Patient: HARDIN, JAMES Date: 03/04/2008 Charted Time: 3/4/08 18:85 Assosement uve VOOMHM E28 GSUNTHA B00z/9T/zT + Page 506 8 ‘Methodist Willowbrook Vital Signs Flowsheet Birthday: 2201972, [**WDL Definition: Alery opens eyes WDL. appropriate to situation} [P°WDL Definition: Regulor rhythm, no WD /DL Defintion: Capilay rofl less WDL ‘han or equal to 2 seconds; 2+ puises all WoL Date Printed, 3/7/2008 3/4/08 19:02 Gibbs, Jessica A 3/4/08 19:02 Gibbs, Jessica A 314/08 19:02 Gibbs, Jesiea A BIAMUS 19:02 Gibbs, Jessica A 314908 19:02 Gibbs, Jessica A 308 19:02 Gibbs, Jessica N 518108 19:02. Gibbs, Jessica A 316/08 19:02 Gibbs, Jessica A DHTOTLSBIOG HARDIN, JAMES M WM 36 E 068 AWB 20/1972 (03/04/2008 tw 0310372008 Fasanella, Autheny R.‘Methodist Willowbrook ‘Date Primed: 3/7/2008 Vital Signs Flowsheet Patient: HARDIN, JAMES day: 2/2097 ** WDL Definition -WDL: No 34408 19:02. Gibbs, essioa A i 3 Evi 34808 20:28 Tobald, Olivia Be 349/08 20:24 a 3408 20:24 5 S408 20:24, 8 i408 20:24 : ios 20:24, a Respurtary Rate in 308 20:28 82 Temperature degrees F 38008 20:28 ne degrees Sms 20.28 ag Temperature Ste Si 20:24 Tab 32 SPO2% 3HM8 20:24 Tob Ss Pain Rating (numerical) Poin Rating 3 348 20:24 Tob 3 (cumeriea) 3 aan 20:24 3 3 Serenings Fall Risk Indiestors ‘CasPaychotepic medication Male Fall Risk Soore 2 Fall Messer implemented Yes Fl Risk Intervertions ‘ist with iting, personal bygone, tleting Place frequent needed items within reach (glasses, 3/5/08 20:24 1 bearing, etc) Lake and Outpu NSIV infision 1000 mil 314/08 21:14 Tabaldo, Olivia HARDIN, JAMES M WM 36 E 064 2291972 030472008 to 03/04/2008 Fasenella, Anthony 8. Page 6008Pulicuts HARDLN, JAMES Date: 03/04/2008 Charted Time: 3/4108 20:21 Intake and Output Comments/Xoies Eduacation/{rstructions ime: 3/408 22:35 ager MMIOMM Exe Guay Bi e00z/at/zt + Intake and Output Assessment Disposition. Page 7008 ‘Methodist Willowbrook Date Printed 37772008 Vital Signs Flowsheet Birthduy: 2201972 NSIV infusion, NoteiCeraments duc iucated On ‘Mathod of instruction Response t Instruotion Systolic BP Systolic Diastolic B/P Diastolic BiP Site BP Sowce BP Position Hleart Rate bpm Respiratory Rate nin Temperature degrees F degrees C Temperature Sito Pain Rating (numerical) Pain Rating, (numerical) NSTV infusion Discontinuation, Disposition Patent Disposition ‘BD Departure Time Transport via ‘Accompanied by ‘Medication List ‘Sp 34408 71:14 Tabaldo, Olivia Recieved pt. ftom MC AOx3 auaiting dispo.ro acute 3%4/08 20:24 Tabaldo, Olivia diszess Expected Medication Outcomes 3/4/08 20:24 ‘Tabaldo, Olivia Plan of Care ‘Treatments / Proceduces Verbal Instruction Verbalized understarsting 31408 20:24 Tabildo, Olivia 128mm He 3/4/08 22:43 Tabuldo, Olivia 2mm fg 3/4/08 22:43 Tabaldo, Olivia Let Am 43/4)08 22:43 Tabaldo, Olivia NIBP 344/08 22:43 Tabaldo, Olivia ‘Siting SEPM 16MIN 988 DEGREES F 371 degrees C Oral Zi 1000 mi Step Catheter inact [ete WDL Discharge 22338 Left unit ambulatory Selt Spouse 34/08 22: Medication lis given 374108 22:43 DHTOTSSBIG HARDIN, JAMES M WM 3% E 68 AWB (2/20/1972 (03/04/2008 to 43/04/2008 asonella, Anthony R.