HomeMy WebLinkAboutSAPD Reports 13-17495_Redacted_Part6I ,· . ; I ••• ' • UNIVERSITY of CALIFORNIA • IRVINE ~ •".:. : ....
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_lt\U(I'" t;srf;I · ''1! HEALTHCARE . ·1
t <\Obhl½ s _a.Pati~l~~be\ •• t Date:~~-6 'H)OO''+Ob .-· . . _:);· .
._.:fH. i 1J\..lll tlJ" ·.: .1
/ ' VITAL SIGNS/GLASGOW COMA SCALE t. f' O ti o II 1-t-it, ;. .1
!1,A.l ll: rf ~
0
RI 'I./ ,i,;,t;h .
TIME -6 : .:li!· ,, C 1...t • .
~ ~ ... . . .,,. [7 k '~· ......... ~A~~~ .#i.•,..i ''!' // l/ I/ / !/ / / I/ i/ I/ ... BP :..JY,m: ~2 . ' ,t,m " .
: 'K_ TEMP
PULSE .... i'--....
RESP .....__
GLUCOSE ............... _
HgB ............ i-,...,_
Pain Score -~
Pain Tool --r--.
Quality/ I/ I/ / I/ I/ i/ / / I/ I/ / b< / / / / V Intervention
ETCO. ...............
~ I/ :/ I/ I/ I/ i/ i/ I/ V V V V V l7 ~ I/ / 0
. ~-...... t--...
µ,4
¢' MOTCR ........... , ....
,i . . .
t , ·1 T~·•
PUPILS A L A L A l R L R L R L R L R ,L R L A L R L R L A L R L R L R L A L
0 mm+/· [7 I/ l/ V V V V V I/ I/ I/ V I/ 1/1/ I/ I/ V V V V V V V V V V V I/ I/ 17 I/ I/ I/
',. .. ,
-;~'.i;-' . apoi~ ' ~ . -f'I:~ . . .. •.•· •. :1.1
~ ~
IV I START STOP ~ SOWTION AMOUNT RA~ AMOUNT IV I START STOP PRODUCT/\JNIT .f AMOUNT TIME TIME INRJS£D TIME TIME SITE INFUSED
I ~ ~ l~u-NS ~ 1... .. ---P: k\v) ~
i"'-,..
0 ......._____ --~ ----" ~ -"'-
TOTAL "-.:[oTAL
... , .. ~
• ~
8QLUTI08 ~t:fr.
-:i!5!5E!! . . .
OUTPU1.
TOTAL
'
0
(
o· (
-I
( ...
0
Moderate
Trauma
Victim
.,.. 1l't,.
~ rw
-
~ ~
'll ... , 1,
~
b _J' ,
'r]'I i.1..J
•
1,-,1--t0as TIIM~-------0 lnmlctlon glftr1 0 i..tt WO lostructlont O AW
.~med type: _________________ _
Mode~ll'lnll>«t-------------------
Tranllwto ----Br-0 RH ' 0 AClS O BI.S □ll-.lll)Ottation t!nw ____ _
"
!
"·_
.. :'--:~~
• .:>··-~ ,//~,\.1._'1-,,;\~ ;l ~\ :\ ... :·
Reportcaled '°-------..--,,=-r---rme _______ _
\11'.a.nt pn,pe,ty t
--.,.\""T,, qo-=t4
EDHU/0BS Start time __ _ Stop time ----
N,11.S -,, ,,.., :., -JY,": ~ : __ " .... :L'-,. ...
Redio-MICN EMS Qare r ~l V\---£KG 11!'Monttor n 12 lead nuA
Cardlo=lorv'defib n external n Internal Pel1cardlocentesls v Bladder Irrigation X
Conscious sedation ThlOOlbolyals, IV; O Irrigation ftuld ml
CPR □Code Cart &•nneuro
Pacer (external) transc1.rt cath/electnxle placement ·.
Pacer llt,l,wnalj ln!mven calh/elecirode ~ .
Foley lnsenlon:
size type
AIJINl,.Y.UPNR -' ' RA,..,,.,_mask -Slralaht calhet&1 Ins ertion x
Crico~ ,l\,uu,ny'.., --r ,r1 '-~ I.Iii i..lj End-lldal CO2 x .:. •·· "' ~ .. ,
lntobatlon, ET .:..:...J;.ii ~ fp{_:___ sta--~ Nasa!,1rach suction v Eve exam
□mx ONTx 1n ... 1 .. oMVV1 ic Flouresceln lamo orocedure
n LMA x . n Combitutie L-n 8ot.dit t.-o-wi_tnm_hou!J Nasal endoscoov
Trach X Peak floww Nasal packina/caut91V
AIRWAY, t.OWla~ •-~ n.-P\.iseQQYll!tl'l nllhMl'J:ontii Slit lamp proced ure
Bro,..,. 'Y Aa,p{mor/ treatment ✓ ~ ~ c-·~
Chest tube Insertion: 0 Time Out Ventf1atol'. , Amoutetlon of
:~:x ?. slz.e fr, ~
ht X ___:_i__ size fr, I 1'I
G-<:olkr. n Hard n Phil/Serra n ~
'('.,..,,
Laryngoscopy y EWALD aspiratlolvtavage X-.-Crutches n direct D Indirect O ftberoptlc D lnigatlon fluid mL Dislocation w/manlculatlon
Thoracentesis X ml • n Pos n Nea n lndet8!1Tllnate
nTimeOut
,
Gastric aspiration/lavage x_ ~
. Fracture stablllzatlon of
D with msnlpuletlon D WO man~latio!
·T'honltotomy • • • 0 ln19!1tlon ffuld mL lm,mbHlzer to
4-"lAccaa I Gastrottonomy tube )[ Inject, block L--t~
Autl:llnlMfuserx n '" □change Needle asolratlon of ml
8 load/ /blood croducts transfusion X NG M>e Insertion: Needle lnjectlon x to
Catheter Insertion: D Nasal D Q-al Pressure cui,~u•= t (Strvkeo
O MUnex size ,~. size □ Splint □ Other
OCordlsx size Perfloneal lavage X Applled lo
QCutdQwnv slz.e 0 lmgetlon ftuid ml □Traction .tvce. applied to
X size OPos □Neg □1~
W~x SW! -J{ ml
size ·. "}
Steinman cln n1,icemeht
Vtbo.n:I -, -· e~•
PIVCB<WII ,.
It
D Saline lock X 8ml BOA 'deive!v!Gare of mother n Triple lumen x size De!IYerY, vaalnaJ
lntraosseous neeQle ~--ml ~ of placen~ Only
Denial of r!Qhts
Leaal hold 5150
1:1x
Lewi.one ftuk:l warmer Newborn care Restraints
~~ Newf>om resuscftatlon
PeMc axamx ~~ •-ESS
Dermabond to size Rectal exam x
Excision of . .. -·: ~.:,.,·
Gelfoam application to slza.__ Btl'n dr1Q O sma1 n med D 1g
Culture x
Tvoe
Glucometer x
I &Dof of
Removal of forem bodv from ... ii§ : '· ........ , :
~ Qntsmed-slm -□Anglo Tllne Suture .. _._ ' r1 CTSCAN -OC-Spme
Repair; plastlc, of -□Doppler -OCXR -5ut1Jr& .. _. ' LJ PeMsXR □MRI
Swgicalto size 0 Treadmill -□Swlmners -~-XR....__ Wound lrrlgatlon to ml
llfMr~ OPos Wound pacidng to with □Neg
Gualac x
Hemocuex
HeaVflnger stick x
Venous bio9d collectlon v .
icP flM o c.mo n U::ox ov <'<OIi,
ICP mo nal" •
-n
__
OOtherXR . -
Initial
\~~ 174C\5
UNIVERSITY of CALIFORNIA • IRVINE
HEALTHCARE
ED NURSING NOTES
, lrrtpalred RIT __ _ • 17 Rape Trauma Syndrome ___ _
10 Grieving R/T ______ _ 18 Skin Integrity, Impaired ____ _
11 lnfedlon Potentlel/Actual R/T __ _ 19 Thought Processes, Altered, ___ _
12 lnjtJry, Potential For _____ _ 20 Tl88U8 Integrity, Impaired, ___ _
13 Know1edge Deftclt R/T ____ _ 21 Tlsaue Perfusion, Altered ___ _
14 Mobility Impaired, Physical RIT __ _ 22 Urinary Ellmlnatton, Altered ___ _
15 Pain, Acute/Ch1'0111c R/T ____ _ 23 Vlolence Potential For ____ _
16 Post Trauma Respol).18 ____ _ 24 other ________ _
RN INITIAL:
___ Signature_. __ __,__ _____ _
___ Signature ________ _
Initial (...£. • Signatur
Initial ___ Signature _________ _
Initial ___ Slgnaturt_________ Initial ___ Slgnaturt ----------
All documentation must Indicate the speclffc date and time of entry and a signature complete with Identifying credential, title or classification.
87223 (Rev. 2-17-10) •