [16:00:00 10/11/2014] id: Creatinine (0-1.3) Chemistry el: 0 cu: CSRU cg: RN v1: 134 rs: Manual st: NotStopd
t0: [16:30:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RN v1: 0.5 u1: torr st: NotStopd t0: [16:30:00 10/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 45 degrees st: NotStopd
t0: [16:45:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [16:45:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [16:45:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [16:45:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [16:45:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:45:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 97 u1: BPM st: NotStopd t0: [16:45:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [16:45:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 83 u1: mmHg v2: 50 u2: mmHg st: NotStopd t0: [16:45:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 59 u1: mmHg st: NotStopd t0: [16:45:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [16:45:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [16:45:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 26 u1: BPM st: NotStopd t0: [16:45:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 98 u1: % st: NotStopd t0: [16:45:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [17:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [17:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [17:00:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [17:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [17:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 98 u1: BPM st: NotStopd t0: [17:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [17:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 78 u1: mmHg v2: 47 u2: mmHg st: NotStopd t0: [17:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 56 u1: mmHg st: NotStopd t0: [17:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [17:00:00 10/11/2014] id: Previous Weight el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [17:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [17:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 27 u1: BPM st: NotStopd t0: [17:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 97 u1: % st: NotStopd t0: [17:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [16:45:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.04 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [16:45:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.02 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [16:45:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip t0: [17:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [17:00:00 10/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip st: Stopped t0: [17:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [16:00:00 10/11/2014] id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vo: 500 vu: ml t0: [17:00:00 10/11/2014] id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vo: 500 vu: ml t0: [17:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [17:00:00 10/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 4 vu: ml t0: [17:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 11.4563 vu: ml t0: [17:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 200 vu: ml t0: [17:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 3 vu: ml t0: [17:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 45 vu: ml
t0: [17:30:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [17:30:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [17:30:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [17:30:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [17:30:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [17:30:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 90 u1: BPM st: NotStopd t0: [17:30:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [17:30:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 98 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [17:30:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 69 u1: mmHg st: NotStopd t0: [17:30:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [17:30:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [17:30:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 17 u1: BPM st: NotStopd t0: [17:30:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [17:30:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [18:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [18:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [18:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [18:00:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [18:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [18:00:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RN v1: 0.5 u1: torr st: NotStopd t0: [18:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 90 u1: BPM st: NotStopd t0: [18:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [18:00:00 10/11/2014] id: O2 Delivery Device el: 0 cu: CSRU cg: RN v1: Aerosol-Cool st: NotStopd t0: [18:00:00 10/11/2014] id: O2 Flow (lpm) el: 0 cu: CSRU cg: RN v1: 12 u1: lpm st: NotStopd t0: [18:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 97 u1: mmHg v2: 56 u2: mmHg st: NotStopd t0: [18:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [18:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [18:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [18:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 19 u1: BPM st: NotStopd t0: [18:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [18:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [17:30:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [17:30:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip t0: [18:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [18:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [14:30:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2717 id: D5W 50.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 109 vu: ml nb: 1 t0: [14:30:00 10/11/2014] id: D5W 50.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 109 vo: 50 vu: ml nb: 1 t0: [15:30:00 10/11/2014] id: D5W 50.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 109 vo: 50 vu: ml t0: [17:30:00 10/11/2014] id: D5W 50.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 109 vo: 50 vu: ml t0: [18:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [18:00:00 10/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 4 vu: ml t0: [18:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 17.625 vu: ml t0: [18:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 80 vu: ml t0: [18:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 0 vu: ml t0: [18:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [17:30:00 10/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 110 rs: Manual st: NotStopd
t0: [18:00:00 10/11/2014] id: OR Crystalloid OR Intake el: 1 cu: CSRU cg: -1 ai: 124 vo: 0 st: D/C'd t0: [18:00:00 10/11/2014] id: D5W 250.0ml + 60mcgkgmin Neosynephrine-k IV Infusions el: 1 cu: CSRU cg: -1 ai: 116 vo: 0 st: D/C'd t0: [18:00:00 10/11/2014] id: Gastric Oral Gastric el: 1 cu: CSRU cg: -1 vo: 0 st: D/C'd t0: [18:00:00 10/11/2014] id: OR Out PACU Urine el: 1 cu: CSRU cg: -1 vo: 0 st: D/C'd
t0: [18:30:00 10/11/2014] tf: [23:00:00 11/11/2014] dt: 1710 id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [18:30:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [19:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [19:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [19:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [19:00:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [19:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [19:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 92 u1: BPM st: NotStopd t0: [19:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [19:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 97 u1: mmHg v2: 57 u2: mmHg st: NotStopd t0: [19:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 70 u1: mmHg st: NotStopd t0: [19:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [19:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [19:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 21 u1: BPM st: NotStopd t0: [19:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [19:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [19:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [19:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 4 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [19:00:00 10/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 1-None to Mild st: NotStopd t0: [19:00:00 10/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [19:00:00 10/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [19:00:00 10/11/2014] id: PainLevel Acceptable el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [19:00:00 10/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: At Rest st: NotStopd t0: [19:00:00 10/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 1-None to Mild st: NotStopd t0: [19:00:00 10/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [19:00:00 10/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Dull st: NotStopd
tf: [18:00:00 11/11/2014] pt: IV Large Volume rt: IV fr: ONCE fs: 19 dn: 1 m1: Hespan v1: 500 u1: ml m2: NS v2: 500 u2: ml
id: Hespan el: 1 cu: CSRU cg: RN io: Hespan IV Infusions du: ml rt: Intravenous Push
t0: [15:00:00 10/11/2014] id: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 14.1 vu: ml st: Stopped t0: [16:00:00 10/11/2014] id: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vu: ml t0: [17:00:00 10/11/2014] id: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vu: ml t0: [18:00:00 10/11/2014] id: N/A 50.0vl + 500mcgkgmin Propofol IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vu: ml t0: [19:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [19:00:00 10/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 4 vu: ml t0: [19:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 17.625 vu: ml t0: [19:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 140 vu: ml t0: [19:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 5 vu: ml t0: [19:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [18:00:00 10/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [18:00:00 10/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 45 degrees st: NotStopd t0: [18:00:00 10/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [18:00:00 10/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Good st: NotStopd t0: [18:00:00 10/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [18:00:00 10/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [18:00:00 10/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [18:00:00 10/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd t0: [18:00:00 10/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 2 Person Assist st: NotStopd t0: [18:00:00 10/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Back st: NotStopd t0: [18:00:00 10/11/2014] id: WarmingDevice/Status el: 0 cu: CSRU cg: RN v1: Blanket v2: On st: NotStopd t0: [18:00:00 10/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 101 rs: Manual st: NotStopd t0: [19:00:00 10/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [19:00:00 10/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd
t0: [19:00:00 10/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 118 rs: Manual st: NotStopd
t0: [19:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2447 id: Hespan IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 500 vu: ml
t0: [23:00:00 10/11/2014] dt: 24 id: Colloids Total el: 3 cu: CSRU cg: RN cv: 500 ap: none
t0: [19:20:00 10/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.36 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 112 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.7 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: 0 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 29 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 49 u1: mmHg rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 95 u1: mmHg rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.36 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 112 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.17 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.7 rs: Final st: NotStopd t0: [19:20:00 10/11/2014] id: SaO2 ABG's el: 0 cu: CSRU cg: 3161 v1: 98 u1: % rs: Final st: NotStopd
t0: [19:00:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RN v1: 0.5 u1: torr st: NotStopd t0: [19:00:00 10/11/2014] id: O2 Delivery Device el: 0 cu: CSRU cg: RN v1: Aerosol-Cool st: NotStopd t0: [19:00:00 10/11/2014] id: O2 Flow (lpm) el: 0 cu: CSRU cg: RN v1: 12 u1: lpm st: NotStopd
t0: [19:00:00 10/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IV Push st: NotStopd
t0: [19:06:00 10/11/2014] id: Magnesium Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.8 rs: Final st: NotStopd t0: [19:06:00 10/11/2014] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.8 rs: Final st: NotStopd
t0: [19:06:00 10/11/2014] id: Hematocrit Hematology el: 0 cu: CSRU cg: 3161 v1: 28.3 u1: % rs: Final st: NotStopd t0: [20:00:00 10/11/2014] id: GI Intub #1/Site el: 0 cu: CSRU cg: -1 st: D/C'd t0: [20:00:00 10/11/2014] id: GI#1 Tube Stat/Drain el: 0 cu: CSRU cg: -1 st: D/C'd
tf: [09:00:00 12/11/2014] pt: Unit Dose rt: IV fr: Q6H:PRN m1: Ondansetron v1: 2 u1: mg
t0: [20:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [20:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [20:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [20:00:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [20:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [20:00:00 10/11/2014] id: FiO2 Set el: 0 cu: CSRU cg: RN v1: 0.5 u1: torr st: NotStopd t0: [20:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 103 u1: BPM st: NotStopd t0: [20:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [20:00:00 10/11/2014] id: O2 Delivery Device el: 0 cu: CSRU cg: RN v1: Aerosol-Cool st: NotStopd t0: [20:00:00 10/11/2014] id: O2 Flow (lpm) el: 0 cu: CSRU cg: RN v1: 12 u1: lpm st: NotStopd t0: [20:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 99 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [20:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 71 u1: mmHg st: NotStopd t0: [20:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [20:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [20:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 25 u1: BPM st: NotStopd t0: [20:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 100 u1: % st: NotStopd t0: [20:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [20:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [20:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [20:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [20:00:00 10/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 4 vu: ml t0: [20:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 17.625 vu: ml t0: [20:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 80 vu: ml t0: [20:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 30 vu: ml t0: [20:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 40 vu: ml
t0: [20:00:00 10/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [20:00:00 10/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [20:00:00 10/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [20:00:00 10/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [20:00:00 10/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [20:00:00 10/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: NPO st: NotStopd t0: [20:00:00 10/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [20:00:00 10/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [20:00:00 10/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [20:00:00 10/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [20:00:00 10/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [20:00:00 10/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [20:00:00 10/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Arouse to Voice st: NotStopd t0: [20:00:00 10/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [20:00:00 10/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [20:00:00 10/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [20:00:00 10/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [20:00:00 10/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [20:00:00 10/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [20:00:00 10/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [20:00:00 10/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [20:00:00 10/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [20:00:00 10/11/2014] id: Pupil Response R/L el: 0 cu: CSRU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [20:00:00 10/11/2014] id: Pupil Size R/L el: 0 cu: CSRU cg: RN v1: 2 mm v2: 2 mm st: NotStopd t0: [20:00:00 10/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [20:00:00 10/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [20:00:00 10/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [20:00:00 10/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [20:00:00 10/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [20:00:00 10/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [20:00:00 10/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Hypoactive st: NotStopd t0: [20:00:00 10/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd t0: [20:00:00 10/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [20:00:00 10/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [20:00:00 10/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [20:00:00 10/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd
t0: [20:00:00 10/11/2014] id: Education Barrier el: 0 cu: CSRU cg: RN v1: Medicated st: NotStopd t0: [20:00:00 10/11/2014] id: Education Learner el: 0 cu: CSRU cg: RN v1: Patient/Family st: NotStopd t0: [20:00:00 10/11/2014] id: Education Method el: 0 cu: CSRU cg: RN v1: Explanation st: NotStopd t0: [20:00:00 10/11/2014] id: Education Readiness el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [20:00:00 10/11/2014] id: Education Response el: 0 cu: CSRU cg: RN v1: Reinforced st: NotStopd t0: [20:00:00 10/11/2014] id: Education Topic #1 el: 0 cu: CSRU cg: RN v1: Plan of Care st: NotStopd t0: [20:00:00 10/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Visited st: NotStopd t0: [20:00:00 10/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [20:00:00 10/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [20:00:00 10/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [20:00:00 10/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [20:00:00 10/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [20:00:00 10/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [20:00:00 10/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [20:00:00 10/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [20:00:00 10/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [20:00:00 10/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [20:00:00 10/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [20:00:00 10/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [20:00:00 10/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Calm st: NotStopd
t0: [20:00:00 10/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 88 rs: Manual st: NotStopd
t0: [20:00:00 10/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [20:00:00 10/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [20:00:00 10/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [20:00:00 10/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [20:00:00 10/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [20:00:00 10/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [20:00:00 10/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [20:00:00 10/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [20:00:00 10/11/2014] id: IV #1 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [20:00:00 10/11/2014] id: IV #1 Site/Size el: 0 cu: CSRU cg: RN v1: Left Antecub v2: 16 gauge st: NotStopd t0: [20:00:00 10/11/2014] id: IV #2 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [20:00:00 10/11/2014] id: IV #2 Site/Size el: 0 cu: CSRU cg: RN v1: Right Antecub v2: 16 gauge st: NotStopd t0: [20:00:00 10/11/2014] id: IV Site Appear #1 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [20:00:00 10/11/2014] id: IV Site Appear #2 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd
t0: [20:00:00 10/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [20:00:00 10/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 35.6111 u1: Deg. C st: NotStopd t0: [20:00:00 10/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 96.1 u1: Deg. F st: NotStopd t0: [21:00:00 10/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [21:00:00 10/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 3 u1: lpm st: NotStopd
t0: [21:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [21:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [21:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [21:00:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [21:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [21:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 108 u1: BPM st: NotStopd t0: [21:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [21:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 102 u1: mmHg v2: 55 u2: mmHg st: NotStopd t0: [21:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 69 u1: mmHg st: NotStopd t0: [21:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [21:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [21:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 24 u1: BPM st: NotStopd t0: [21:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 99 u1: % st: NotStopd t0: [21:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [21:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [21:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [20:00:00 10/11/2014] id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 200 vu: ml t0: [21:00:00 10/11/2014] id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 100 vu: ml t0: [21:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [21:00:00 10/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 2 vu: ml t0: [21:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 17.625 vu: ml t0: [21:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 140 vu: ml t0: [21:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [21:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [21:00:00 10/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 114 rs: Manual st: NotStopd
t0: [21:00:00 10/11/2014] id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vu: ml nb: 1
t0: [21:20:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [21:20:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [21:20:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [21:20:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [21:20:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 111 u1: BPM st: NotStopd t0: [21:20:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [21:20:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 87 u1: mmHg v2: 45 u2: mmHg st: NotStopd t0: [21:20:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 58 u1: mmHg st: NotStopd t0: [21:20:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [21:20:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [21:20:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 32 u1: BPM st: NotStopd t0: [21:20:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 98 u1: % st: NotStopd t0: [21:20:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [21:20:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [21:20:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
tf: [08:00:00 11/11/2014] pt: Unit Dose rt: NG fr: BID fs: 10, 22 dn: 2 m1: Docusate Sodium (Liquid) v1: 100 u1: mg tf: [08:00:00 11/11/2014] pt: Unit Dose rt: NG fr: BID fs: 10, 22 dn: 2 m1: Ranitidine v1: 150 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Docusate Sodium v1: 100 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Ranitidine v1: 150 u1: mg
t0: [22:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [22:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [22:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [22:00:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [22:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [22:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 106 u1: BPM st: NotStopd t0: [22:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [22:00:00 10/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [22:00:00 10/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 3 u1: lpm st: NotStopd t0: [22:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 101 u1: mmHg v2: 53 u2: mmHg st: NotStopd t0: [22:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 67 u1: mmHg st: NotStopd t0: [22:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [22:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [22:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 22 u1: BPM st: NotStopd t0: [22:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 99 u1: % st: NotStopd t0: [22:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [22:00:00 10/11/2014] id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vo: 1000 vu: ml t0: [22:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [22:00:00 10/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 2 vu: ml t0: [22:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 19.975 vu: ml t0: [22:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 225 vu: ml t0: [22:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [22:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 20 vu: ml
t0: [22:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [22:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [22:00:00 10/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 3-Mild to Mod st: NotStopd t0: [22:00:00 10/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [22:00:00 10/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [22:00:00 10/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: At Rest st: NotStopd t0: [22:00:00 10/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 3-Mild to Mod st: NotStopd t0: [22:00:00 10/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [22:00:00 10/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IV Push st: NotStopd t0: [22:00:00 10/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Constant st: NotStopd t0: [23:00:00 10/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [23:00:00 10/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [23:00:00 10/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [23:00:00 10/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [23:00:00 10/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [23:00:00 10/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 104 u1: BPM st: NotStopd t0: [23:00:00 10/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [23:00:00 10/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [23:00:00 10/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 3 u1: lpm st: NotStopd t0: [23:00:00 10/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 94 u1: mmHg v2: 49 u2: mmHg st: NotStopd t0: [23:00:00 10/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [23:00:00 10/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [23:00:00 10/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [23:00:00 10/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 25 u1: BPM st: NotStopd t0: [23:00:00 10/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 97 u1: % st: NotStopd t0: [23:00:00 10/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [23:00:00 10/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [23:00:00 10/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [22:30:00 10/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 108 rs: Manual st: NotStopd
t0: [23:00:00 10/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [23:00:00 10/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 2 vu: ml t0: [23:00:00 10/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [23:00:00 10/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 140 vu: ml
t0: [23:00:00 10/11/2014] dt: 24 id: Urine Out Total el: 3 cu: CSRU cg: RN pv: 140 cv: 2925 ap: none
t0: [16:00:00 10/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v2: None st: NotStopd t0: [18:00:00 10/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v2: None st: NotStopd t0: [20:00:00 10/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [20:00:00 10/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [20:00:00 10/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v2: None st: NotStopd t0: [21:00:00 10/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [21:00:00 10/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [21:00:00 10/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v2: None st: NotStopd t0: [22:00:00 10/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [22:00:00 10/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 45 degrees st: NotStopd t0: [22:00:00 10/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [22:00:00 10/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Good st: NotStopd t0: [22:00:00 10/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [22:00:00 10/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [22:00:00 10/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [22:00:00 10/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Left Side st: NotStopd t0: [22:00:00 10/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 2 Person Assist st: NotStopd t0: [22:00:00 10/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v2: None st: NotStopd t0: [22:00:00 10/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd
t0: [22:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2267 id: Drain Out #1 Jackson Pratt el: 1 cu: CSRU cg: RN vo: 35 vu: ml
t0: [23:00:00 10/11/2014] dt: 24 id: Drain #1 Total Out el: 3 cu: CSRU cg: RN cv: 35 ap: none
t0: [23:00:00 10/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IM Inject st: NotStopd
t0: [23:00:00 10/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 50 vu: ml t0: [23:00:00 10/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 30 vu: ml
t0: [23:00:00 10/11/2014] dt: 1 id: Total Hourly Output el: 3 cu: CSRU cg: RN pv: 220 cv: 220 ap: none t0: [23:00:00 10/11/2014] dt: 24 id: 24h Total Out el: 3 cu: CSRU cg: RN pv: 220 cv: 4871 ap: none t0: [23:00:00 10/11/2014] dt: 24 id: Chest Tube Out Total el: 3 cu: CSRU cg: RN pv: 80 cv: 551 ap: none
t0: [00:00:00 11/11/2014] id: Range of Motion el: 0 cu: CSRU cg: -1 st: D/C'd t0: [00:00:00 11/11/2014] id: Circulation/SkinInt el: 0 cu: CSRU cg: -1 st: D/C'd t0: [00:00:00 11/11/2014] id: Position Change el: 0 cu: CSRU cg: -1 st: D/C'd t0: [00:00:00 11/11/2014] id: Reason For Restraint el: 0 cu: CSRU cg: -1 st: D/C'd t0: [00:00:00 11/11/2014] id: Removed x 5 Mins el: 0 cu: CSRU cg: -1 st: D/C'd t0: [00:00:00 11/11/2014] id: Restraint Location el: 0 cu: CSRU cg: -1 st: D/C'd t0: [00:00:00 11/11/2014] id: Restraint Type el: 0 cu: CSRU cg: -1 st: D/C'd
tf: [23:00:00 11/11/2014] pt: IV Large Volume rt: IV fr: ONCE fs: 0 dn: 1 m1: Hespan v1: 500 u1: ml m2: NS v2: 500 u2: ml tf: [09:00:00 12/11/2014] pt: IV Piggyback rt: IV DRIP fr: INFUSION m1: Norepinephrine v1: 4 u1: mg m2: D5W v2: 250 u2: ml
t0: [00:00:00 11/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [00:00:00 11/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [00:00:00 11/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [00:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [00:00:00 11/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [00:00:00 11/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [00:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [00:00:00 11/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [00:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [00:00:00 11/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Clear Liquid st: NotStopd t0: [00:00:00 11/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [00:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [00:00:00 11/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [00:00:00 11/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [00:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 97 u1: BPM st: NotStopd t0: [00:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [00:00:00 11/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [00:00:00 11/11/2014] id: INV Line#1 Zero/Cal el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [00:00:00 11/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [00:00:00 11/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [00:00:00 11/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [00:00:00 11/11/2014] id: INV Line#2 Zero/Cal el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [00:00:00 11/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [00:00:00 11/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [00:00:00 11/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [00:00:00 11/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [00:00:00 11/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [00:00:00 11/11/2014] id: IV #1 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [00:00:00 11/11/2014] id: IV #1 Site/Size el: 0 cu: CSRU cg: RN v1: Left Antecub v2: 16 gauge st: NotStopd t0: [00:00:00 11/11/2014] id: IV #2 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [00:00:00 11/11/2014] id: IV #2 Site/Size el: 0 cu: CSRU cg: RN v1: Right Antecub v2: 16 gauge st: NotStopd t0: [00:00:00 11/11/2014] id: IV Site Appear #1 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [00:00:00 11/11/2014] id: IV Site Appear #2 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [00:00:00 11/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [00:00:00 11/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [00:00:00 11/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [00:00:00 11/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [00:00:00 11/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [00:00:00 11/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [00:00:00 11/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [00:00:00 11/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [00:00:00 11/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [00:00:00 11/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [00:00:00 11/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [00:00:00 11/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Alert st: NotStopd t0: [00:00:00 11/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [00:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [00:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [00:00:00 11/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [00:00:00 11/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [00:00:00 11/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [00:00:00 11/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [00:00:00 11/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [00:00:00 11/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [00:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 93 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [00:00:00 11/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [00:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [00:00:00 11/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [00:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [00:00:00 11/11/2014] id: Atrial Sens/Capture el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [00:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [00:00:00 11/11/2014] id: Pupil Response R/L el: 0 cu: CSRU cg: RN v1: Brisk v2: Brisk st: NotStopd t0: [00:00:00 11/11/2014] id: Pupil Size R/L el: 0 cu: CSRU cg: RN v1: 3 mm v2: 3 mm st: NotStopd t0: [00:00:00 11/11/2014] id: AtrialmA/Sensitivity el: 0 cu: CSRU cg: RN v2: 0.4 st: NotStopd t0: [00:00:00 11/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Crackles st: NotStopd t0: [00:00:00 11/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [00:00:00 11/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [00:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 28 u1: BPM st: NotStopd t0: [00:00:00 11/11/2014] id: Restraints Evaluated el: 0 cu: CSRU cg: RN v1: Restraint DC'd st: NotStopd t0: [00:00:00 11/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [00:00:00 11/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [00:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 97 u1: % st: NotStopd t0: [00:00:00 11/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [00:00:00 11/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [00:00:00 11/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 36.3889 u1: Deg. C st: NotStopd t0: [00:00:00 11/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 97.5 u1: Deg. F st: NotStopd t0: [00:00:00 11/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Yellow v2: Clear st: NotStopd t0: [00:00:00 11/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [00:00:00 11/11/2014] id: Vent Sens/Capture el: 0 cu: CSRU cg: RN v1: Yes v2: Yes st: NotStopd t0: [00:00:00 11/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [00:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [00:00:00 11/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Sleeping st: NotStopd t0: [00:00:00 11/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 120 rs: Manual st: NotStopd t0: [00:00:00 11/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Hypoactive st: NotStopd t0: [00:00:00 11/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Bedfast st: NotStopd t0: [00:00:00 11/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: Potential Prob st: NotStopd t0: [00:00:00 11/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: Sl. Limited st: NotStopd t0: [00:00:00 11/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Rarely Moist st: NotStopd t0: [00:00:00 11/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Prob. Inadequate st: NotStopd t0: [00:00:00 11/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 15 u1: number st: NotStopd t0: [00:00:00 11/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: Sl. Limited st: NotStopd t0: [00:00:00 11/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd t0: [00:00:00 11/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [00:00:00 11/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [00:00:00 11/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [00:00:00 11/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd
t0: [00:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [00:00:00 11/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 2 vu: ml t0: [00:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 21.15 vu: ml t0: [00:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 160 vu: ml t0: [00:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 22 vu: ml t0: [00:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 25 vu: ml
t0: [00:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [00:00:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [01:00:00 11/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 5-Moderate st: NotStopd t0: [01:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [01:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [01:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [01:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [01:00:00 11/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [01:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [01:00:00 11/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Good st: NotStopd t0: [01:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [01:00:00 11/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [01:00:00 11/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [01:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Cough/DeepBreath st: NotStopd t0: [01:00:00 11/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 5-Moderate st: NotStopd t0: [01:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [01:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IV Push st: NotStopd t0: [01:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [01:00:00 11/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd t0: [01:00:00 11/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 2 Person Assist st: NotStopd t0: [01:00:00 11/11/2014] id: Skin Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [01:00:00 11/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd t0: [01:00:00 11/11/2014] id: Back Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd
t0: [00:30:00 11/11/2014] id: Hespan IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 500 vu: ml nb: 1
t0: [23:00:00 10/11/2014] tf: [11:47:00 12/11/2014] dt: 2207 id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [00:00:00 11/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [00:30:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 3 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [23:00:00 11/11/2014] dt: 24 id: Colloids Total el: 3 cu: CSRU cg: RN cv: 500 ap: none
t0: [01:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [01:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [01:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [01:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [01:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 103 u1: BPM st: NotStopd t0: [01:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [01:00:00 11/11/2014] id: Airway Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [01:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [01:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 1 u1: lpm st: NotStopd t0: [01:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 100 u1: mmHg v2: 49 u2: mmHg st: NotStopd t0: [01:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 65 u1: mmHg st: NotStopd t0: [01:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [01:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [01:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 19 u1: BPM st: NotStopd t0: [01:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 95 u1: % st: NotStopd t0: [01:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [00:00:00 11/11/2014] tf: [11:47:00 12/11/2014] dt: 2147 id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 20 vu: ml t0: [01:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [01:00:00 11/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 2.5 vu: ml t0: [01:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 21.15 vu: ml t0: [01:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 100 vu: ml t0: [01:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 12 vu: ml t0: [01:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [01:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [01:00:00 11/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [01:00:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 3 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [23:00:00 11/11/2014] dt: 24 id: PO/Gastric In Total el: 3 cu: CSRU cg: RN pv: 30 cv: 780 ap: none
t0: [01:20:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [01:20:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [01:20:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [01:20:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: Vent. Bigeminy st: NotStopd t0: [01:20:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 100 u1: BPM st: NotStopd t0: [01:20:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [01:20:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 87 u1: mmHg v2: 43 u2: mmHg st: NotStopd t0: [01:20:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 56 u1: mmHg st: NotStopd t0: [01:20:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [01:20:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [01:20:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 20 u1: BPM st: NotStopd t0: [01:20:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [01:20:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:20:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [01:20:00 11/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [01:20:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 3 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [01:15:00 11/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 117 rs: Manual st: NotStopd
t0: [01:00:00 11/11/2014] tf: [06:00:00 11/11/2014] dt: 300 id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 0 vu: ml t0: [01:00:00 11/11/2014] id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 5.64 vu: ml
t0: [23:00:00 10/11/2014] dt: 1 id: Net Hourly Balance el: 3 cu: CSRU cg: RN pv: -183.325 cv: -183.325 ap: none t0: [23:00:00 10/11/2014] dt: 24 id: IV Infusion In Total el: 3 cu: CSRU cg: RN pv: 36.675 cv: 3865.86 ap: none t0: [23:00:00 10/11/2014] dt: 24 id: 24h Total In el: 3 cu: CSRU cg: RN pv: 36.675 cv: 7865.86 ap: none t0: [23:00:00 10/11/2014] dt: 24 id: 24h Net Body Balance el: 3 cu: CSRU cg: RN pv: -183.325 cv: 2994.86 ap: none t0: [23:00:00 10/11/2014] dt: multiple days id: LOS Net Body Balance el: 3 cu: CSRU cg: RN pv: -183.325 cv: 2994.86 ap: none
t0: [01:20:00 11/11/2014] id: WBC (4-11,000) Hematology el: 0 cu: CSRU cg: 3161 v1: 7.7 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: WBC Hematology el: 0 cu: CSRU cg: 3161 v1: 7.7 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Hematocrit Hematology el: 0 cu: CSRU cg: 3161 v1: 24.3 u1: % rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Hemoglobin Hematology el: 0 cu: CSRU cg: 3161 v1: 8.6 u1: gm/dl rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Platelets Hematology el: 0 cu: CSRU cg: 3161 v1: 171 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: RBC Hematology el: 0 cu: CSRU cg: 3161 v1: 2.77 u1: /mic l rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: WBC (4-11,000) Hematology el: 0 cu: CSRU cg: 3161 v1: 7.7 rs: Final st: NotStopd
t0: [01:20:00 11/11/2014] id: BUN el: 0 cu: CSRU cg: 3161 v1: 8 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Chloride Chemistry el: 0 cu: CSRU cg: 3161 v1: 103 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Creatinine Chemistry el: 0 cu: CSRU cg: 3161 v1: 0.6 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 105 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Magnesium Chemistry el: 0 cu: CSRU cg: 3161 v1: 2 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.1 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Sodium Chemistry el: 0 cu: CSRU cg: 3161 v1: 132 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: BUN (6-20) Chemistry el: 0 cu: CSRU cg: 3161 v1: 8 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Carbon Dioxide Chemistry el: 0 cu: CSRU cg: 3161 v1: 27 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Chloride (100-112) Chemistry el: 0 cu: CSRU cg: 3161 v1: 103 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Creatinine (0-1.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 0.6 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 105 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Magnesium (1.6-2.6) Chemistry el: 0 cu: CSRU cg: 3161 v1: 2 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.1 rs: Final st: NotStopd t0: [01:20:00 11/11/2014] id: Sodium (135-148) Chemistry el: 0 cu: CSRU cg: 3161 v1: 132 rs: Final st: NotStopd
t0: [00:00:00 11/11/2014] id: Significant Events el: 0 cu: CSRU cg: RN v1: Fluid Bolus st: NotStopd t0: [02:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [02:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [02:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [02:00:00 11/11/2014] id: Ectopy Frequency el: 0 cu: CSRU cg: RN v1: Rare st: NotStopd t0: [02:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: PVC's st: NotStopd t0: [02:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 97 u1: BPM st: NotStopd t0: [02:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [02:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [02:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [02:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 94 u1: mmHg v2: 43 u2: mmHg st: NotStopd t0: [02:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 59 u1: mmHg st: NotStopd t0: [02:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [02:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [02:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 21 u1: BPM st: NotStopd t0: [02:00:00 11/11/2014] id: Significant Events el: 0 cu: CSRU cg: RN v1: Fluid Bolus st: NotStopd t0: [02:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [02:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:00:00 11/11/2014] id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vo: 500 vu: ml nb: 1 t0: [02:00:00 11/11/2014] id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 2.82 vu: ml t0: [02:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [02:00:00 11/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 3 vu: ml t0: [02:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 23.5 vu: ml t0: [02:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 220 vu: ml t0: [02:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [02:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [02:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [02:00:00 11/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [02:00:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 3 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [02:30:00 11/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 99 rs: Manual st: NotStopd
t0: [02:30:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [03:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [03:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [03:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [03:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [03:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 103 u1: BPM st: NotStopd t0: [03:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [03:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 92 u1: mmHg v2: 42 u2: mmHg st: NotStopd t0: [03:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 58 u1: mmHg st: NotStopd t0: [03:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [03:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [03:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 22 u1: BPM st: NotStopd t0: [03:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 96 u1: % st: NotStopd t0: [03:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [03:00:00 11/11/2014] id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 2.82 vu: ml t0: [03:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [03:00:00 11/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 2.5 vu: ml t0: [03:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [03:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 540 vu: ml t0: [03:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [03:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 20 vu: ml
t0: [03:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [03:00:00 11/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [03:00:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 2 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [23:00:00 11/11/2014] dt: 1 id: Total Hourly Output el: 3 cu: CSRU cg: RN pv: 180 cv: 180 ap: none t0: [23:00:00 11/11/2014] dt: 1 id: Net Hourly Balance el: 3 cu: CSRU cg: RN pv: -72.375 cv: -72.375 ap: none t0: [23:00:00 11/11/2014] dt: 24 id: IV Infusion In Total el: 3 cu: CSRU cg: RN pv: 77.625 cv: 3320.4 ap: none t0: [23:00:00 11/11/2014] dt: 24 id: 24h Total In el: 3 cu: CSRU cg: RN pv: 107.625 cv: 4600.4 ap: none t0: [23:00:00 11/11/2014] dt: 24 id: Urine Out Total el: 3 cu: CSRU cg: RN pv: 180 cv: 4485 ap: none t0: [23:00:00 11/11/2014] dt: 24 id: 24h Net Body Balance el: 3 cu: CSRU cg: RN pv: -72.375 cv: -618.605 ap: none t0: [23:00:00 11/11/2014] dt: 24 id: 24h Total Out el: 3 cu: CSRU cg: RN pv: 180 cv: 5219 ap: none t0: [23:00:00 11/11/2014] dt: 24 id: Chest Tube Out Total el: 3 cu: CSRU cg: RN pv: 0 cv: 704 ap: none t0: [23:00:00 11/11/2014] dt: multiple days id: LOS Net Body Balance el: 3 cu: CSRU cg: RN pv: -72.375 cv: 2376.25 ap: none
t0: [03:00:00 11/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 6-Mod to Severe st: NotStopd t0: [03:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [03:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [03:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [03:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [03:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: At Rest st: NotStopd t0: [03:00:00 11/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 6-Mod to Severe st: NotStopd t0: [03:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [03:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: PO Med st: NotStopd t0: [03:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [04:00:00 11/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 4-Mild to Mod st: NotStopd t0: [04:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [04:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [04:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [04:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [04:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [04:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [04:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [04:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [04:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 96 u1: BPM st: NotStopd t0: [04:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [04:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 102 u1: mmHg v2: 47 u2: mmHg st: NotStopd t0: [04:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Cough/DeepBreath st: NotStopd t0: [04:00:00 11/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 4-Mild to Mod st: NotStopd t0: [04:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [04:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IM Inject st: NotStopd t0: [04:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [04:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 62 u1: mmHg st: NotStopd t0: [04:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [04:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [04:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 32 u1: BPM st: NotStopd t0: [04:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 96 u1: % st: NotStopd t0: [04:00:00 11/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [04:00:00 11/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 37.0556 u1: Deg. C st: NotStopd t0: [04:00:00 11/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 98.7 u1: Deg. F st: NotStopd t0: [04:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [03:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 80 vu: ml t0: [04:00:00 11/11/2014] id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vo: 1000 vu: ml nb: 1 t0: [04:00:00 11/11/2014] id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 2.82 vu: ml t0: [04:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [04:00:00 11/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 2 vu: ml t0: [04:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [04:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 260 vu: ml t0: [04:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 12 vu: ml t0: [04:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 15 vu: ml
t0: [04:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [04:00:00 11/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.2 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [04:00:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 1 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [03:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [03:00:00 11/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [03:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [03:00:00 11/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [03:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [03:00:00 11/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [03:00:00 11/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Supine st: NotStopd t0: [03:00:00 11/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 1 Person Assist st: NotStopd t0: [03:00:00 11/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Back st: NotStopd t0: [04:00:00 11/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [04:00:00 11/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [04:00:00 11/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [04:00:00 11/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [04:00:00 11/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [04:00:00 11/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [04:00:00 11/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Clear Liquid st: NotStopd t0: [04:00:00 11/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [04:00:00 11/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [04:00:00 11/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [04:00:00 11/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [04:00:00 11/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [04:00:00 11/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [04:00:00 11/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [04:00:00 11/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [04:00:00 11/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [04:00:00 11/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [04:00:00 11/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [04:00:00 11/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [04:00:00 11/11/2014] id: IV #1 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [04:00:00 11/11/2014] id: IV #1 Site/Size el: 0 cu: CSRU cg: RN v1: Left Antecub v2: 16 gauge st: NotStopd t0: [04:00:00 11/11/2014] id: IV #2 Insert Date el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [04:00:00 11/11/2014] id: IV #2 Site/Size el: 0 cu: CSRU cg: RN v1: Right Antecub v2: 16 gauge st: NotStopd t0: [04:00:00 11/11/2014] id: IV Site Appear #1 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [04:00:00 11/11/2014] id: IV Site Appear #2 el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [04:00:00 11/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [04:00:00 11/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [04:00:00 11/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Alert st: NotStopd t0: [04:00:00 11/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [04:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [04:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [04:00:00 11/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [04:00:00 11/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [04:00:00 11/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [04:00:00 11/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [04:00:00 11/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [04:00:00 11/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [04:00:00 11/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [04:00:00 11/11/2014] id: Atrial Sens/Capture el: 0 cu: CSRU cg: RN v1: Yes v2: Yes st: NotStopd t0: [04:00:00 11/11/2014] id: Atrial Threshold el: 0 cu: CSRU cg: RN v1: mA v2: 5 u2: V-mA st: NotStopd t0: [04:00:00 11/11/2014] id: AtrialmA/Sensitivity el: 0 cu: CSRU cg: RN v2: 0.4 st: NotStopd t0: [04:00:00 11/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [04:00:00 11/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [04:00:00 11/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [04:00:00 11/11/2014] id: Significant Events el: 0 cu: CSRU cg: RN v1: Fluid Bolus st: NotStopd t0: [04:00:00 11/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [04:00:00 11/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [04:00:00 11/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [04:00:00 11/11/2014] id: Vent Sens/Capture el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [04:00:00 11/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [04:00:00 11/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Calm st: NotStopd t0: [04:00:00 11/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Hypoactive st: NotStopd t0: [04:00:00 11/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd t0: [04:00:00 11/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [04:00:00 11/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [04:00:00 11/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [04:00:00 11/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Sanguinous st: NotStopd
t0: [03:00:00 11/11/2014] id: Lactated Ringers IV Infusions el: 1 cu: CSRU cg: RN ai: 304 vo: 250 vu: ml
t0: [05:00:00 11/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.4 rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 76 rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.1 rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: 2 rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 30 rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 47 u1: mmHg rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 77 u1: mmHg rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.4 rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 76 rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.09 rs: Final st: NotStopd t0: [05:00:00 11/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.1 rs: Final st: NotStopd
t0: [05:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [05:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [05:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [05:00:00 11/11/2014] id: Ectopy Frequency el: 0 cu: CSRU cg: RN v1: Rare st: NotStopd t0: [05:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: PAC's st: NotStopd t0: [05:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 99 u1: BPM st: NotStopd t0: [05:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [05:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 96 u1: mmHg v2: 45 u2: mmHg st: NotStopd t0: [05:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 60 u1: mmHg st: NotStopd t0: [05:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [05:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [05:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 28 u1: BPM st: NotStopd t0: [05:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [05:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [05:00:00 11/11/2014] id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 120 vu: ml t0: [05:00:00 11/11/2014] id: D5W 50.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 109 vo: 50 vu: ml t0: [05:00:00 11/11/2014] id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: RN ai: 107 vo: 2.82 vu: ml t0: [05:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [05:00:00 11/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 1 vu: ml t0: [05:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [05:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 250 vu: ml t0: [05:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 8 vu: ml t0: [05:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 15 vu: ml
t0: [05:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [05:00:00 11/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [05:00:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 0 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [04:45:00 11/11/2014] id: Hematocrit Hematology el: 0 cu: CSRU cg: 3161 v1: 22.2 u1: % rs: Final st: NotStopd
t0: [06:00:00 11/11/2014] id: IV #1 Insert Date el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 11/11/2014] id: IV #1 Site/Size el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 11/11/2014] id: IV #2 Insert Date el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 11/11/2014] id: IV #2 Site/Size el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 11/11/2014] id: IV Site Appear #1 el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 11/11/2014] id: IV Site Appear #2 el: 0 cu: CSRU cg: -1 st: D/C'd
t0: [06:00:00 11/11/2014] id: D5W 250.0ml + 100mcgkgmin Nitroglycerine-k IV Infusions el: 1 cu: CSRU cg: -1 ai: 107 vo: 0 st: D/C'd
t0: [06:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [06:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [06:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [06:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [06:00:00 11/11/2014] id: Ectopy Frequency el: 0 cu: CSRU cg: RN v1: Rare st: NotStopd t0: [06:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: PVC's st: NotStopd t0: [06:00:00 11/11/2014] id: Education Topic #1 el: 0 cu: CSRU cg: RN v1: Plan of Care st: NotStopd t0: [06:00:00 11/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [06:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 92 u1: BPM st: NotStopd t0: [06:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [06:00:00 11/11/2014] id: IV #1 D/C Date el: 0 cu: CSRU cg: RN v1: 9 v2: 30 st: NotStopd t0: [06:00:00 11/11/2014] id: IV #2 D/C Date el: 0 cu: CSRU cg: RN v1: 9 v2: 30 st: NotStopd t0: [06:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [06:00:00 11/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Good st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Closure/Appear#1 el: 0 cu: CSRU cg: RN v1: Steri-strip v2: Clean and Dry st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Closure/Appear#2 el: 0 cu: CSRU cg: RN v1: Approximated v2: Clean and Dry st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Closure/Appear#3 el: 0 cu: CSRU cg: RN v1: Steri-strip v2: Clean and Dry st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: Sanguinous v2: Moderate st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: Sanguinous v2: Scant st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Changed st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Changed st: NotStopd t0: [06:00:00 11/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Changed st: NotStopd t0: [06:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [06:00:00 11/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [06:00:00 11/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [06:00:00 11/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [06:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 87 u1: mmHg v2: 46 u2: mmHg st: NotStopd t0: [06:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 59.6667 u1: mmHg st: NotStopd t0: [06:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [06:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [06:00:00 11/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [06:00:00 11/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [06:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 91 u1: mmHg v2: 43 u2: mmHg st: NotStopd t0: [06:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 57 u1: mmHg st: NotStopd t0: [06:00:00 11/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd t0: [06:00:00 11/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 2 Person Assist st: NotStopd t0: [06:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [06:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [06:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 15 u1: BPM st: NotStopd t0: [06:00:00 11/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [06:00:00 11/11/2014] id: Skin Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [06:00:00 11/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [06:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 95 u1: % st: NotStopd t0: [06:00:00 11/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [06:00:00 11/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Side to Side st: NotStopd t0: [06:00:00 11/11/2014] id: Back Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [06:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [06:00:00 11/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Calm st: NotStopd
t0: [06:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [06:00:00 11/11/2014] id: .9% Normal Saline 100.0ml + 100Uhr Insulin IV Infusions el: 1 cu: CSRU cg: RN ai: 115 vo: 0 vu: ml t0: [06:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [06:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 225 vu: ml t0: [06:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 45 vu: ml t0: [06:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 0 vu: ml
t0: [06:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [06:00:00 11/11/2014] id: Nitroglycerine-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [06:00:00 11/11/2014] id: Insulin el: 1 cu: CSRU cg: RN so: .9% Normal Saline vo: 0 v1: 0 du: Uhr sv: 100 su: ml rt: IV Drip
t0: [07:00:00 11/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 97 rs: Manual st: NotStopd
t0: [07:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [07:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [07:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [07:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [07:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 99 u1: BPM st: NotStopd t0: [07:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [07:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 88 u1: mmHg v2: 45 u2: mmHg st: NotStopd t0: [07:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 59.3333 u1: mmHg st: NotStopd t0: [07:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 89 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [07:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 60 u1: mmHg st: NotStopd t0: [07:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [07:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [07:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 25 u1: BPM st: NotStopd t0: [07:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 96 u1: % st: NotStopd t0: [07:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [07:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 20 vu: ml t0: [07:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [07:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [07:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 100 vu: ml
t0: [07:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [06:00:00 11/11/2014] id: Drain Out #1 Jackson Pratt el: 1 cu: CSRU cg: RN vo: 15 vu: ml
t0: [08:00:00 11/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 11/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [08:00:00 11/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [08:00:00 11/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 4-Mild to Mod st: NotStopd t0: [08:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [08:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [08:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [08:00:00 11/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [08:00:00 11/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [08:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [08:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [08:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [08:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [08:00:00 11/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [08:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [08:00:00 11/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Clear Liquid st: NotStopd t0: [08:00:00 11/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [08:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [08:00:00 11/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [08:00:00 11/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Fam Talked to RN st: NotStopd t0: [08:00:00 11/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [08:00:00 11/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [08:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 103 u1: BPM st: NotStopd t0: [08:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [08:00:00 11/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [08:00:00 11/11/2014] id: INV Line#1 Zero/Cal el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [08:00:00 11/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [08:00:00 11/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [08:00:00 11/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [08:00:00 11/11/2014] id: INV Line#2 Zero/Cal el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [08:00:00 11/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [08:00:00 11/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [08:00:00 11/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [08:00:00 11/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [08:00:00 11/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [08:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [08:00:00 11/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [08:00:00 11/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [08:00:00 11/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [08:00:00 11/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [08:00:00 11/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [08:00:00 11/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [08:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [08:00:00 11/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [08:00:00 11/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [08:00:00 11/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [08:00:00 11/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 11/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [08:00:00 11/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Alert st: NotStopd t0: [08:00:00 11/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [08:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 91 u1: mmHg v2: 47 u2: mmHg st: NotStopd t0: [08:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 61.6667 u1: mmHg st: NotStopd t0: [08:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [08:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [08:00:00 11/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [08:00:00 11/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [08:00:00 11/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [08:00:00 11/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [08:00:00 11/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [08:00:00 11/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [08:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 99 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [08:00:00 11/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [08:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Cough/DeepBreath st: NotStopd t0: [08:00:00 11/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 4-Mild to Mod st: NotStopd t0: [08:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [08:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: PO Med st: NotStopd t0: [08:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [08:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 63 u1: mmHg st: NotStopd t0: [08:00:00 11/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Supine st: NotStopd t0: [08:00:00 11/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [08:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [08:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [08:00:00 11/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [08:00:00 11/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [08:00:00 11/11/2014] id: Radiologic Study el: 0 cu: CSRU cg: RN v1: Chest Xray st: NotStopd t0: [08:00:00 11/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [08:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 26 u1: BPM st: NotStopd t0: [08:00:00 11/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [08:00:00 11/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [08:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 93 u1: % st: NotStopd t0: [08:00:00 11/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v1: Expectorated v2: None st: NotStopd t0: [08:00:00 11/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [08:00:00 11/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [08:00:00 11/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 36.1111 u1: Deg. C st: NotStopd t0: [08:00:00 11/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 97 u1: Deg. F st: NotStopd t0: [08:00:00 11/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [08:00:00 11/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 11/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [08:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [08:00:00 11/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Calm st: NotStopd t0: [08:00:00 11/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Hypoactive st: NotStopd t0: [08:00:00 11/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Bedfast st: NotStopd t0: [08:00:00 11/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: No Apparent Prob st: NotStopd t0: [08:00:00 11/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: No Limitations st: NotStopd t0: [08:00:00 11/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Rarely Moist st: NotStopd t0: [08:00:00 11/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Adequate st: NotStopd t0: [08:00:00 11/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 19 u1: number st: NotStopd t0: [08:00:00 11/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: No Impairment st: NotStopd t0: [08:00:00 11/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd t0: [08:00:00 11/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 11/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [08:00:00 11/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [08:00:00 11/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd
t0: [08:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [08:00:00 11/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 127 rs: Manual st: NotStopd
t0: [08:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 50 vu: ml t0: [08:00:00 11/11/2014] id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 200 vu: ml t0: [08:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [08:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [08:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 120 vu: ml t0: [08:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 40 vu: ml t0: [08:00:00 11/11/2014] tf: [14:00:00 11/11/2014] dt: 360 id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 20 vu: ml
t0: [09:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [09:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [09:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [09:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [09:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [09:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 113 u1: BPM st: NotStopd t0: [09:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [09:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 86 u1: mmHg v2: 45 u2: mmHg st: NotStopd t0: [09:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 58.6667 u1: mmHg st: NotStopd t0: [09:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 115 u1: mmHg v2: 65 u2: mmHg st: NotStopd t0: [09:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 80 u1: mmHg st: NotStopd t0: [09:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [09:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [09:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 19 u1: BPM st: NotStopd t0: [09:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [09:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [09:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [09:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 21.15 vu: ml t0: [09:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 100 vu: ml t0: [09:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 20 vu: ml t0: [09:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [09:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip
tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Atorvastatin v1: 10 u1: mg
t0: [10:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [10:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [10:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [10:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [10:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [10:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [10:00:00 11/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [10:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 108 u1: BPM st: NotStopd t0: [10:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [10:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [10:00:00 11/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Good st: NotStopd t0: [10:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 96 u1: mmHg v2: 45 u2: mmHg st: NotStopd t0: [10:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 62 u1: mmHg st: NotStopd t0: [10:00:00 11/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [10:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 88 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [10:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 64 u1: mmHg st: NotStopd t0: [10:00:00 11/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd t0: [10:00:00 11/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 2 Person Assist st: NotStopd t0: [10:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [10:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [10:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 24 u1: BPM st: NotStopd t0: [10:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 92 u1: % st: NotStopd t0: [10:00:00 11/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [10:00:00 11/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 36.3333 u1: Deg. C st: NotStopd t0: [10:00:00 11/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 97.4 u1: Deg. F st: NotStopd t0: [10:00:00 11/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd t0: [10:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [09:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 100 vu: ml t0: [10:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [10:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 21.15 vu: ml t0: [10:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 50 vu: ml t0: [10:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 20 vu: ml t0: [10:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [10:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [10:15:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [10:15:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [10:15:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [10:15:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [10:15:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [10:15:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 102 u1: BPM st: NotStopd t0: [10:15:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [10:15:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 87 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [10:15:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 60 u1: mmHg st: NotStopd t0: [10:15:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [10:15:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [10:15:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 29 u1: BPM st: NotStopd t0: [10:15:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 95 u1: % st: NotStopd t0: [10:15:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:15:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [10:15:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [10:15:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 3 u1: lpm st: NotStopd t0: [10:20:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [10:20:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [10:20:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [10:20:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [10:20:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [10:20:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 99 u1: BPM st: NotStopd t0: [10:20:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [10:20:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 81 u1: mmHg v2: 45 u2: mmHg st: NotStopd t0: [10:20:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 55 u1: mmHg st: NotStopd t0: [10:20:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [10:20:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [10:20:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 21 u1: BPM st: NotStopd t0: [10:20:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 96 u1: % st: NotStopd t0: [10:20:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:20:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.08 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [10:45:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [10:45:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [10:45:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [10:45:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [10:45:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [10:45:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 101 u1: BPM st: NotStopd t0: [10:45:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [10:45:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 102 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [10:45:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 67 u1: mmHg st: NotStopd t0: [10:45:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [10:45:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [10:45:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 30 u1: BPM st: NotStopd t0: [10:45:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 96 u1: % st: NotStopd t0: [10:45:00 11/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [10:45:00 11/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 37.3333 u1: Deg. C st: NotStopd t0: [10:45:00 11/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 99.2 u1: Deg. F st: NotStopd t0: [10:45:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [10:45:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.08 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [10:46:00 11/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.41 rs: Final st: NotStopd t0: [10:46:00 11/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 u1: mmHg rs: Final st: NotStopd t0: [10:46:00 11/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 u1: mmHg rs: Final st: NotStopd t0: [10:46:00 11/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.41 rs: Final st: NotStopd
t0: [10:46:00 11/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.3 rs: Final st: NotStopd t0: [10:46:00 11/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.3 rs: Final st: NotStopd t0: [10:46:00 11/11/2014] id: SaO2 ABG's el: 0 cu: CSRU cg: 3161 v1: 97 u1: % rs: Final st: NotStopd
t0: [10:46:00 11/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 214 rs: Final st: NotStopd t0: [10:46:00 11/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: RN v1: 214 rs: Final st: NotStopd t0: [10:46:00 11/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: RN v1: 1.09 rs: Final st: NotStopd t0: [11:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [11:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [11:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [11:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [11:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [11:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 102 u1: BPM st: NotStopd t0: [11:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [11:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 88 u1: mmHg v2: 47 u2: mmHg st: NotStopd t0: [11:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 60.6667 u1: mmHg st: NotStopd t0: [11:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 105 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [11:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [11:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [11:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [11:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 33 u1: BPM st: NotStopd t0: [11:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 96 u1: % st: NotStopd t0: [11:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [11:00:00 11/11/2014] id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 120 vu: ml t0: [11:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [11:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 26.1438 vu: ml t0: [11:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 60 vu: ml t0: [11:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [11:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 5 vu: ml
t0: [11:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [12:00:00 11/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [12:00:00 11/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [12:00:00 11/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [12:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: No st: NotStopd t0: [12:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [12:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [12:00:00 11/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [12:00:00 11/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [12:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [12:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [12:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [12:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [12:00:00 11/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [12:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [12:00:00 11/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Diabetic st: NotStopd t0: [12:00:00 11/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [12:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [12:00:00 11/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [12:00:00 11/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [12:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 105 u1: BPM st: NotStopd t0: [12:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [12:00:00 11/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [12:00:00 11/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [12:00:00 11/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [12:00:00 11/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [12:00:00 11/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [12:00:00 11/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [12:00:00 11/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [12:00:00 11/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [12:00:00 11/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [12:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Chair st: NotStopd t0: [12:00:00 11/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [12:00:00 11/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [12:00:00 11/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [12:00:00 11/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [12:00:00 11/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [12:00:00 11/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [12:00:00 11/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [12:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [12:00:00 11/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [12:00:00 11/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [12:00:00 11/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [12:00:00 11/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 11/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [12:00:00 11/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Alert st: NotStopd t0: [12:00:00 11/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [12:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 101 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [12:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 65.6667 u1: mmHg st: NotStopd t0: [12:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [12:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 3 u1: lpm st: NotStopd t0: [12:00:00 11/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [12:00:00 11/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [12:00:00 11/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [12:00:00 11/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [12:00:00 11/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [12:00:00 11/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [12:00:00 11/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [12:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 128 u1: mmHg v2: 53 u2: mmHg st: NotStopd t0: [12:00:00 11/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [12:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 74 u1: mmHg st: NotStopd t0: [12:00:00 11/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [12:00:00 11/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 2 Person Assist st: NotStopd t0: [12:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [12:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [12:00:00 11/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [12:00:00 11/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [12:00:00 11/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [12:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 30 u1: BPM st: NotStopd t0: [12:00:00 11/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [12:00:00 11/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [12:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [12:00:00 11/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v1: Expectorated v2: None st: NotStopd t0: [12:00:00 11/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [12:00:00 11/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 36.4444 u1: Deg. C st: NotStopd t0: [12:00:00 11/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 97.6 u1: Deg. F st: NotStopd t0: [12:00:00 11/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [12:00:00 11/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [12:00:00 11/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [12:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [12:00:00 11/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Calm st: NotStopd t0: [12:00:00 11/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Present st: NotStopd t0: [12:00:00 11/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Chairfast st: NotStopd t0: [12:00:00 11/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: No Apparent Prob st: NotStopd t0: [12:00:00 11/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: No Limitations st: NotStopd t0: [12:00:00 11/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Rarely Moist st: NotStopd t0: [12:00:00 11/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Adequate st: NotStopd t0: [12:00:00 11/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 20 u1: number st: NotStopd t0: [12:00:00 11/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: No Impairment st: NotStopd t0: [12:00:00 11/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd t0: [12:00:00 11/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [12:00:00 11/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [12:00:00 11/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [12:00:00 11/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd
t0: [12:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [12:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [12:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 400 vu: ml t0: [12:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 90 vu: ml t0: [12:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 20 vu: ml
t0: [12:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [12:00:00 11/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: PCT v1: 162 rs: Manual st: NotStopd
t0: [13:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [13:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [13:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [13:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [13:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [13:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [13:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [13:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [13:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 116 u1: BPM st: NotStopd t0: [13:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [13:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [13:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [13:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 95 u1: mmHg v2: 55 u2: mmHg st: NotStopd t0: [13:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Cough/DeepBreath st: NotStopd t0: [13:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [13:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: PO Med st: NotStopd t0: [13:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [13:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 70 u1: mmHg st: NotStopd t0: [13:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [13:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [13:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 15 u1: BPM st: NotStopd t0: [13:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 95 u1: % st: NotStopd t0: [13:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [13:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [13:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [13:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 220 vu: ml
t0: [13:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [13:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 91 u1: mmHg v2: 50 u2: mmHg st: NotStopd t0: [13:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 63.6667 u1: mmHg st: NotStopd
t0: [14:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [14:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [14:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [14:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [14:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [14:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 110 u1: BPM st: NotStopd t0: [14:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [14:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 101 u1: mmHg v2: 49 u2: mmHg st: NotStopd t0: [14:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 66.3333 u1: mmHg st: NotStopd t0: [14:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 110 u1: mmHg v2: 49 u2: mmHg st: NotStopd t0: [14:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [14:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [14:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [14:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 29 u1: BPM st: NotStopd t0: [14:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 96 u1: % st: NotStopd t0: [14:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [14:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [14:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 21.15 vu: ml t0: [14:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 200 vu: ml t0: [14:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [14:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 0 vu: ml
t0: [14:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [13:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 150 vu: ml
t0: [15:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [15:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [15:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [15:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [15:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [15:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 115 u1: BPM st: NotStopd t0: [15:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [15:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 99 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [15:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 66 u1: mmHg st: NotStopd t0: [15:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [15:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [15:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 23 u1: BPM st: NotStopd t0: [15:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 96 u1: % st: NotStopd t0: [15:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [15:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [15:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 21.15 vu: ml t0: [15:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 200 vu: ml t0: [15:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 30 vu: ml t0: [15:00:00 11/11/2014] tf: [23:00:00 11/11/2014] dt: 480 id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [15:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [13:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [13:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [14:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [14:00:00 11/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Visited st: NotStopd t0: [14:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [14:00:00 11/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [15:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [15:00:00 11/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Visited st: NotStopd t0: [15:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Chair st: NotStopd t0: [15:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [15:00:00 11/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [16:00:00 11/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [16:00:00 11/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [16:00:00 11/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [16:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [16:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [16:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [16:00:00 11/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [16:00:00 11/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [16:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [16:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [16:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [16:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [16:00:00 11/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [16:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [16:00:00 11/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Diabetic st: NotStopd t0: [16:00:00 11/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [16:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:00:00 11/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [16:00:00 11/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Visited st: NotStopd t0: [16:00:00 11/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [16:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 99 u1: BPM st: NotStopd t0: [16:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Normal Sinus st: NotStopd t0: [16:00:00 11/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [16:00:00 11/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [16:00:00 11/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [16:00:00 11/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [16:00:00 11/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [16:00:00 11/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [16:00:00 11/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [16:00:00 11/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [16:00:00 11/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [16:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Chair st: NotStopd t0: [16:00:00 11/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:00:00 11/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:00:00 11/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [16:00:00 11/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [16:00:00 11/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [16:00:00 11/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [16:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [16:00:00 11/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [16:00:00 11/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [16:00:00 11/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [16:00:00 11/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 11/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [16:00:00 11/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Alert st: NotStopd t0: [16:00:00 11/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [16:00:00 11/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [16:00:00 11/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [16:00:00 11/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [16:00:00 11/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [16:00:00 11/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [16:00:00 11/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [16:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 108 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [16:00:00 11/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [16:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Cough/DeepBreath st: NotStopd t0: [16:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [16:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IM Inject st: NotStopd t0: [16:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [16:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 66 u1: mmHg st: NotStopd t0: [16:00:00 11/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Strong/Palpable st: NotStopd t0: [16:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [16:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [16:00:00 11/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [16:00:00 11/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [16:00:00 11/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [16:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 16 u1: BPM st: NotStopd t0: [16:00:00 11/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [16:00:00 11/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [16:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 97 u1: % st: NotStopd t0: [16:00:00 11/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [16:00:00 11/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [16:00:00 11/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [16:00:00 11/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [16:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [16:00:00 11/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 156 rs: Manual st: NotStopd t0: [16:00:00 11/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Present st: NotStopd t0: [16:00:00 11/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Bedfast st: NotStopd t0: [16:00:00 11/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: No Apparent Prob st: NotStopd t0: [16:00:00 11/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: No Limitations st: NotStopd t0: [16:00:00 11/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Rarely Moist st: NotStopd t0: [16:00:00 11/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Excellent st: NotStopd t0: [16:00:00 11/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 20 u1: number st: NotStopd t0: [16:00:00 11/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: No Impairment st: NotStopd t0: [16:00:00 11/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd t0: [16:00:00 11/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [16:00:00 11/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [16:00:00 11/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [16:00:00 11/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd
t0: [16:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [16:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 21.15 vu: ml t0: [16:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 100 vu: ml
t0: [16:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [17:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [17:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [17:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [17:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [17:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [17:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [17:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [17:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [17:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 107 u1: BPM st: NotStopd t0: [17:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [17:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 98 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [17:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Cough/DeepBreath st: NotStopd t0: [17:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [17:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: PO Med st: NotStopd t0: [17:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [17:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [17:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [17:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [17:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 17 u1: BPM st: NotStopd t0: [17:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 97 u1: % st: NotStopd t0: [17:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [12:00:00 11/11/2014] id: Drain Out #1 Jackson Pratt el: 1 cu: CSRU cg: RN vo: 15 vu: ml t0: [17:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [17:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [17:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 200 vu: ml t0: [17:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 30 vu: ml t0: [17:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 30 vu: ml
t0: [17:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [23:00:00 11/11/2014] dt: 24 id: Drain #1 Total Out el: 3 cu: CSRU cg: RN cv: 30 ap: none
t0: [17:33:00 11/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.42 rs: Final st: NotStopd t0: [17:33:00 11/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.3 rs: Final st: NotStopd t0: [17:33:00 11/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 u1: mmHg rs: Final st: NotStopd t0: [17:33:00 11/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 u1: mmHg rs: Final st: NotStopd t0: [17:33:00 11/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.42 rs: Final st: NotStopd t0: [17:33:00 11/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.14 rs: Final st: NotStopd t0: [17:33:00 11/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.3 rs: Final st: NotStopd
t0: [17:33:00 11/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 168 rs: Final st: NotStopd t0: [17:33:00 11/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: RN v1: 168 rs: Final st: NotStopd
t0: [17:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [17:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd
t0: [18:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [18:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [18:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [18:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [18:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [18:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 110 u1: BPM st: NotStopd t0: [18:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [18:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 93 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [18:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 65 u1: mmHg st: NotStopd t0: [18:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [18:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [18:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 25 u1: BPM st: NotStopd t0: [18:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 95 u1: % st: NotStopd t0: [18:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [18:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [18:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [18:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 240 vu: ml
t0: [18:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.07 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [17:08:00 11/11/2014] id: Hematocrit Hematology el: 0 cu: CSRU cg: 3161 v1: 24.4 u1: % rs: Final st: NotStopd
t0: [19:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [19:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [19:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [19:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [19:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [19:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 112 u1: BPM st: NotStopd t0: [19:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [19:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 100 u1: mmHg v2: 49 u2: mmHg st: NotStopd t0: [19:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 64 u1: mmHg st: NotStopd t0: [19:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [19:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [19:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 23 u1: BPM st: NotStopd t0: [19:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 95 u1: % st: NotStopd t0: [19:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [18:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 150 vu: ml t0: [19:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [19:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 24.675 vu: ml t0: [19:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 120 vu: ml t0: [19:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 20 vu: ml t0: [19:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [19:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.08 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [19:00:00 11/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [19:00:00 11/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [19:00:00 11/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [19:00:00 11/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [19:00:00 11/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [19:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [19:00:00 11/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [19:00:00 11/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Diabetic st: NotStopd t0: [19:00:00 11/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [19:00:00 11/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [19:00:00 11/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [19:00:00 11/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [19:00:00 11/11/2014] id: INV Line#1 Zero/Cal el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [19:00:00 11/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [19:00:00 11/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [19:00:00 11/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [19:00:00 11/11/2014] id: INV Line#2 Zero/Cal el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [19:00:00 11/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [19:00:00 11/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [19:00:00 11/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [19:00:00 11/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [19:00:00 11/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [19:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Chair st: NotStopd t0: [19:00:00 11/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [19:00:00 11/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [19:00:00 11/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [19:00:00 11/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [19:00:00 11/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [19:00:00 11/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [19:00:00 11/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [19:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [19:00:00 11/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [19:00:00 11/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [19:00:00 11/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [19:00:00 11/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Crackles st: NotStopd t0: [19:00:00 11/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [19:00:00 11/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Alert st: NotStopd t0: [19:00:00 11/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [19:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [19:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [19:00:00 11/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [19:00:00 11/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [19:00:00 11/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [19:00:00 11/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [19:00:00 11/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [19:00:00 11/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [19:00:00 11/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [19:00:00 11/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [19:00:00 11/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [19:00:00 11/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [19:00:00 11/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [19:00:00 11/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [19:00:00 11/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [19:00:00 11/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [19:00:00 11/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [19:00:00 11/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [19:00:00 11/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [19:00:00 11/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [19:00:00 11/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Present st: NotStopd t0: [19:00:00 11/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Chairfast st: NotStopd t0: [19:00:00 11/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: No Apparent Prob st: NotStopd t0: [19:00:00 11/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: No Limitations st: NotStopd t0: [19:00:00 11/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Rarely Moist st: NotStopd t0: [19:00:00 11/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Excellent st: NotStopd t0: [19:00:00 11/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 21 u1: number st: NotStopd t0: [19:00:00 11/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: No Impairment st: NotStopd t0: [19:00:00 11/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd t0: [19:00:00 11/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [19:00:00 11/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [19:00:00 11/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [19:00:00 11/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd
t0: [20:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [20:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [20:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [20:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [20:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 112 u1: BPM st: NotStopd t0: [20:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [20:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 92 u1: mmHg v2: 47 u2: mmHg st: NotStopd t0: [20:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 62 u1: mmHg st: NotStopd t0: [20:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [20:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [20:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 24 u1: BPM st: NotStopd t0: [20:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [20:00:00 11/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [20:00:00 11/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 37.6667 u1: Deg. C st: NotStopd t0: [20:00:00 11/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 99.8 u1: Deg. F st: NotStopd t0: [20:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [20:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [20:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 28.2 vu: ml t0: [20:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 210 vu: ml
t0: [20:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.08 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [20:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [20:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [20:50:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [20:50:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [20:50:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [20:50:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 111 u1: BPM st: NotStopd t0: [20:50:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 107 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [20:50:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 74.3333 u1: mmHg st: NotStopd t0: [20:50:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 123 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [20:50:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 77 u1: mmHg st: NotStopd t0: [20:50:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [20:50:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [20:50:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 29 u1: BPM st: NotStopd t0: [20:50:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [21:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [21:00:00 11/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 9 u1: mmHg st: NotStopd t0: [21:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [21:00:00 11/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [21:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [21:00:00 11/11/2014] id: Ectopy Frequency el: 0 cu: CSRU cg: RN v1: Rare st: NotStopd t0: [21:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: PAC's st: NotStopd t0: [21:00:00 11/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [21:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 112 u1: BPM st: NotStopd t0: [21:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [21:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [21:00:00 11/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [21:00:00 11/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [21:00:00 11/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 107 u1: mmHg v2: 58 u2: mmHg st: NotStopd t0: [21:00:00 11/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 74.3333 u1: mmHg st: NotStopd t0: [21:00:00 11/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [21:00:00 11/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [21:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 122 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [21:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 72 u1: mmHg st: NotStopd t0: [21:00:00 11/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Supine st: NotStopd t0: [21:00:00 11/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 2 Person Assist st: NotStopd t0: [21:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [21:00:00 11/11/2014] id: Previous Weight el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [21:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [21:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 28 u1: BPM st: NotStopd t0: [21:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 92 u1: % st: NotStopd t0: [21:00:00 11/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Left Side st: NotStopd t0: [21:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [21:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 120 vu: ml t0: [21:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [21:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 27.025 vu: ml t0: [21:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 100 vu: ml t0: [21:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 70 vu: ml t0: [21:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 35 vu: ml
t0: [20:50:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip t0: [21:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.06 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [21:15:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [21:15:00 11/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 10 u1: mmHg st: NotStopd t0: [21:15:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [21:15:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [21:15:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [21:15:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 115 u1: BPM st: NotStopd t0: [21:15:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [21:15:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 122 u1: mmHg v2: 48 u2: mmHg st: NotStopd t0: [21:15:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 70 u1: mmHg st: NotStopd t0: [21:15:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [21:15:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [21:15:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 35 u1: BPM st: NotStopd t0: [21:15:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [21:15:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [21:15:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [21:00:00 11/11/2014] id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 200 vu: ml
tf: [07:00:00 12/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Metoprolol v1: 12.5 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: HS fs: 22 dn: 1 m1: Nortriptyline v1: 25 u1: mg
t0: [22:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [22:00:00 11/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 9 u1: mmHg st: NotStopd t0: [22:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [22:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [22:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [22:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 121 u1: BPM st: NotStopd t0: [22:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [22:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 111 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [22:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [22:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [22:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [22:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 22 u1: BPM st: NotStopd t0: [22:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 93 u1: % st: NotStopd t0: [22:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [22:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 60 vu: ml t0: [22:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [22:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 18.5063 vu: ml t0: [22:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 130 vu: ml
t0: [22:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [22:00:00 11/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [22:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [22:00:00 11/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [22:00:00 11/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [22:00:00 11/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd t0: [22:00:00 11/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 1 Person Assist st: NotStopd t0: [22:00:00 11/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Right Side st: NotStopd
t0: [22:17:00 11/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.41 rs: Final st: NotStopd t0: [22:17:00 11/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 u1: mmHg rs: Final st: NotStopd t0: [22:17:00 11/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 u1: mmHg rs: Final st: NotStopd t0: [22:17:00 11/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.41 rs: Final st: NotStopd
t0: [22:17:00 11/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 195 rs: Final st: NotStopd t0: [22:17:00 11/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4 rs: Final st: NotStopd t0: [22:17:00 11/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 195 rs: Final st: NotStopd t0: [22:17:00 11/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.14 rs: Final st: NotStopd t0: [22:17:00 11/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4 rs: Final st: NotStopd
t0: [22:30:00 11/11/2014] id: D5W 50.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 109 vo: 50 vu: ml
t0: [22:17:00 11/11/2014] id: Hematocrit Hematology el: 0 cu: CSRU cg: 3161 v1: 25 u1: % rs: Final st: NotStopd
t0: [23:00:00 11/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [23:00:00 11/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 11 u1: mmHg st: NotStopd t0: [23:00:00 11/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [23:00:00 11/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [23:00:00 11/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [23:00:00 11/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 108 u1: BPM st: NotStopd t0: [23:00:00 11/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [23:00:00 11/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 97 u1: mmHg v2: 53 u2: mmHg st: NotStopd t0: [23:00:00 11/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 66 u1: mmHg st: NotStopd t0: [23:00:00 11/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [23:00:00 11/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [23:00:00 11/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 27 u1: BPM st: NotStopd t0: [23:00:00 11/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 95 u1: % st: NotStopd t0: [23:00:00 11/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [23:00:00 11/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 37.8889 u1: Deg. C st: NotStopd t0: [23:00:00 11/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 100.2 u1: Deg. F st: NotStopd t0: [23:00:00 11/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [23:00:00 11/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 30 vu: ml t0: [23:00:00 11/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [23:00:00 11/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 17.625 vu: ml t0: [23:00:00 11/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 180 vu: ml t0: [23:00:00 11/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 0 vu: ml t0: [23:00:00 11/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 0 vu: ml
t0: [23:00:00 11/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip
tf: [09:00:00 12/11/2014] pt: Unit Dose rt: IV fr: ONCE MR1 fs: 23 dn: 1 m1: Metoprolol v1: 2.5 u1: mg
t0: [23:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd
t0: [20:00:00 11/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Ambulate st: NotStopd
t0: [20:00:00 11/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Visited st: NotStopd t0: [21:00:00 11/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 6-Mod to Severe st: NotStopd t0: [21:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [21:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [21:00:00 11/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [21:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [21:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Movement/Turning st: NotStopd t0: [21:00:00 11/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 6-Mod to Severe st: NotStopd t0: [21:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [21:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: PO Med st: NotStopd t0: [21:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [23:00:00 11/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 4-Mild to Mod st: NotStopd t0: [23:00:00 11/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [23:00:00 11/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [23:00:00 11/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [23:00:00 11/11/2014] id: Family Communication el: 0 cu: CSRU cg: RN v1: Family Called st: NotStopd t0: [23:00:00 11/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [23:00:00 11/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [23:00:00 11/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: At Rest st: NotStopd t0: [23:00:00 11/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 4-Mild to Mod st: NotStopd t0: [23:00:00 11/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [23:00:00 11/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: IV Push st: NotStopd t0: [23:00:00 11/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Throbbing st: NotStopd t0: [23:00:00 11/11/2014] id: Sputum Source/Amt el: 0 cu: CSRU cg: RN v1: Expectorated v2: None st: NotStopd t0: [00:00:00 12/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [00:00:00 12/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [00:00:00 12/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [00:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [00:00:00 12/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 10 u1: mmHg st: NotStopd t0: [00:00:00 12/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [00:00:00 12/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [00:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [00:00:00 12/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [00:00:00 12/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [00:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [00:00:00 12/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Diabetic st: NotStopd t0: [00:00:00 12/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [00:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [00:00:00 12/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [00:00:00 12/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [00:00:00 12/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [00:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 110 u1: BPM st: NotStopd t0: [00:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [00:00:00 12/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [00:00:00 12/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [00:00:00 12/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [00:00:00 12/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [00:00:00 12/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [00:00:00 12/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [00:00:00 12/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [00:00:00 12/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [00:00:00 12/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [00:00:00 12/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [00:00:00 12/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [00:00:00 12/11/2014] id: Inc Closure/Appear#3 el: 0 cu: CSRU cg: RN v1: Steri-strip v2: Clean and Dry st: NotStopd t0: [00:00:00 12/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [00:00:00 12/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [00:00:00 12/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [00:00:00 12/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [00:00:00 12/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [00:00:00 12/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Changed st: NotStopd t0: [00:00:00 12/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [00:00:00 12/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [00:00:00 12/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [00:00:00 12/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [00:00:00 12/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Crackles st: NotStopd t0: [00:00:00 12/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [00:00:00 12/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Sleeping st: NotStopd t0: [00:00:00 12/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [00:00:00 12/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [00:00:00 12/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [00:00:00 12/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [00:00:00 12/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [00:00:00 12/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [00:00:00 12/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [00:00:00 12/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [00:00:00 12/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [00:00:00 12/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 102 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [00:00:00 12/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [00:00:00 12/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 67 u1: mmHg st: NotStopd t0: [00:00:00 12/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Supine st: NotStopd t0: [00:00:00 12/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 1 Person Assist st: NotStopd t0: [00:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [00:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [00:00:00 12/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [00:00:00 12/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [00:00:00 12/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [00:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 30 u1: BPM st: NotStopd t0: [00:00:00 12/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [00:00:00 12/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [00:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 97 u1: % st: NotStopd t0: [00:00:00 12/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [00:00:00 12/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Back st: NotStopd t0: [00:00:00 12/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [00:00:00 12/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [00:00:00 12/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [00:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [00:00:00 12/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Present st: NotStopd t0: [00:00:00 12/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Chairfast st: NotStopd t0: [00:00:00 12/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: Potential Prob st: NotStopd t0: [00:00:00 12/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: Sl. Limited st: NotStopd t0: [00:00:00 12/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Rarely Moist st: NotStopd t0: [00:00:00 12/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Prob. Inadequate st: NotStopd t0: [00:00:00 12/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 17 u1: number st: NotStopd t0: [00:00:00 12/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: No Impairment st: NotStopd t0: [00:00:00 12/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd t0: [00:00:00 12/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [00:00:00 12/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [00:00:00 12/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [00:00:00 12/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd
t0: [00:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [00:00:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 17.625 vu: ml t0: [00:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 160 vu: ml
t0: [00:00:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.05 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [01:00:00 12/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 5-Moderate st: NotStopd t0: [01:00:00 12/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [01:00:00 12/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [01:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [01:00:00 12/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 11 u1: mmHg st: NotStopd t0: [01:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [01:00:00 12/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [01:00:00 12/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [01:00:00 12/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [01:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [01:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [01:00:00 12/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [01:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 105 u1: BPM st: NotStopd t0: [01:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [01:00:00 12/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [01:00:00 12/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [01:00:00 12/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [01:00:00 12/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [01:00:00 12/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [01:00:00 12/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 102 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [01:00:00 12/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [01:00:00 12/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 5-Moderate st: NotStopd t0: [01:00:00 12/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [01:00:00 12/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: PO Med st: NotStopd t0: [01:00:00 12/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [01:00:00 12/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 66 u1: mmHg st: NotStopd t0: [01:00:00 12/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Left Side st: NotStopd t0: [01:00:00 12/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 1 Person Assist st: NotStopd t0: [01:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [01:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [01:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 24 u1: BPM st: NotStopd t0: [01:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [01:00:00 12/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Left Side st: NotStopd t0: [01:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [01:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [01:00:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 17.625 vu: ml t0: [01:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 180 vu: ml t0: [01:00:00 12/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 0 vu: ml t0: [01:00:00 12/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 0 vu: ml
t0: [01:00:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.04 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [02:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [02:00:00 12/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 12 u1: mmHg st: NotStopd t0: [02:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [02:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [02:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [02:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 105 u1: BPM st: NotStopd t0: [02:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [02:00:00 12/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 107 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [02:00:00 12/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [02:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [02:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [02:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 33 u1: BPM st: NotStopd t0: [02:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 93 u1: % st: NotStopd t0: [02:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [02:00:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 14.1 vu: ml t0: [02:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 110 vu: ml t0: [02:00:00 12/11/2014] tf: [11:47:00 12/11/2014] dt: 587 id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 5 vu: ml t0: [02:00:00 12/11/2014] tf: [03:00:00 12/11/2014] dt: 60 id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 5 vu: ml
t0: [02:00:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.03 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [02:20:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [02:20:00 12/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 11 u1: mmHg st: NotStopd t0: [02:20:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [02:20:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [02:20:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 101 u1: BPM st: NotStopd t0: [02:20:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [02:20:00 12/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 99 u1: mmHg v2: 49 u2: mmHg st: NotStopd t0: [02:20:00 12/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 64 u1: mmHg st: NotStopd t0: [02:20:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [02:20:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [02:20:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 28 u1: BPM st: NotStopd t0: [02:20:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 92 u1: % st: NotStopd t0: [02:20:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [02:20:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.02 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [03:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [03:00:00 12/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 8 u1: mmHg st: NotStopd t0: [03:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [03:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [03:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [03:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 107 u1: BPM st: NotStopd t0: [03:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [03:00:00 12/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 102 u1: mmHg v2: 51 u2: mmHg st: NotStopd t0: [03:00:00 12/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 67 u1: mmHg st: NotStopd t0: [03:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [03:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [03:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 32 u1: BPM st: NotStopd t0: [03:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 93 u1: % st: NotStopd t0: [03:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [03:00:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0.01 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [03:00:00 12/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 37.8333 u1: Deg. C st: NotStopd t0: [03:00:00 12/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 100.1 u1: Deg. F st: NotStopd
t0: [03:00:00 12/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 50 vu: ml t0: [03:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [03:00:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 8.225 vu: ml t0: [03:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 180 vu: ml t0: [03:00:00 12/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 10 vu: ml t0: [03:00:00 12/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 0 vu: ml
t0: [23:00:00 12/11/2014] dt: 1 id: Total Hourly Output el: 3 cu: -1 cg: RN cv: 0 ap: none t0: [23:00:00 12/11/2014] dt: 1 id: Net Hourly Balance el: 3 cu: -1 cg: RN cv: 0 ap: none t0: [23:00:00 12/11/2014] dt: 24 id: IV Infusion In Total el: 3 cu: -1 cg: RN cv: 461.1 ap: none t0: [23:00:00 12/11/2014] dt: 24 id: 24h Total In el: 3 cu: -1 cg: RN cv: 671.1 ap: none t0: [23:00:00 12/11/2014] dt: 24 id: PO/Gastric In Total el: 3 cu: -1 cg: RN cv: 210 ap: none t0: [23:00:00 12/11/2014] dt: 24 id: Urine Out Total el: 3 cu: -1 cg: RN cv: 1775 ap: none t0: [23:00:00 12/11/2014] dt: 24 id: 24h Net Body Balance el: 3 cu: -1 cg: RN cv: -1338.9 ap: none t0: [23:00:00 12/11/2014] dt: 24 id: 24h Total Out el: 3 cu: -1 cg: RN cv: 2010 ap: none t0: [23:00:00 12/11/2014] dt: 24 id: Chest Tube Out Total el: 3 cu: -1 cg: RN cv: 205 ap: none t0: [23:00:00 12/11/2014] dt: multiple days id: LOS Net Body Balance el: 3 cu: -1 cg: RN cv: 1037.35 ap: none
t0: [03:15:00 12/11/2014] id: Art.pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.44 rs: Final st: NotStopd t0: [03:15:00 12/11/2014] id: Arterial Base Excess ABG el: 0 cu: CSRU cg: 3161 v1: 3 rs: Final st: NotStopd t0: [03:15:00 12/11/2014] id: Arterial CO2(Calc) ABG el: 0 cu: CSRU cg: 3161 v1: 29 rs: Final st: NotStopd t0: [03:15:00 12/11/2014] id: Arterial PaCO2 ABG el: 0 cu: CSRU cg: 3161 v1: 41 u1: mmHg rs: Final st: NotStopd t0: [03:15:00 12/11/2014] id: Arterial PaO2 ABG el: 0 cu: CSRU cg: 3161 v1: 87 u1: mmHg rs: Final st: NotStopd t0: [03:15:00 12/11/2014] id: Arterial pH ABG el: 0 cu: CSRU cg: 3161 v1: 7.44 rs: Final st: NotStopd t0: [03:15:00 12/11/2014] id: Ionized Calcium Chemistry el: 0 cu: CSRU cg: 3161 v1: 1.1 rs: Final st: NotStopd
t0: [03:00:00 12/11/2014] id: WBC (4-11,000) Hematology el: 0 cu: CSRU cg: 3161 v1: 6.4 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: WBC Hematology el: 0 cu: CSRU cg: 3161 v1: 6.4 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Hematocrit Hematology el: 0 cu: CSRU cg: 3161 v1: 22.8 u1: % rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Hemoglobin Hematology el: 0 cu: CSRU cg: 3161 v1: 7.6 u1: gm/dl rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Platelets Hematology el: 0 cu: CSRU cg: 3161 v1: 137 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: RBC Hematology el: 0 cu: CSRU cg: 3161 v1: 2.54 u1: /mic l rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: WBC (4-11,000) Hematology el: 0 cu: CSRU cg: 3161 v1: 6.4 rs: Final st: NotStopd
t0: [00:00:00 12/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Sleeping st: NotStopd t0: [03:00:00 12/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [03:00:00 12/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [03:00:00 12/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [03:00:00 12/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [03:00:00 12/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [03:00:00 12/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: RN v1: WNL st: NotStopd t0: [03:00:00 12/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [03:00:00 12/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: RN v1: Sharp st: NotStopd t0: [03:00:00 12/11/2014] id: IV #3 Insert Date el: 0 cu: CSRU cg: RN v1: 10 v2: 1 st: NotStopd t0: [03:00:00 12/11/2014] id: IV #3 Site/Size el: 0 cu: CSRU cg: RN v1: LU Ant Forearm v2: 20 gauge st: NotStopd t0: [03:00:00 12/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [03:00:00 12/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 1 u1: lpm st: NotStopd t0: [04:00:00 12/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [04:00:00 12/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [04:00:00 12/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [04:00:00 12/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [04:00:00 12/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [04:00:00 12/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [04:00:00 12/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [04:00:00 12/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Diabetic st: NotStopd t0: [04:00:00 12/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Easily Palpable v2: Easily Palpable st: NotStopd t0: [04:00:00 12/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [04:00:00 12/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [04:00:00 12/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 30 degrees st: NotStopd t0: [04:00:00 12/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [04:00:00 12/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [04:00:00 12/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [04:00:00 12/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [04:00:00 12/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [04:00:00 12/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [04:00:00 12/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [04:00:00 12/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [04:00:00 12/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [04:00:00 12/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [04:00:00 12/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [04:00:00 12/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [04:00:00 12/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [04:00:00 12/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [04:00:00 12/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [04:00:00 12/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Alert st: NotStopd t0: [04:00:00 12/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [04:00:00 12/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [04:00:00 12/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [04:00:00 12/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [04:00:00 12/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [04:00:00 12/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [04:00:00 12/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [04:00:00 12/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [04:00:00 12/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [04:00:00 12/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [04:00:00 12/11/2014] id: Position el: 0 cu: CSRU cg: RN v1: Supine st: NotStopd t0: [04:00:00 12/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: Independent st: NotStopd t0: [04:00:00 12/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [04:00:00 12/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [04:00:00 12/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [04:00:00 12/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [04:00:00 12/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [04:00:00 12/11/2014] id: Support Systems el: 0 cu: CSRU cg: RN v1: Spouse st: NotStopd t0: [04:00:00 12/11/2014] id: Turn el: 0 cu: CSRU cg: RN v1: Back st: NotStopd t0: [04:00:00 12/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [04:00:00 12/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [04:00:00 12/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [04:00:00 12/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Appropriate st: NotStopd t0: [04:00:00 12/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Present st: NotStopd t0: [04:00:00 12/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Chairfast st: NotStopd t0: [04:00:00 12/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: Potential Prob st: NotStopd t0: [04:00:00 12/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: Sl. Limited st: NotStopd t0: [04:00:00 12/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Rarely Moist st: NotStopd t0: [04:00:00 12/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Prob. Inadequate st: NotStopd t0: [04:00:00 12/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 17 u1: number st: NotStopd t0: [04:00:00 12/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: No Impairment st: NotStopd t0: [04:00:00 12/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd t0: [04:00:00 12/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [04:00:00 12/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [04:00:00 12/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [04:00:00 12/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd
t0: [03:30:00 12/11/2014] id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 110 vu: ml
t0: [03:00:00 12/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd
t0: [03:00:00 12/11/2014] id: BUN el: 0 cu: CSRU cg: 3161 v1: 8 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Chloride Chemistry el: 0 cu: CSRU cg: 3161 v1: 104 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Creatinine Chemistry el: 0 cu: CSRU cg: 3161 v1: 0.8 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Glucose Chemistry el: 0 cu: CSRU cg: 3161 v1: 135 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Potassium Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.3 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Sodium Chemistry el: 0 cu: CSRU cg: 3161 v1: 134 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: BUN (6-20) Chemistry el: 0 cu: CSRU cg: 3161 v1: 8 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Carbon Dioxide Chemistry el: 0 cu: CSRU cg: 3161 v1: 26 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Chloride (100-112) Chemistry el: 0 cu: CSRU cg: 3161 v1: 104 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Creatinine (0-1.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 0.8 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Glucose (70-105) Chemistry el: 0 cu: CSRU cg: 3161 v1: 135 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Potassium (3.5-5.3) Chemistry el: 0 cu: CSRU cg: 3161 v1: 4.3 rs: Final st: NotStopd t0: [03:00:00 12/11/2014] id: Sodium (135-148) Chemistry el: 0 cu: CSRU cg: 3161 v1: 134 rs: Final st: NotStopd
t0: [04:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [04:00:00 12/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 10 u1: mmHg st: NotStopd t0: [04:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [04:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [04:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [04:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 104 u1: BPM st: NotStopd t0: [04:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [04:00:00 12/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 103 u1: mmHg v2: 52 u2: mmHg st: NotStopd t0: [04:00:00 12/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 67 u1: mmHg st: NotStopd t0: [04:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [04:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 94 u1: kg st: NotStopd t0: [04:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 31 u1: BPM st: NotStopd t0: [04:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 91 u1: % st: NotStopd t0: [04:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [04:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [04:00:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 3.525 vu: ml t0: [04:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 105 vu: ml
t0: [04:00:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [05:00:00 12/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 5-Moderate st: NotStopd t0: [05:00:00 12/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [05:00:00 12/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [05:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [05:00:00 12/11/2014] id: CVP el: 0 cu: CSRU cg: RN v1: 9 u1: mmHg st: NotStopd t0: [05:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [05:00:00 12/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [05:00:00 12/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [05:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [05:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [05:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 108 u1: BPM st: NotStopd t0: [05:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [05:00:00 12/11/2014] id: Arterial BP el: 0 cu: CSRU cg: RN v1: 104 u1: mmHg v2: 50 u2: mmHg st: NotStopd t0: [05:00:00 12/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [05:00:00 12/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 5-Moderate st: NotStopd t0: [05:00:00 12/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [05:00:00 12/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: PO Med st: NotStopd t0: [05:00:00 12/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [05:00:00 12/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: RN v1: 67 u1: mmHg st: NotStopd t0: [05:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [05:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 24 u1: BPM st: NotStopd t0: [05:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 93 u1: % st: NotStopd t0: [05:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [05:00:00 12/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 60 vu: ml t0: [05:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [05:00:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 0 vu: ml t0: [05:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 180 vu: ml
t0: [05:00:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [06:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [06:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [06:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [06:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [06:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 103 u1: BPM st: NotStopd t0: [06:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [06:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [06:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 36 u1: BPM st: NotStopd t0: [06:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 87 u1: % st: NotStopd t0: [06:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [06:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [06:00:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 0 vu: ml t0: [06:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 160 vu: ml t0: [06:00:00 12/11/2014] id: Drain Out #1 Jackson Pratt el: 1 cu: CSRU cg: RN vo: 30 vu: ml
t0: [06:00:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [23:00:00 12/11/2014] dt: 24 id: Drain #1 Total Out el: 3 cu: -1 cg: RN cv: 30 ap: none
t0: [06:00:00 12/11/2014] id: CVP el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 12/11/2014] id: INV Line#1 Zero/Cal el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 12/11/2014] id: INV Line#1SiteAppear el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 12/11/2014] id: INV Line#2 Zero/Cal el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 12/11/2014] id: INV Line#2SiteAppear el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 12/11/2014] id: INV#1 WaveformAppear el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 12/11/2014] id: INV#2 WaveformAppear el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 12/11/2014] id: Arterial BP el: 0 cu: CSRU cg: -1 st: D/C'd t0: [06:00:00 12/11/2014] id: Arterial BP Mean el: 0 cu: CSRU cg: -1 st: D/C'd
t0: [07:00:00 12/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [07:00:00 12/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 45 degrees st: NotStopd t0: [07:00:00 12/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Chair st: NotStopd t0: [07:00:00 12/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [07:00:00 12/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [07:00:00 12/11/2014] id: Oral Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [07:00:00 12/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [07:00:00 12/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 1 Person Assist st: NotStopd t0: [07:00:00 12/11/2014] id: Skin Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [07:00:00 12/11/2014] id: Back Care el: 0 cu: CSRU cg: RN v1: Done st: NotStopd
t0: [07:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [07:00:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: RN ai: 210 vo: 0 vu: ml t0: [07:00:00 12/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 105 vu: ml t0: [07:00:00 12/11/2014] tf: [08:00:00 12/11/2014] dt: 60 id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 10 vu: ml
t0: [07:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [07:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [07:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [07:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [07:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 104 u1: BPM st: NotStopd t0: [07:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [07:00:00 12/11/2014] id: INV Line#1 D/C Date el: 0 cu: CSRU cg: RN v1: 10 v2: 1 st: NotStopd t0: [07:00:00 12/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: RN v1: Multi-lumen v2: Right IJ st: NotStopd t0: [07:00:00 12/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [07:00:00 12/11/2014] id: INV Line#2 D/C Date el: 0 cu: CSRU cg: RN v1: 10 v2: 1 st: NotStopd t0: [07:00:00 12/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: RN v1: A-Line v2: Right Radial st: NotStopd t0: [07:00:00 12/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: RN v1: 9 v2: 29 st: NotStopd t0: [07:00:00 12/11/2014] id: IV #3 Insert Date el: 0 cu: CSRU cg: RN v1: 10 v2: 1 st: NotStopd t0: [07:00:00 12/11/2014] id: IV #3 Site/Size el: 0 cu: CSRU cg: RN v1: LU Ant Forearm v2: 20 gauge st: NotStopd t0: [07:00:00 12/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 102 u1: mmHg v2: 46 u2: mmHg st: NotStopd t0: [07:00:00 12/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 64.6667 u1: mmHg st: NotStopd t0: [07:00:00 12/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [07:00:00 12/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 1 u1: lpm st: NotStopd t0: [07:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [07:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 35 u1: BPM st: NotStopd t0: [07:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [07:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [07:00:00 12/11/2014] id: Po Intake PO/Gastric el: 1 cu: CSRU cg: RN ai: 103 vo: 100 vu: ml t0: [07:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 95 vu: ml
t0: [07:00:00 12/11/2014] id: Levophed-k el: 1 cu: CSRU cg: RN so: D5W vo: 0 v1: 0 du: mcgkgmin sv: 250 su: ml rt: IV Drip
t0: [07:01:00 12/11/2014] id: INV Line#1 D/C Date el: 0 cu: CSRU cg: -1 st: D/C'd t0: [07:01:00 12/11/2014] id: INV Line#1 Type/Site el: 0 cu: CSRU cg: -1 st: D/C'd t0: [07:01:00 12/11/2014] id: INV Line#1InsertDate el: 0 cu: CSRU cg: -1 st: D/C'd t0: [07:01:00 12/11/2014] id: INV Line#2 D/C Date el: 0 cu: CSRU cg: -1 st: D/C'd t0: [07:01:00 12/11/2014] id: INV Line#2 Type/Site el: 0 cu: CSRU cg: -1 st: D/C'd t0: [07:01:00 12/11/2014] id: INV Line#2InsertDate el: 0 cu: CSRU cg: -1 st: D/C'd
t0: [07:01:00 12/11/2014] id: D5W 250.0ml + 4mcgkgmin Levophed-k IV Infusions el: 1 cu: CSRU cg: -1 ai: 210 vo: 0 st: D/C'd
t0: [08:00:00 12/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 12/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [08:00:00 12/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [08:00:00 12/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: No st: NotStopd t0: [08:00:00 12/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [08:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [08:00:00 12/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [08:00:00 12/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [08:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [08:00:00 12/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [08:00:00 12/11/2014] id: Cough/Deep Breathe el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [08:00:00 12/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [08:00:00 12/11/2014] id: GI Prophylaxis el: 0 cu: CSRU cg: RN v1: H2 Blocker st: NotStopd t0: [08:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [08:00:00 12/11/2014] id: Diet Type el: 0 cu: CSRU cg: RN v1: Diabetic st: NotStopd t0: [08:00:00 12/11/2014] id: Dorsal PedPulse R/L el: 0 cu: CSRU cg: RN v1: Strong/Palpable v2: Strong/Palpable st: NotStopd t0: [08:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [08:00:00 12/11/2014] id: Eye Opening el: 0 cu: CSRU cg: RN v1: 4 Spontaneously st: NotStopd t0: [08:00:00 12/11/2014] id: GCS Total el: 0 cu: CSRU cg: RN v1: 15 u1: points st: NotStopd t0: [08:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 107 u1: BPM st: NotStopd t0: [08:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [08:00:00 12/11/2014] id: Abdominal Assessment el: 0 cu: CSRU cg: RN v1: Soft st: NotStopd t0: [08:00:00 12/11/2014] id: IV #3 Insert Date el: 0 cu: CSRU cg: RN v1: 10 v2: 1 st: NotStopd t0: [08:00:00 12/11/2014] id: IV #3 Site/Size el: 0 cu: CSRU cg: RN v1: LU Ant Forearm v2: 20 gauge st: NotStopd t0: [08:00:00 12/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Chair st: NotStopd t0: [08:00:00 12/11/2014] id: Inc Closure/Appear#1 el: 0 cu: CSRU cg: RN v1: Steri-strip v2: Clean and Dry st: NotStopd t0: [08:00:00 12/11/2014] id: Inc Drainage/Amt #1 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [08:00:00 12/11/2014] id: Inc Drainage/Amt #2 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [08:00:00 12/11/2014] id: Inc Drainage/Amt #3 el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [08:00:00 12/11/2014] id: Inc Dsg/Status #1 el: 0 cu: CSRU cg: RN v1: None v2: Intact st: NotStopd t0: [08:00:00 12/11/2014] id: Inc Dsg/Status #2 el: 0 cu: CSRU cg: RN v1: Dry Sterile Dsg v2: Intact st: NotStopd t0: [08:00:00 12/11/2014] id: Inc Dsg/Status #3 el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: Intact st: NotStopd t0: [08:00:00 12/11/2014] id: Incentive Spirometry el: 0 cu: CSRU cg: RN v1: Done st: NotStopd t0: [08:00:00 12/11/2014] id: Incision/Wound #1 el: 0 cu: CSRU cg: RN v1: Sternum st: NotStopd t0: [08:00:00 12/11/2014] id: Incision/Wound #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [08:00:00 12/11/2014] id: Incision/Wound #3 el: 0 cu: CSRU cg: RN v1: Right Leg st: NotStopd t0: [08:00:00 12/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [08:00:00 12/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [08:00:00 12/11/2014] id: Level of Conscious el: 0 cu: CSRU cg: RN v1: Alert st: NotStopd t0: [08:00:00 12/11/2014] id: Motor Response el: 0 cu: CSRU cg: RN v1: 6 Obeys Commands st: NotStopd t0: [08:00:00 12/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 87 u1: mmHg v2: 49 u2: mmHg st: NotStopd t0: [08:00:00 12/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 61.6667 u1: mmHg st: NotStopd t0: [08:00:00 12/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [08:00:00 12/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 1 u1: lpm st: NotStopd t0: [08:00:00 12/11/2014] id: Oral Cavity el: 0 cu: CSRU cg: RN v1: Teeth/Tissue WNL st: NotStopd t0: [08:00:00 12/11/2014] id: Orientation el: 0 cu: CSRU cg: RN v1: Oriented x 3 st: NotStopd t0: [08:00:00 12/11/2014] id: Pacemaker Mode el: 0 cu: CSRU cg: RN v1: Pacer Turned Off st: NotStopd t0: [08:00:00 12/11/2014] id: Pacemaker Type el: 0 cu: CSRU cg: RN v1: Epicardial Wires st: NotStopd t0: [08:00:00 12/11/2014] id: Pacer Wire Condition el: 0 cu: CSRU cg: RN v1: Attached-pacer st: NotStopd t0: [08:00:00 12/11/2014] id: Pacer Wires Atrial el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [08:00:00 12/11/2014] id: Pacer Wires Vent el: 0 cu: CSRU cg: RN v1: 2 st: NotStopd t0: [08:00:00 12/11/2014] id: PostTib. Pulses R/L el: 0 cu: CSRU cg: RN v1: Weak Palpable v2: Weak Palpable st: NotStopd t0: [08:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [08:00:00 12/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [08:00:00 12/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [08:00:00 12/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [08:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 28 u1: BPM st: NotStopd t0: [08:00:00 12/11/2014] id: Side Rails el: 0 cu: CSRU cg: RN v1: Side Rails Up st: NotStopd t0: [08:00:00 12/11/2014] id: Skin Integrity el: 0 cu: CSRU cg: RN v1: Intact st: NotStopd t0: [08:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 95 u1: % st: NotStopd t0: [08:00:00 12/11/2014] id: Temp. Site el: 0 cu: CSRU cg: RN v1: Oral st: NotStopd t0: [08:00:00 12/11/2014] id: Temperature C (calc) el: 0 cu: CSRU cg: RN v1: 36.4444 u1: Deg. C st: NotStopd t0: [08:00:00 12/11/2014] id: Temperature F el: 0 cu: CSRU cg: RN v1: 97.6 u1: Deg. F st: NotStopd t0: [08:00:00 12/11/2014] id: Urine Color/Appear el: 0 cu: CSRU cg: RN v1: Light Yellow v2: Clear st: NotStopd t0: [08:00:00 12/11/2014] id: Urine Source el: 0 cu: CSRU cg: RN v1: Indwelling Cath st: NotStopd t0: [08:00:00 12/11/2014] id: Verbal Response el: 0 cu: CSRU cg: RN v1: 5 Oriented st: NotStopd t0: [08:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [08:00:00 12/11/2014] id: Behavior el: 0 cu: CSRU cg: RN v1: Calm st: NotStopd t0: [08:00:00 12/11/2014] id: Bowel Sounds el: 0 cu: CSRU cg: RN v1: Present st: NotStopd t0: [08:00:00 12/11/2014] id: Braden Activity el: 0 cu: CSRU cg: RN v1: Bedfast st: NotStopd t0: [08:00:00 12/11/2014] id: Braden Frict/Shear el: 0 cu: CSRU cg: RN v1: No Apparent Prob st: NotStopd t0: [08:00:00 12/11/2014] id: Braden Mobility el: 0 cu: CSRU cg: RN v1: No Limitations st: NotStopd t0: [08:00:00 12/11/2014] id: Braden Moisture el: 0 cu: CSRU cg: RN v1: Rarely Moist st: NotStopd t0: [08:00:00 12/11/2014] id: Braden Nutrition el: 0 cu: CSRU cg: RN v1: Excellent st: NotStopd t0: [08:00:00 12/11/2014] id: Braden Score el: 0 cu: CSRU cg: RN v1: 20 u1: number st: NotStopd t0: [08:00:00 12/11/2014] id: Braden SensoryPercep el: 0 cu: CSRU cg: RN v1: No Impairment st: NotStopd t0: [08:00:00 12/11/2014] id: CT #1 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd t0: [08:00:00 12/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [08:00:00 12/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Positive v2: Negative st: NotStopd t0: [08:00:00 12/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [08:00:00 12/11/2014] id: CT #2 Drainage el: 0 cu: CSRU cg: RN v1: Serosanguinous st: NotStopd
t0: [08:00:00 12/11/2014] id: D5W 100.0ml IV Infusions el: 1 cu: CSRU cg: RN ai: 105 vo: 200 vu: ml t0: [08:00:00 12/11/2014] id: D5W IV Infusions el: 1 cu: CSRU cg: RN ai: 189 vo: 10 vu: ml t0: [08:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 60 vu: ml t0: [08:00:00 12/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 40 vu: ml t0: [08:00:00 12/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 0 vu: ml
t0: [08:00:00 12/11/2014] id: Fingerstick Glucose Chemistry el: 0 cu: CSRU cg: RN v1: 134 rs: Manual st: NotStopd t0: [09:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [09:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [09:00:00 12/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [09:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [09:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [09:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 102 u1: BPM st: NotStopd t0: [09:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [09:00:00 12/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 93 u1: mmHg v2: 47 u2: mmHg st: NotStopd t0: [09:00:00 12/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 62.3333 u1: mmHg st: NotStopd t0: [09:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [09:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 25 u1: BPM st: NotStopd t0: [09:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 94 u1: % st: NotStopd t0: [09:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd
t0: [09:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 45 vu: ml t0: [09:00:00 12/11/2014] id: Chest Tubes CTICU CT 1 el: 1 cu: CSRU cg: RN vo: 30 vu: ml t0: [09:00:00 12/11/2014] id: Chest Tubes Mediastinal el: 1 cu: CSRU cg: RN vo: 0 vu: ml
t0: [05:00:00 12/11/2014] id: Previous Weight el: 0 cu: CSRU cg: RN v1: 100.7 u1: kg st: NotStopd t0: [05:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 100.7 u1: kg st: NotStopd t0: [05:00:00 12/11/2014] id: BSA - English el: 0 cu: CSRU cg: RN v1: 1.39862 u1: m2 st: NotStopd t0: [05:00:00 12/11/2014] id: BSA - Metric el: 0 cu: CSRU cg: RN v1: 1.62739 u1: m2 st: NotStopd t0: [05:00:00 12/11/2014] id: Weight Change el: 0 cu: CSRU cg: RN v1: 0 u1: kg st: NotStopd t0: [05:00:00 12/11/2014] id: Daily Weight el: 0 cu: CSRU cg: RN v1: 100.7 u1: kg st: NotStopd t0: [06:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 100.7 u1: kg st: NotStopd t0: [07:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 100.7 u1: kg st: NotStopd t0: [08:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 100.7 u1: kg st: NotStopd t0: [09:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 100.7 u1: kg st: NotStopd
tf: [16:00:00 12/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Isosorbide Mononitrate (Extended Release) v1: 30 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: IV fr: BID fs: 10, 22 dn: 2 m1: Furosemide v1: 20 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Metoprolol v1: 25 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Isosorbide Mononitrate (Extended Release) v1: 30 u1: mg tf: [18:00:00 12/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Polysaccharide Iron Complex v1: 150 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Aspirin EC v1: 325 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Atorvastatin v1: 10 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Polysaccharide Iron Complex v1: 150 u1: mg
t0: [10:00:00 12/11/2014] id: CT #2 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [10:00:00 12/11/2014] id: CT #2 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [10:00:00 12/11/2014] id: CT #2 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd t0: [10:00:00 12/11/2014] id: Pain Level el: 0 cu: CSRU cg: RN v1: 5-Moderate st: NotStopd t0: [10:00:00 12/11/2014] id: Pain Present el: 0 cu: CSRU cg: RN v1: Yes st: NotStopd t0: [10:00:00 12/11/2014] id: Pain Assess Method el: 0 cu: CSRU cg: RN v1: Pt Verbalized st: NotStopd t0: [10:00:00 12/11/2014] id: Service Type el: 0 cu: CSRU cg: RN v1: CSRU st: NotStopd t0: [10:00:00 12/11/2014] id: Chest Tube Site #1 el: 0 cu: CSRU cg: RN v1: Left Anterior st: NotStopd t0: [10:00:00 12/11/2014] id: Chest Tube Site #2 el: 0 cu: CSRU cg: RN v1: Mediastinal st: NotStopd t0: [10:00:00 12/11/2014] id: Code Status el: 0 cu: CSRU cg: RN v1: Full Code st: NotStopd t0: [10:00:00 12/11/2014] id: Riker-SAS Scale el: 0 cu: CSRU cg: RN v1: Calm/Cooperative st: NotStopd t0: [10:00:00 12/11/2014] id: Daily Wake Up el: 1 cu: CSRU cg: RN v1: No/Not Sedated st: NotStopd t0: [10:00:00 12/11/2014] id: Risk for Falls el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [10:00:00 12/11/2014] id: Ectopy Type el: 0 cu: CSRU cg: RN v1: None st: NotStopd t0: [10:00:00 12/11/2014] id: HOB el: 0 cu: CSRU cg: RN v1: 15 degrees st: NotStopd t0: [10:00:00 12/11/2014] id: Heart Rate el: 0 cu: CSRU cg: RN v1: 115 u1: BPM st: NotStopd t0: [10:00:00 12/11/2014] id: Heart Rhythm el: 0 cu: CSRU cg: RN v1: Sinus Tachy st: NotStopd t0: [10:00:00 12/11/2014] id: Activity el: 0 cu: CSRU cg: RN v1: Bedrest st: NotStopd t0: [10:00:00 12/11/2014] id: Activity Tolerance el: 0 cu: CSRU cg: RN v1: Tolerated Well st: NotStopd t0: [10:00:00 12/11/2014] id: LLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Diminished st: NotStopd t0: [10:00:00 12/11/2014] id: LUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [10:00:00 12/11/2014] id: NBP el: 0 cu: CSRU cg: RN v1: 94 u1: mmHg v2: 55 u2: mmHg st: NotStopd t0: [10:00:00 12/11/2014] id: NBP Mean el: 0 cu: CSRU cg: RN v1: 68 u1: mmHg st: NotStopd t0: [10:00:00 12/11/2014] id: O2 Delivery Device#2 el: 0 cu: CSRU cg: RN v1: Nasal Cannula st: NotStopd t0: [10:00:00 12/11/2014] id: O2 Flow (lpm) #2 el: 0 cu: CSRU cg: RN v1: 2 u1: lpm st: NotStopd t0: [10:00:00 12/11/2014] id: AntiEmbDevice/Status el: 0 cu: CSRU cg: RN v1: Ace Wrap v2: On st: NotStopd t0: [10:00:00 12/11/2014] id: Pain Cause el: 0 cu: CSRU cg: RN v1: Procedural st: NotStopd t0: [10:00:00 12/11/2014] id: Pain Level (Rest) el: 0 cu: CSRU cg: RN v1: 5-Moderate st: NotStopd t0: [10:00:00 12/11/2014] id: Pain Location el: 0 cu: CSRU cg: RN v1: Incisional st: NotStopd t0: [10:00:00 12/11/2014] id: Pain Management el: 1 cu: CSRU cg: RN v1: PO Med st: NotStopd t0: [10:00:00 12/11/2014] id: Pain Type el: 0 cu: CSRU cg: RN v1: Aching st: NotStopd t0: [10:00:00 12/11/2014] id: Assistance Device el: 0 cu: CSRU cg: RN v1: 1 Person Assist st: NotStopd t0: [10:00:00 12/11/2014] id: Precautions el: 0 cu: CSRU cg: RN v1: Universal st: NotStopd t0: [10:00:00 12/11/2014] id: Previous WeightF el: 0 cu: CSRU cg: RN v1: 100.7 u1: kg st: NotStopd t0: [10:00:00 12/11/2014] id: Procedures el: 0 cu: CSRU cg: RN v1: Chest Tube D/C st: NotStopd t0: [10:00:00 12/11/2014] id: RLL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [10:00:00 12/11/2014] id: RUL Lung Sounds el: 0 cu: CSRU cg: RN v1: Clear st: NotStopd t0: [10:00:00 12/11/2014] id: Respiratory Pattern el: 0 cu: CSRU cg: RN v1: Regular st: NotStopd t0: [10:00:00 12/11/2014] id: Respiratory Rate el: 0 cu: CSRU cg: RN v1: 36 u1: BPM st: NotStopd t0: [10:00:00 12/11/2014] id: SpO2 el: 0 cu: CSRU cg: RN v1: 93 u1: % st: NotStopd t0: [10:00:00 12/11/2014] id: calprevflg el: 0 cu: CSRU cg: RN v1: 1 u1: kg st: NotStopd t0: [10:00:00 12/11/2014] id: CT #1 Dressing el: 0 cu: CSRU cg: RN v1: Dry and Intact st: NotStopd t0: [10:00:00 12/11/2014] id: CT #1 Fluctuate/Leak el: 0 cu: CSRU cg: RN v1: Other/Remarks st: NotStopd t0: [10:00:00 12/11/2014] id: CT #1 Suction Amount el: 0 cu: CSRU cg: RN v1: 20 cm st: NotStopd
t0: [10:00:00 12/11/2014] id: Urine Out Foley el: 1 cu: CSRU cg: RN vo: 500 vu: ml
tf: [11:00:00 13/11/2014] pt: Unit Dose rt: IV fr: Q12H fs: 12, 0 dn: 2 m1: Furosemide v1: 20 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: Q12H fs: 12, 0 dn: 2 m1: Furosemide v1: 20 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: Q12H fs: 12, 0 dn: 2 m1: Potassium Chloride v1: 20 u1: mEq tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: Q4H:PRN m1: Acetaminophen v1: 650 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: Q4H:PRN m1: Oxycodone-Acetaminophen v1: 1-2 u1: TAB tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: Q6H:PRN m1: Ibuprofen v1: 400 u1: mg
tf: [10:00:00 13/11/2014] pt: Unit Dose rt: PR fr: QD:PRN m1: Bisacodyl (Rectal) v1: 10 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: HS:PRN m1: Diphenhydramine HCl v1: 25 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: HS:PRN m1: Milk of Magnesia v1: 30 u1: ml tf: [17:00:00 14/11/2014] pt: Unit Dose rt: SC fr: ASDIR m1: Insulin v1: 0 u1: UNIT tf: [17:00:00 14/11/2014] pt: Unit Dose rt: SC fr: Q3-4H:PRN m1: Morphine Sulfate v1: 1-5 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: SC fr: Q3-4H:PRN m1: Morphine Sulfate v1: 1-5 u1: mg
tf: [17:00:00 14/11/2014] pt: Unit Dose rt: IV fr: Q6H:PRN m1: Ondansetron v1: 2 u1: mg
tf: [22:00:00 12/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Metoprolol v1: 25 u1: mg tf: [07:00:00 13/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Metoprolol v1: 50 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Ascorbic Acid v1: 500 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Docusate Sodium v1: 100 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Ranitidine v1: 150 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: HS fs: 22 dn: 1 m1: Nortriptyline v1: 25 u1: mg
tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: BID fs: 10, 22 dn: 2 m1: Metoprolol v1: 37.5 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: QD fs: 10 dn: 1 m1: Multivitamins v1: 1 u1: CAP
tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: QD:PRN m1: Bisacodyl v1: 10 u1: mg tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PR fr: QD:PRN m1: Bisacodyl (Rectal) v1: 10 u1: mg
tf: [17:00:00 14/11/2014] pt: Unit Dose rt: PO fr: ONCE fs: 9 dn: 1 m1: Magnesium Citrate v1: 150 u1: ml
dd: 2724 ds: 3 ld: HYPERLIPIDEMIA NEC/NOS dd: 4019 ds: 2 ld: HYPERTENSION NOS dd: 41401 ds: 1 ld: CORON ATHEROSCLER NATIVE
dd: 41400 ds: 1 ld: CORNARY ATHERO-VESL NOS
dd: 72885 ds: 1 ld: SPASM OF MUSCLE dd: 7993 ds: 2 ld: DEBILITY NOS
dd: V700 ds: 1 ld: ROUTINE MEDICAL EXAM
dd: 41400 ds: 4 ld: CORNARY ATHERO-VESL NOS dd: 79431 ds: 1 ld: ABNORM ELECTROCARDIOGRAM dd: V4581 ds: 3 ld: AORTOCORONARY BYPASS dd: V717 ds: 2 ld: OBS-SUSP CARDIOVASC DIS
dd: 25000 ds: 1 ld: DIABETES MELLITUS W/OUT
dd: 2774 ds: 1 ld: DIS BILIRUBIN EXCRETION
dd: 25000 ds: 1 ld: DIABETES MELLITUS W/OUT dd: 2724 ds: 2 ld: HYPERLIPIDEMIA NEC/NOS dd: 4011 ds: 3 ld: BENIGN HYPERTENSION