Nursing Templates

8/6/2019 Nursing Templates

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Insulin Adjustment - Medication ManagementNote, Vr. 2.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

5/10/06 L. Dale /M. Gillard

5/10/06 T. Niu 6/5/08 D. BrownC. Davies

INSULIN ADJUSTMENT - MEDICATION MANAGEMENT NOTE, Vr. 2.0

ASSESSMENT:Received Blood Glucose Levels from patient.Current insulin dose:(type, dose, time)

NURSING IMPRESSION:Needs insulin adjustment per protocol (explain):

PLAN:l. New dose: 2. Call/fax Blood Glucose Levels to: 3. Call if unexplained Blood Glucose Level > 300 mg/dl or < 70

mg/dl more than two times in one week.


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[ ] ALT greater than 70 IU/L: PCP notified[ ] Patient at maximum dose; Referred to PCP[ ] Goal achieved: LDL less than 100: recheck LDL in 1 year[ ] Simplified drug regimen to fewest number of pills.

In 1-2 months Date: [ ] Check cholesterol and CHD profile 1 -2 months after dose

adjustment/Pt instructed/ Requisition in lab[ ] Notation made in CWN Future Follow Up


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Prescription Authorization Request Medication Management Note, Vr. 3.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

7/24/06 S. Smith 7/24/06 T. Niu 6/5/08 D. BrownC. Davies

PRESCRIPTION AUTHORIZATION REQUEST - MEDICATION MANAGEMENT NOTE,Vr. 3.0

Patient Name: Reg #: DOB: Age: Gender: Patient Daytime Phone (Home) #: Patient Alternate Phone (Contact) #:Insurance: Prescription Insurance:

Prescription Insurance Phone#: Member ID #: Provider (first and last name): Clinic Contact: Clinic Contact Phone:

Related URL orReferences:

Oral and Injectable Anti-DiabeticMedication Management Note, Vr. 1.0

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Creation

Date:

Created

By:

Approved

Date:

Approved

By:

Revised

Date:

Revised

By:9/08 Mary Sue Webb

Patty Lindsay-Carr9/08 D. Kowalczyk

ORAL AND INJECTABLE ANTI -DIABETIC MEDICATION MANAGEMENT NOTE, Vr.1.0

ASSESSMENT:CURRENT DIABETIC MEDICATIONS AND DOSE: Length of time on this dose

RECENT LAB/VITAL SIGNS:HgA1C: Blood Pressure Weight:

BMI:

RECENT SELF BLOOD GLUCOSE TEST RESULTS:Average of Morning Fasting for the Last Week: Average of ac Lunch for the Last Week: Average of ac Dinner for the Last Week: Average of Bedtime for the Last Week:

Highest Reading for the Last Week: Lowest Reading for the Last Week:


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NURSING DIAGNOSIS:[ ] Blood Glucose not within target range of to

PLAN:[ ] Patient with overnight or fasting glucose goal ofless than 130.

[ ] Increased dose of (medication) from to per protocol/algorithm

[ ] Side effects and signs and symptoms of hypoglycemia andhyperglycemia reviewed with the patient.

[ ] Patient to check blood glucose times per

[ ] Patient to call office if he/she has three bloodglucoses over 200 or two blood glucoses under 70

[ ] Patient has adequate supplies to last unt il next clinicvisit

[ ] Other:


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INSTRUCTIONS


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Allergy Injection - Patient Instructions, Vr. 2.0 Back to Top

Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

3/15/06 T. Thielan 3/15/06 K Ford 6/5/08 D. BrownC. Davies

ALLERGY INJECTION - PATIENT INSTRUCTION, Vr. 2.0

[ ] Patient

[ ] Spouse/ Significant Other

[ ] Others (List):

PATIENT INSTRUCTION PLAN: Patient will be instructed about

Allergy Injections, Action, Side Effects, Medication Management,

and Appointments.

INSTRUCTIONS GIVEN TODAY:[ ] ACTIONS of ALLERGY INJECTION: Exposes the body to allergens

to desensitize the b ody. Does not provide immediate relief.

[ ] SIDE EFFECTS OF ALLERGY SHOTS: flushing, periorbitaledema,

wheezing or hives, local reaction at site of injection.

[ ] WHEN NOT TO GET AN INJECTION: Symptoms of illness, serious

medical problems, pregnancy, inc rease in allergy symptoms.

[ ] MEDICATIONS:

Importance of informing Health Care Professionals of new

medications, i.e. Beta Blockers

[ ] APPOINTMENTS:

Weekly appointments for 8 to 12 months, pending response to

Allergy Injection

Clinic hours/appointmen ts and locations given

Extract reorder process explained

[ ] IMMUNOTHERAPY INFORMATIONPACKET describing potential value

and risks of Allergy shots, Received and Reviewed

[ ] IMMUNOTHERAPY INFORMATION FORM signed.

[ ] Patient/Family restates instructio ns.

[ ] Patient will evaluate information and contact Health CareProfessional with decision.

Related URL or

References:

Dry Powder Inhaler - Patient Instructions, Vr. Back to Top


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2.0Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

3/15/06 T. Thielan 3/15/06 K Ford 6/5/08 D. BrownC. Davies

DRY POWDER INHALER - PATIENT INSTRUCTION, Vr.2.0

DATE OF LAST PATIENT EDUCATION ASSESSMENT:

(Must have been completed within

the past 12 months.)

LEARNERS PARTICIPATING TODAY

[] Patient


[ ] Others (Specify):

PATIENT INSTRUCTION PLAN:Teach Patient Dry Powder Breath Actuated Inhaler Technique

INSTRUCTIONS GIVENTODAY: Patient Instructed on the fol lowing:

[ ] Medication:

When to use: Daily as directed.

Proper inhalation technique: Breathe in, exhale. Then holding

the inhaler to their mouth, breathe in steadily and deeply.

Hold breath for 10 counts. Rinse mouth after use.

Number of Doses avai lable in device and when to get refills

Demonstration with inhaler model

How to clean inhaler

How to store inhaler

[ ] Written material given/reviewed with patient

[ ] Patient/Family restates instructions and agrees to plan.

[ ] Instructed About Resourc es or Number To Call With Ongoing

Question(s).

Related URL or

References:

Epinephrine Auto Injector- PatientInstructions, Vr.1.0

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Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

4/17/08 T. Thielan 34/17/08 D. Kowalczyk

EPINEPHRINE AUTO -INJECTOR - PATIENT INSTRUCTION, Vr.1.0


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LEARNERS PARTICIPATING TODAY:

[ ] Patient

[ ] Parent/Caregiver

[ ] Others (Specify):

MEDICATION:

[ ] EpiPen

[ ] Twinject

PATIENT INSTRUCTION PLAN:

Instruct patient epinephrine auto -injector dose/technique, causes

of anaphylaxis, indications for use, how to store/dispose of and

return demonstration.

INSTRUCTIONAL INTERVENTIONS IMPLEMENTED TODAY:

Patient Instructed on the following:

MEDICATION: [ ] EpiPen [ ] Twinject

[ ] Dose: 0.15mg or 0.3mg as ordered

Immediately call 911 or seek emergency treatment as indicated

May repeat dose in ten minutes if no relief or symptoms return

After dose has been given fr om EpiPen, extra medication will

remain in syringe that cant be used

Additional dose of medication is contained in a syringe

within the Twinject after initial injection.

Directions are on Twinject injector if second dose of

epinephrine is needed.

Auto-injector should remain in close proximity in case ofneed at any given time

INDICATION: Allergic reaction of anaphylaxis due to:

[ ] Bite or sting from insect

[ ] Foods

[ ] Medications

[ ] Latex

[ ] Unknown

[ ] Other (specify):

[ ] REVIEW OF SYMPTOMS SIGNS AND SYMPTOMS REQUIRING USE OF

EPINEPHRINE AUTO-INJECTOR: This is for emergency supportive

therapy only and is not a replacement or substitute for

immediate medical care.Tingling or warm sensation

Itching, hives

Metallic taste or swelling of the mouth and throat

Wheezing, coughing, difficulty breathing

Vomiting, diarrhea, or cramping

Loss of consciousness

[ ] PROPER INJECTION TECHNIQUE

Remove auto-injector from hard plastic case and remove safety


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cap(s)

With dominant hand, g rasp injector and inject through

clothing (if necessary), into large thigh muscle

Hold for count of ten, auto -injector is spring loaded

Massage area for ten seconds

If second dose is necessary, follow directions imprinted on

the Twinject auto -injector. EpiPen auto-injectors are

single dosed and therefore, should remain together as

dispensed.

[ ] STORAGE AND DISPOSAL OF AUTO -INJECTORS

Protect from light, store at room temperature, protect from

freezing, do not refrigerate

Observe expiration dates or discolored fluid in injector,

replace as necessary

Dispose of in approved sharps collector

[ ] COMMON SIDE EFFECTS:

Anxiety, apprehensiveness, restlessness

Weakness, tremor, dizziness, headache, sweating

Irregular heartbeat, nausea, vomiting, bre athing difficulty

[ ] WRITTEN MATERIAL, DVD, AUTO-INJECTOR TRAINER GIVEN/REVIEWED

WITH PATIENT

[ ] Patient able to state Indication for Medication, Signs and

Symptoms requiring usage, storage and disposal and common side

effects.

[ ] Patient demonstra ted proper Injection Technique

DISPOSITION:

[ ] Re-Instruct

[ ] Review

[ ] Refer to Ordering Provider with further questions

[ ] Instructed about resources or number to call with ongoingquestions

Related URL or

References:

Gynecology Procedure Patient DischargeInstructions, Vr. 1.0

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Creation

Date:

Created

By:

Approved

Date:

Approved

By:

Revised

Date:

Revised

By:

4/10/09 Rochelle SlayCheri Rice 4/27/09No response HIMBilling

GYNECOLOGY PROCEDURE PATIENT DISCHARGE INSTRUCTIONS, Vr. 1.0

LEARNERS PARTICIPATING TODAY:

[ ] Patient

[ ] Spouse



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PROCEDURE:

[ ] Cervical Loop Electrosurgical Excision Procedure

[ ] Cervical Laser

[ ] Conization of the Cervix

[ ] Vaginal Laser

INSTRUCTION GIVEN TODAY:

[ ] You have received a local (cervical) anesthetic; the

effects will wear off within several hours

[ ] You have received anesthesia for your procedure. Do not

sign any legal forms, drive or operate machinery for 24

hours.

[ ]Physical activity as tolerated

[ ] Avoid vaginal douching, sexual intercourse and tampons for

2-4 weeks as they increase your risk of bleeding and/or

infection

[ ] You may have a bloody vaginal discharge with black specks

for about two days.

[ ] You may have a clear, pinkish, or brownish vaginal discharge

for approximately 2 -4 weeks.

[ ] No special diet needed; resume your previous diet.

[ ] If your physician recommends taking pain medication you

may take:

[ ] Ibuprofen 600 mg. orally every 6 -8 hours

[ ] Acetaminophen 650 mg. orally every 4 hours[ ] Prescription medication as ordered by provider

CONTACT YOUR HEALTH CARE PROVIDER IF YOU DEVELOP THE F OLLOWING:

[ ] Vaginal bleeding heavier than a normal menstrual period

[ ] Foul smelling vaginal discharge

[ ] Abdominal or vaginal pain not relieved by your pain

medication

[ ] Temperature over 100.4 degrees Fahrenheit

MONDAY THROUGH FRIDAY 8 AM-4:30 PM:

Gynecology-Oncology clinic (734) 647 -8906

AFTER OFFICE HOURS C ONTACT:

[ ] Gynecology resident on call at (734) 936 -6267[ ] Gynecology-Oncology answering service at (734) 4 77-6437

Follow-up:

[ ] Post procedure appointment in 2 -8 weeks, or as advised by

your physician. To confirm that post -op appointment has been

scheduled, call 734 -647-8906.


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[ ] Patient/Family restates instructions and agrees with plan.

Related URL or

References:

Liver Biopsy Patient Prep Instructions,Vr. 1.0

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Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

4/16/08 Lisa S. Sylvest 4/16/08 D. Kowalczyk

LIVER BIOPSY PATIENT PREP INSTRUCTIONS, Vr. 1.0

Ordering Provider:

Date Liver Biopsy Scheduled:

PRECAUTIONS/SPECIAL INSTRUCTIONS:

[ ] Patient is diabetic. Handout "Instructions for Patients with

Diabetes having Outpatient Procedures/Tests" provided

[ ] Insulin (or Insulin and Pills)

[ ] Pills only

[ ] Patient is on Coumadin

[ ] Patient is to hold medication for days without bridging

per Ordering Provider.

[ ] Patient to be bridged to Lovenox injections

[ ] REFERRED TO RN. Name of RN:

[ ] Patient to follow up with Anticoagulation Clinic or

[ ] Patient is on Anti -platelet drugs:

Aggrenox (aspirin plus dipryridamole), Aggrastat (tero fiban)

Plavix(clopidogrel), Persantine(dipyridamole)

Integrillin (eptifibatide), Ticlid (ticlopidine) ReoPro

(abciximab)

[ ] Patient advised to hold one week prior to procedure

[ ] Aspirin or NSAIDs

[ ] Patient advised to hold one week prior to proce dure

Instructions:

Handouts given (specify): UM Liver Biopsy (last updated June2007)

Patient Informed of:

[ ] Reason for test.

[ ] Diet and medication restrictions prior to test

Light or Liquid breakfast the morning of procedure

[ ] Need for driver due to restrictions

[ ] No driving for 12 hours post procedure


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[ ] Need for activity restrictions

No lifting more than 10 pounds for seven days

No travel/flying for seven days

[ ] Patient able to state reason for test, diet and medication

restrictions, driving restrictions, activity restrictions.

[ ] Patient given the opportunity to ask questions in clinic

and/or number to call nurse. Patient advised to call with any

questions or concerns.

Related URL or

References:

Methacholine Challenge Test - Patient

Instructions, Vr. 2.0

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Creation

Date:

Created

By:

Approved

Date:

Approved

By:

Revised

Date:

Revised

By:

04/19/06 Sheila Kato 04/19/06 T. Niu 6/5/08 D. BrownC. Davies

METHACHOLINE CHALLENGE TEST - PATIENT INSTRUCTIONS, Vr. 2.0

Blood Pressure (BP):

PATIENT INSTRUCTION PLAN: Instruct the patient in preparation for

Methacholinine Challenge Test

INSTRUCTION DONE:

[ ] By Phone

[ ] Face to face

[ ] Patient


[ ] Others (specify):

NOTE: This test cannot be perfo rmed on patients if the following

conditions exist:

[ ] Currently receiving Beta -Blocker agents

[ ] Systolic BP > 200 or diastolic BP > 100

[ ] Pregnant / Nursing mothers

[ ] Known aortic aneurysm heart attack or stroke in last 3 months

[ ] Respiratory inf ection in the past 4 weeks (Does not includesinus infections)

[ ] Currently using Cholinesterase inhibitor (for Myasthenia

Gravis)

[ ] No contraindications

PATIENT HAS BEEN INS TRUCTED:

[ ] Not eat/drink any food that contains caffeine for 6 hours

before test


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[ ] Avoid exercise and cold air for 2 hours prior to testing

[ ] Avoid smoking and second hand smoke for 6 hours prior to

testing

THESE MEDICATIONS MU ST BE HELDFOR 48 HOU RS PRIOR TO TEST:

[ ] Oral, inhaled or injected bronchodilators

[ ] Oral methylxanthines (Theophylline)

[ ] Corticosteroids, oral or inhaled

[ ] Leukotriene modifiers

[ ] Cromolyn Sodium (Intal)

[ ] Tilade (Nedocromil)

[ ] Primatine Mist

[ ] Any prep containing Ephedrine

THESE MEDICATIONS MU ST BE HELD FOR 72 HOURS PRIOR TO TEST:

[ ] Hydroxyzine

[ ] Vistaril

[ ] Atarax

[ ] Marax

[ ] Zyrtec[ ] Cetirizine

THIS MEDICATION MUST BE HELD FOR 1 WEEK PRIOR TO TEST:

[ ] Tiotropium (long acting Atrovent)

INSTRUCTIONS:


[ ] Instructed About Resources or Number To Call With Ongoing

Questions

[ ] Written information given to patient

[ ] Written information mailed to patient

Related URL or

References:

Test Prep - Patient Instructions, Vr. 3.0 Back to Top

Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

4/29/05 C. Laughlin

L. Sylvest

4/29/09 M. Kiss

K. Ford

6/5/08

4/24/09D. Brown C. Davies

D. Brown

TEST PREP - PATIENT INSTRUCTIONS, Vr. 3.0

Allergies:

Test Preparation Instructions:

Ordering Provider:

Scheduled Test(s) : Date Test Scheduled:


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(FOR LIVER BIOPSY, USE LIVER BIOPSY PATIENT PREP INSTRUCTION

NOTE)

PRECAUTIONS/SPECIAL INSTRUCTIONS:

[ ] Patient is diabetic. Handout "Instructions for Patients

with Diabetes having Outpatient Procedures/Tests" provided

[ ] Insulin (or Insulin and Pills)

[ ] Pills only

[ ] If patient is on any Metformin containing oral agent

(Glucophage, Glucovance, etc), and is having a CT or

test with contrast, the Metformin contai ning oral agent

must be held for 48 hours after test, and the patient

should have BUN/Creatinine checked before restarting

med.

[ ] Patient is on Coumadin

[ ] Patient is to hold medication for days without

bridging.

[ ] Patient to be bridged to Lovenox injections

[ ] REFERRED TO RN: Name of RN: [ ] Patient to follow up with Anticoagulation Clinic or

[ ] Patient is on Anti -platelet drugs:

Aggrenox (aspirin plus dipryridamole), Aggrastat,

(terofiban) Plavix(clopidogrel), Persa ntine(dipyridamole)

Integrillin (eptifibatide), Ticlid (ticlopidine) ReoPro

(abciximab)

[ ] Patient advised to hold one week prior to procedure

[ ] Patient is allergic to radiographic contrast or iodine

[ ]For CT, MRI, Angiography, steroid prep given

[ ]For ERCP, have schedulers note in comments

[ ] Patient has a history of kidney disease. Check with

provider if prep involves magnesium citrate or phospho -

soda laxative.

Instructions:

[ ] Handouts given (specify):

Patient informed of:

[ ] Reason for test(s):

[ ] Prep medications needed and where to obtain

[ ] Diet and medication restrictions prior to test

[ ] Need for driver for procedures using sedation[ ] Need for day off work or activity restrictions

[ ] Written instructions and/or prescription given for colon

prep:

[ ] Nulytely [ ] One Day Prep

[ ] Halflytely [ ] Two Day Prep

[ ] MoviPrep

[ ] Polyethylene Glycol 3350

[ ] Osmoprep


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[ ] Other

[ ] Special Instructions (specify):

[ ] Patient able to sta te reason for test, prep medication

usage, need for driver, need for activity restrictions and

agrees with plan.

[ ] Patient was given the opportunity to ask questions in

clinic and/or number to call nurse. Patient advised to

call with any questions or concerns.

Related URL or

References:

Sildenafil Citrate (Viagra) - PatientInstructions,Vr. 2.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

07/07 A. R. Liechty,

LPN

12/07 H. Rodriguez 6/5/08 D. Brown

C. Davies

SILDENAFIL CITRATE (VIAGRA) PATIENT INSTRUCTIONS ,Vr. 2.0

LEARNERS PARTICIPATING TODAY

[ ] Patient


[ ] Others (specify):

Blood Pressure:

PATIENT EDUCATION PLAN: Patient will receive instruction on safe

use of Viagra.

[ ] MEDICATION NAME: Viagra/ Sildenafil Citrate

DOSE:

ROUTE: Oral

FREQUENCY: As needed no more than once daily

DIRECTIONS: As directed p er Provider

[ ] INDICATION FOR MEDICATION: Erectile Dysfunction; Difficulty

having an erection

[ ] SPECIAL INSTRUCTIONS:

Take 60 minutes before having sex

Do not use more than once a day.

[ ] PRECAUTIONS:

Do not take with Nitrates such as Nitroglyce rin


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[ ] COMMON SIDE EFFECTS

May experience headache

Bluish discoloration to vision is common

Stuffy nose

Weakness

Upset stomach nausea diarrhea or indigestion

Warmth or redness in your face, neck, arms, or upper chest

[ ] WHEN TO CALL THE PROVIDER OR N URSE

Call right away for:

Priapism (erections lasting over 4 hours)

Feeling lightheaded, dizziness or faint

Also:

Call Clinic if decrease in efficacy.

Vision loss- Bluish discoloration is common.

Not an indication to call the doctor or nurse.

[ ] Patient verbalizes understanding and agrees with plan.

[ ] Instructed about resources or number to call with ongoing

questions changes.

Related URL or

References:

Testing Instructions Pre-Transplant Patient

Instructions, Vr. 3.0

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Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

4/30/07 L. Carver 4/30/07 D. Kowalczyk 6/5/08 D. BrownC. Davies

TESTING INSTRUCTIONS PRE-TRANSPLANT PATIENT INSTUCTIONS, Vr.

3.0

Dear ,

Please remember to HOLD your for 3 days prior to your

Dobutamine Echo heart study. This is very important as this

medication slows your heart rate while the medicine you will begiven as part of the "stress" on your heart, speeds your heart

rate. You should have nothing to eat or drink 4 hours prior to

this study.

You may resume your the day after your study.

If a University of Michigan scheduler or local cardiac testing

office informs you there are no restrictions regarding


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medications, that information is incorrect. For our purposes,

evaluating you for Live r Transplantation, we require that you

STOP your for 3 days (72 hours) prior to this test.

We have provided a description of the test for you as well. We

appreciate your intention to comply with these instructions. If

you have any questions feel f ree to call at 1 -800-395-6431

#3, #4.

Sincerely,

Related URL or

References:


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NURSING NOTES


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Allergen Immunotherapy Systemic ReactionNurse Visit Note, Vr. 5.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

10/27/08 C. Argiero 10/27/08 D. KowalczykE. Reynolds (Legal),

S. Anderson(RskMgt), T. Jackson

(HIM)

6/5/08

02/11/2011

D. BrownC. Davies

T. Jackson

ALLERGEN IMMUNOTHERAPY SYSTEMIC REACTION NURSE VISIT NOTE, Vr.5.0

NOTE: A copy of this form must be completed and submitted toprescribing allergy physician for each SYSTEMIC REACTION TOIMMUNOTHERAPY by the nurse administering the immunotherapy. Thisform must be reviewed by the allergist prescribing immunotherapywithin 10 days from the event.

Date of Systemic Reaction to allergen immunotherapy: Date patient began allergen immunotherapy:

Extract contents: Dosage(s):

Time from injection to onset of symptoms: Number of previous syste mic reactions: Number of previous local reactions:

PRE REACTION VITAL SIGNS:Blood Pressure Pulse Respiratory Rate PEFR

REACTION DESCRIPTION

Manifestation of Reaction (include systemic and local):

NURSING IMPRESSION: ALLERGEN IMMUNOTHERAPY SYSTEMIC REACTION

THERAPY: [ ] Benadryl mg route [ ] Epinephrine mg IM[ ] Other (specify):

VITAL SIGNS DURIN G REACTION:Blood pressure Pulse Respiratory rate PEFRAdditional vital signs may be found in Continuity.

ADDITIONAL FACTORS[ ] Exercise within 4 hours[ ] ETOH[ ] History of allergies/asthma[ ] Other health status/varia bles (specify):[ ] Recent change in medications (specify):[ ] Beta Blocker use[ ] ACE I / ARB use[ ] Current infection/antibiotics[ ] Major recent allergen exposure (specify):[ ] Injection given during seasonal allergy exposure


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[ ] Recent symptoms increase[ ] Pregnant; Last Menstrual Period (LMP)[ ] Interval since last food[ ] Use of Antihistamines in the past 24 hours[ ] Inconsistent use of Antihistamines before/on shot days[ ] New extract formulation in past 1 year[ ] New extract (specify adjustment made if any)

[ ] Dosage increased today[ ] Other (specify):

PROBABLE ETIOLOGY OF SYSTEMIC REACTION:

Discharge Vital Signs:Blood pressure Pulse Respiratory rate PEFR

DISPOSITION[ ] Discharged to home with instruction[ ] Discharged to Emergency Room[ ] Hospitalized[ ] Died


RECOMMENDATION FOR FUTURE:[ ] Discontinue allergen immunotherapy[ ] Continue allergen immunotherapy without modification[ ] Continue allerg en immunotherapy with modifications


Adult Blood Pressure Check, Vr. 2.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

4/29/2005 C. Laughlin 4/29/2005 M. KissK. Ford

6/5/08 D. BrownC. Davies

ADULT BLOOD PRESSURE (BP) CHECK, Vr. 2.0

Patient returns today for Blood pressure (BP) check per order ofDiagnosis: Elevated blood pressure

Medications: BP: Pulse: Arm [ ] Right [ ] LeftSize of cuff:

DISPOSITION:

[ ] The patients blood pressure is above 160/100 or below 100/60and on no medication. Second measurement was taken (recordedabove). A provider was asked to review today.

[ ] The patients blood pressure is above 160/100 or below 100/60and on medication. Second measurement was taken (recorded above).An appointment with a provider was scheduled in 2 3 days:


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[ ] The patients BP is above 200/120. The nurse or provider wasconsulted immediately.

[ ] The patients BP is in the desired range. The patient wasinformed and advised to continue current regimen, and scheduledto return for any additionally prescribed blo od pressure checks

and/or provider visit for ongoing management

Name/Title:


Chemotherapy Infusion Nursing Note, Vr. 2.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

06/09/06 S. Gillesse 06/09/06 T. Niu 6/5/08 D. BrownC. Davies

CHEMOTHERPAY INFUSION NURSING NOTE, Vr. 2.0

VITAL SIGNS: See Care Web -CONTINUITY

ALLERGIES: Reviewed and as documented in the Problem Summary List

ASSESSMENT: SUBJECTIVE:

HOLD parameters reviewed and within acceptable limits

INTERVENTIONS DURING ENCOUNTER:A time-out was completed verifying correct patient,procedure and site for IV placement.

INTRAVENOUS ACCESS (specify):[ ] Left arm [ ] Right arm

PRE-MEDICATIONS:

OTHER MEDICATIONS:

CHEMOTHERAPY GIVE N (Drug, dose):

[ ] NO ADVERSE REACTIONS NOTED.

[ ] PATIENT HAD FOLLOWING REACTION:[ ] IV discontinued.

PLAN: Patient has return appointment scheduled.Other (specify):

PATIENT INSTRUCTION:Reinforced post infusion instruction as per P atient EducationNote.


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Patient states appropriate management of side effectPatient advised to Call Provider with Questions, Concerns, orChange in Symptoms.


Chronic Pain Management Nurse Visit Note,Vr. 2.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

4/30/07 S. JonesP. Lindsey-Carr

4/30/07 D. Kowalczyk 6/5/08 D. BrownC. Davies

CHRONIC PAIN MANAGEMENT NURSE VISIT NOTE, Vr. 2.0

REASON FOR NURSING ENCOUNTER: Monthly controlled substancecontract nursing visit.

ASSESSMENT:Per Pain assessment Questionnaire: On a scale of 1 -10 (0 = NOPain and 10 = worst imaginable pain)

Pain level at its worst: Pain level at its best: Pain level most of the time: [ ] Patient is able to perform activities of daily living[ ] Pain level interferes with patients work responsibilities[ ] Yes [ ] No Patient is able to perform activities of dailyliving[ ] Yes [ ] No Pain level interferes with patients workresponsibilities:

DEPRESSION ASSESSMENT QUESTIONS:[ ] Patient has little interest in activities

[ ] Patient has felt sad, miserable, or hopeless during the pastfew weeks

NURSING IMPRESSION: Chronic Pain

PLAN:

Prescription/s given today: Other (specify):

DISPOSITION OF CARE AT DISCHARGE FROM VIS IT:[ ] Advice per protocol (specify): [ ] Appointment advised[ ] Appointment made - date:

[ ] Emergency Room advised - facility: [ ] Provider consulted, recommendations: [ ] Patient advised to call with questions, concerns, o r changeinsymptoms[ ] Patient to call for earlier appointment with physician ifstatus changes.[ ] Provider follow -up action requested[ ] Contact patient[ ] Other (specify):


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Depo-Provera Nursing Note, Vr. 2.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

09/06 S. Jones 09/06 T. Niu 6/5/08 D. BrownC. Davies

DEPO-PROVERA NURSING NOTE, Vr. 2.0

Date of provider order: Date of first Depo -Provera injection: Date of most recent injection: Date of last Pap smear:

Any serious medical problems since last Depo Provera? [ ] No [ ]Yes; (If yes explain):

Describe bleeding since last injection:[ ] No menstruation[ ] Intermittent spotting[ ] Continuous spotting[ ] Regular menses[ ] Irregular bleeding[ ] Irregular heavy bleeding[ ] Heavy and continuous bleeding[ ] Other (specify):

Bleeding pattern tolerable: [] Yes [] No; (If no explain):

Reported side effects:

Side effects tolerable: [ ] Yes [ ] No; (If no explain):

NURSING IMPRESSION:

Medication:[ ] DEPO-PROVERA 150 MG IM GIVEN AND RECORDED IN PSLLocation given: Lot#:Exp date: Next injection due:

[ ] Patient stated that prolonged use of Depo -Provera may resultin loss of bone density, as stated in patient informationbrochure.Related URL or

References:

Depo-Provera, Vr. 2.0 Back to Top

CreationDate:

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ApprovedDate:

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RevisedBy:



DEPO-PROVERA, Vr. 2.0


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Weight: Blood pressure (BP): Date of provider order: Date of first Depo-Provera injection: Date of most recent injection: Date of last Pap smear: Refer to RN or Provider if any Yes responses:

[ ] Depo-Provera order > one year old[ ] Pap smear on chart > one year old[ ] Is this first Depo -Provera injection[ ] Interval since last injection 13 Weeks[ ] Wt gain >8 lbs. since last injection or >10 lbs over lastyear[ ] Diastolic BP>10 mm Hg above B/P at last injection

patient has complaints of:Refer to RN or Provider if any Yes responses:[ ] sharp chest pain, sudden SOB or hemoptysis[ ] sudden severe headache, vomiting, fainting or dizziness[ ] visual changes[ ] difficulty with speech[ ] extremity weakness or numbness

[ ] severe pain or swelling in the calf[ ] unusually heavy bleeding[ ] severe pain or tenderness in lower abdominal area[ ] persistent pain, pus or bleeding at the injection site[ ] Other (specify):

Describe bleeding since last injection:[ ] No menstruation[ ] Intermittent spotting[ ] Continuous spotting[] Regular menses[ ] Irregular bleeding[ ] Irregular heavy bleeding[ ] Heavy and continuous bleeding


Bleeding patternPatient reports bleeding pattern is tolerable.[ ] Yes [ ] No; (If no refer to RN or provider )

Reported side effects:Patient reports Side effects are tolerable[ ] Yes [ ] No; (If no refer to RN or provider)

Medication:[ ] DEPO-PROVERA 150 MG IM GIVEN AND RECORDED IN PSLLocation given: Lot#:

Exp date: Next injection due: [ ] Patient given appointment information.

[ ] Patient stated that prolonged use of Depo -Provera may resultin loss of bone density, as stated in patient informationbrochure.

Name/Title:

Related URL or


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References:

Dermatology Treatment Discharge Care PlanNursing Note, Vr. 1.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

4/10/09 J. Witten 4/27/09No response

HIM

Billing

DERMATOLOGY TREATMENT DISCHARGE CARE PLAN NURSING NOTE, Vr. 1.0

Subjective:

Objective:Treated at the Dermatology TaubmanCenter for days withModified Goeckerman therapy.[ ] At discharge, skin integrity presents with decreasederythema.[ ] Plaques have decreased area of thickness[ ] Other:

Assessment:[ ] Patient outcome of skin improvement achieved[ ]Patient outcome of skin improvement not achieved[ ]Other:

Plan:[ ] Return visit scheduled: Date [ ] See Ambulatory Phototherapy Treatment Center sheet fordischarge orders

PATIENT INSTRUCTIONWritten home care instructions included in Patient Handbookand reviewed with patient. Reviewed rationale for homecareplan and stress importance of compliance with plan for

optimum results. Questions answered.

[ ] Patient/Family restates instructions and agrees wi th plan.

[ ] Instructed About Resources and Number To Call With OngoingQuestion(s).


Dermatology Treatment Nursing Assessment, Vr. 1.0 Back to TopCreation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

4/10/09 Jeanine Witten 4/27/09No response HIMBillingDERMATOLOGY TREATMENT NURSING ASSESSMENT, Vr. 1.0

ADMITTED FROM:

MEDICAL DIAGNOSIS/Chief Complaint: Reason for Admission/ Transfer: CHIEF COMPLAINTDuration: Previous Admissions:


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Previous Treatments: Treatments during Past Month: Other Medical Problems/ Conditions:

CURRENT MEDICATIONS:

VITAL SIGNS:Blood Pressure: Pulse: Temperature:

PATIENTS EXPECTATIONS DURING ADMISSION: ANY LIMITATIONS OF ADMISSION:

LAST OUTPATIENT CLINIC VISIT:Date: Location: Physician:

HEALTH HISTORY REVI EW OF SYSTEMSCIRCULATORY:

[ ] Hypertension [ ] Chest Pain [ ] Palpitations[ ] Syncope [ ] Edema[ ] Other:

RESPIRATORY:[ ]SOB[ ]Cough[ ]Sputum[ ]Smoking History[ ]Other (specify):

MOTOR:[ ]Stiff Joints[ ]Weakness

[ ]Other:

NEUROLOGIC:[ ]Headache[ ]Seizure[ ]Tremor[ ]Other:

UROLOGIC:[ ] Infection/Discharge[ ] Genital Sores[ ] Dysuria[ ] Urinary Frequency[ ] Other:

GASTROINTESTINAL:[ ] Constipation [ ] Diarrhea [ ] Nausea[ ] Vomiting [ ] Ora l Sores [ ] Heartburn[ ] Weight Gain lbs [ ] Weight Loss lbs[ ] Other:

ENDOCRINE:[ ] Diabetes[ ] Other:


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SPECIAL SENSES:[ ] Alterations in Vision[ ] Hearing[ ] Taste[ ] Smell[ ] Other:

REST AND COMFORT:[ ] Pain Describe: Pain Scale: /10[ ] Usual/Sleep Pattern Hrs/Night[ ] Sleep Dysfunction[ ] Sleep Aid: [ ] Other:

MENTAL/ EMOTIONAL: General Appearance during Interview:[ ]Cooperative[ ]Angry[ ]Depressed[ ]Anxious[ ]Other:

STRESS FACTORS:Recent Changes at:[ ]Home[ ]Work[ ]School[ ]Other: Coping Mechanisms:

SKIN:General Appearance: [ ] Fissures [ ] Exfoliation [ ] Excoriations[ ] Erythema: [ ] Excessive [ ] Moderate [ ] Minimal[ ] Pruritus: [ ] Severe [ ] Moderate [ ] Minimal[ ] Nail Disorder: [ ] Thickened [ ] Pitted [ ] Other:

[ ] Scalp Disorder:[ ] Scalp Lesions [ ] Ear Lesions[ ]Scales [ ] Erythema [ ] Other: [ ]Facial Involvement:[ ] Erythema [ ] Scales [ ] Other:

NURSING IMPRESSION:

DISPOSITION OF CARE:

PATIENT INSTURCTIONS:[ ] Oriented to Dermatology TaubmanCenter and Protocols


Diagnostic Testing (Pediatric Infusion) -Nursing Note, Vr 1.0

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CreationDate:

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ApprovedBy:

RevisedDate:

RevisedBy:

2/28/06 M. Wlodyga 3/2/06 Tori NiuDIAGNOSIC TESTING (PEDIATRIC INFUSION) NURSING NOTE VR 1.0

TEST NAME:


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ASSESSMENT:SUBJECTIVE: Patient is adequately prepared prior to diagnostictesting to ensure successful test Yes< ____>No

OBJECTIVE:Weight:Height:

Allergies: Describe:

INTERVENTIONS DURING ENCOUNTER:A time-out was completed verifying correct patient,procedure, site, positioning, and implant(s) or specialequipment.[ ] Heplock placed:[ ] Venipuncture:[ ] Patient tolerated the access procedure age appropriate[] Labs obtained per test protocol.[ ] Other (Specify):

PRESUMED DIAGNOSIS:

OUTCOME:[ ] Completed test[ ] Reschedule testing

DISPOSITION OF CARE AT DISCHARGE FROM VISIT:

[ ] PROVIDER CONSULTED, RECOMMENDATIONS:

PATIENT EDUCATION:[ ] Test protocol reviewed w/parent and patient.[ ] Expect test results within 2 weeks after testing.[ ] Expect follow-up per Provider following test result.[ ] Verbalized understanding [] Yes [] No[ ] Patient/Parent advised to call Provider with questions,

concerns, or change in symptoms.[ ] Other (specify):


Dressing Change, Vr. 2.0 Back to Top

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DRESSING CHANGE, Vr. 2.0

This patient returns today to have dressing changed per order of.

RN/Provider notified if patient reports:[ ] Worsening or no improvement of wound.[ ] Continued or worsening pain at wound site.[ ] Thick, purulent or bloody drainage[ ] Fever. If yes, temperature today:

Other (specify):


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OBSERVATIONS AND CARE:Wound location: Appearance of wound: Drainage color and amount: Cleaned/irrigated with: Technique: [ ] clean [ ] sterile

Type of dressing applied:

Patient tolerated the procedure well. Signs and symptoms ofinfection reviewed per patient education materials and patientinstructed to call clinic if noted.

Name/Title:


Ear Irrigation, Vr. 2.0 Back to Top

Creation

Date:

Created

By:

Approved

Date:

Approved

By:

Revised

Date:

Revised

By:4/29/2005 C. Laughlin 4/29/2005 M. KissK. Ford


EAR IRRIGATION, Vr. 2.0

Patient returns today to have ear irrigation per order of

[ ] Right [ ] Left Ear [ ] Both

Solution Used:[ ] Tepid water[ ] Hydrogen Peroxide and tepid water[ ] Other (specify):

[ ] Ear Wax Softener Used (specify):

Results of Procedure: Amount of Return: Color of Cerumen:

Patient Tolerated Procedure:[ ] No problems[ ] Patient complains of d izziness or pain. Procedure stopped.[ ] Provider notified[ ] RN notified[ ] Other (specify):

NAME/TITLE:


Epinephrine Auto Injector- Patient Instruction,Vr.1.0

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4/17/08 T. Thielan 34/17/08 D. KowalczykEPINEPHRINE AUTO -INJECTOR - PATIENT INSTRUCTION, Vr.1.0

LEARNERS PARTICIPATING TODAY[ ] Patient[ ] Parent/Caregiver[ ] Others (specify):

MEDICATION:[ ] EpiPen[ ] Twinject

PATIENT INSTRUCTION PLAN:Instruct patient epinephrine auto -injector dose/technique, causesof anaphylaxis, indications for use, how to store/dispose of andreturn demonstration.

INSTRUCTIONAL INTERVENTIONS IMPLEMENTED TODAY:Patient Instructed on the following:MEDICATION: [ ] EpiPen [ ] Twinject[ ] Dose: 0.15mg or 0.3mg as orderedImmediately call 911 or seek emergency treatment as indicated

May repeat dose in ten minutes if no relief or symptoms returnAfter dose has been given from EpiPen, e xtra medication willremain in syringe that cant be used

Additional dose of medication is contained in a syringe withinthe Twinject after initial injection.

Directions are on Twinject injector if second dose ofepinephrine is needed.Auto-injector should remain in close proximity in case of needat any given time

INDICATION: Allergic reaction of anaphylaxis due to:

[ ] Bite or sting from insect[ ] Foods[ ] Medications[ ] Latex[ ] Unknown[ ] Other:

[ ] REVIEW OF SYMPTOMS S IGNS AND SYMPTOMS REQUIRIN G USE OFEPINEPHRINE AUTO-INJECTOR: This is for emergency supportivetherapy only and is not a replacement or substitute forimmediate medical care.Tingling or warm sensationItching, hivesMetallic taste or swelling of the mouth and throat

Wheezing, coughing, difficulty breathingVomiting, diarrhea, or crampingLoss of consciousness[ ] PROPER INJECTION TECHNIQUERemove auto-injector from hard plastic case and remove safetycap(s)With dominant hand, grasp injector and inj ect throughclothing (if necessary), into large thigh muscleHold for count of ten, auto -injector is spring loadedMassage area for ten secondsIf second dose is necessary, follow directions imprinted on


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the Twinject auto-injector. EpiPen auto -injectors aresingle dosed and therefore, should remain together asdispensed.

[ ] STORAGE AND DISPOSAL OF AUTO -INJECTORSProtect from light, store at room temperature, protect fromfreezing, do not refrigerate

Observe expiration dates or discolored fluid in injector,replace as necessaryDispose of in approved sharps collector[ ] COMMON SIDE EFFECTS:Anxiety, apprehensiveness, restlessnessWeakness, tremor, dizziness, headache, sweatingIrregular heartbeat, nausea, vomiting, breathing difficulty

[ ] WRITTEN MATERIAL, DVD, AUTO-INJECTOR TRAINER GIVEN/REVIEWEDWITH PATIENT

[ ] Patient able to state Indication for Medication, Signs andSymptoms requiring usage, storage and disposal and common sideeffects.

[ ] Patient demonstrated proper Injecti on Technique

DISPOSITION [ ] Re-Instruct[ ] Review[ ] Refer to Ordering Provider with further questions[ ] Instructed about resources or number to call with ongoingquestions


Headache Assessment Pediatric Neurology

Nursing Note, Vr. 2.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

4/30/07 H. Murrel 4/30/07 D. Kowalczyk 6/5/08 D. BrownC. Davies

HEADACHE ASSESSMENT PEDIATRIC NEUROLOGY NURSING NOTE, Vr. 2.0

ASSESSMENT:Number of headaches per day , per week ,Per month Duration of headache: Minutes, Hours, Days[ ] Concurrent illness describe: , Febrile [ ]

CURRENT HEADACHE MEDICATIONS:[ ] Missed doses (When): [ ] Adverse Effects(describe): OTC Meds used:

DESCRIPTION OF HEADA CHE[ ] Typical headache for this child. See Care Web Note dated:[ ] Missing school days per week, per month[ ] Need letter [ ]Mail [ ]fax


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DETAILS OF HEADACHE:[ ] Level of pain (0= No Pain to 10 = M ost Severe): [ ] Cried[ ] Confused[ ] Blurred vision [ ] right eye [ ] left eye[ ] Numbness/tinglingArms: Right. [ ] Left [ ]

Legs: Right. [ ] Left [ ][ ] Dizziness[ ] Emesis (describe): [ ] Disturbed/behavior (describe): [ ] Other (specify):

DURING HEADACHE:[ ] Photophobia[ ] Phonophobia[ ] Area of pain [ ] Possible triggers (including sleep, hygiene): [ ] Other (Specify):

POST HEADACHE:[ ] Confusion

[ ] Irritability[ ] Child returned to school[ ] Participated in school activities[ ] Other (Specify):

Additional information:

NURSING IMPRESSION:

PLAN:[ ] Review with physician[ ] Increase medication to: [ ] Decrease medication to : [ ] Start new medication:

[ ] Medication changes called to pharmacy Phone fax [ ] Repeat labs (specify): Repeat days [ ] weeks [ ] month [ ] not needed [ ]

PATIENT EDUCATION :[ ] Drug information and dosing instruc tions:Discussed [ ] Mailed copy [ ] date [][ ] Emergency Care and Safety Issues discussed [ ] date [ ] Emergency contact after office hours given [ ][ ] Caregiver will continue to keep log of headaches.[ ] Caregiver will call if side effects or headaches continue[ ] Caregiver verbalizes instructions and agrees to plan


Hyperlipidemia Assessment for DiabeticPatients Nursing Note OrEducation Note, Vr.1.0

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RevisedBy:


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10/7/08 Patty Lindsay-CarrMary Sue Webb

Diane Brown

10/7/08 Daniel Kowalczyk

HYPERLIPIDEMIA ASSESSMENT FOR DIABETIC PATIENTS NURSING NOTE OREDUCATION NOTE, Vr. 1.0

LEARNERS PARTICIPATING TODAY:[ ] Patient[ ] Spouse/ Significant other[ ] Others (specify):

[ ] Patient is currently taking antidyslipidemics(specify):Length of time on this dose:

Patient is currently making lifestyle changes by:[ ] Following a low -saturated fat, low -cholesterol diet.[ ] Working on weight reduction diet (specify):

[ ] Patient is physically active and has a routine exerciseprogram. Type of activity: minutes times a week

[ ] Working on increasing exercise (specify):

[ ] Patient has set Individual Goal(s)(specify):

[ ] Educated per the Lipid Screening and Management clinicalcare guideline www.med.umich.edu/i/oca/practiceguides [ ] Other

NURSING IMPRESSION:[ ] Patient ready to make changes as discussed above.[ ] Other

EVALUATION:[ ] Knowledge Achieved

[ ] Developing Knowledge[ ] No Learning Evident

EVIDENCE OF LEARNING:[ ] Return Demonstration[ ] Teach-Back[ ] Other (specify):

DISPOSITION:[ ] Reteach:[ ] Reinforce/More Practice/Review[ ] Referral to Another Provider Advised/Made (Describe):[ ] Other (specify):[ ] Referred to dietician

[ ] Instructed About Resources or Number To Call With OngoingQuestion


Hypertension Assessment for DiabeticPatients Nursing Note orEducation Note, Vr.

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1.0Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:10/7/08 Patty Lindsay-Carr

Mary Sue WebbDiane Brown

10/7/08 D. Kowalczyk

HYPERTENSION ASSESSMENT FOR DIABETIC PATIENTS NURSING NOTE OREDUCATION NOTE, Vr. 1.0

LEARNERS PRESENT TODAY:[ ] Patient[ ] Spouse, Significant other[ ] Others (specify):

[ ] Patient is on antihypertensive medication (specify): Length of time on this dose:

[ ] Patient is able to state own blood pressure goal: If No:[ ] Informed patient of documented goal of [ ] Informed of goal less than 135/80 (no other documented goal)

[ ] Patient monitors own blood pressure at home [ ] Yes [ ] No(Readings): If No[ ] Patient is interested in learning how to take own BP at home.[ ] Instructed and describes Blood press ure monitoring andrecommended equipment How to contact provider with elevatedreadings

[ ] Patient is currently making lifestyle changes[ ] Follows a weight reduction diet (specify):[ ] Monitors the amount of salt/sodium intake[ ] Discussed ways of decreasing sodium in diet[ ] Other diet (specify) :

[ ] Patient is physically active and has a routine exerciseprogram. Type of activity: minutes times a week[ ] Working on increasing exercise (specify):

[ ] Patient not making Life Style changes[ ] Instructed on benefits of weight reduction, exercise,smoking cessation and healthy diet

[ ] Patient has set Individual Goal(s)(specify):

NURSING IMPRESSION:[ ] Patient ready to make changes as discus sed above

[ ] Comments:

EVALUATION:[ ] Knowledge Achieved[ ] Developing Knowledge[ ] No Learning Evident

EVIDENCE OF LEARNING:[ ] Return Demonstration[] Teach-Back[ ] Other (specify):


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DISPOSITION:[ ] Reteach: [ ] Reinforce/More Practice/Review[ ] Referral to Another Provider Advised/Made (Describe):[ ] Other (specify):

[ ] Instructed About Resources or Number To Call With OngoingQuestion


Immune Globulin Intravenous (IVIG) InfusionNursing Note, Vr. 2.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

3/15/06 E. Edwards 3/15/06 K Ford 6/5/08 D. BrownC. Davies

IMMUNE GLOBULIN INTR AVENOUS (IVIG) INFUSION NURSING NOTE Vr. 2.0

ASSESSMENT: SUBJECTIVE: [ ] Denies any complications since last infusion.[ ] Other (specify):

OBJECTIVE: Alert and oriented to time, place and person. Skin iswarm, dry and pink.Initial vital signs are:Blood Pressure (BP):Pulse (P):

NURSING IMPRESSION:

INTERVENTIONS DURING ENCOUNTER:A time-out was completed verifying correct patient,procedure, site, positioning, and implant(s) or specialequipment.

Premeds:

gauge. Angio started in with brisk flow of bloodreturned.

Immune Globulin Intravenous gms. Reconstituted with mL normal saline.

Lot Number: ; Expiration date:

Infused over hours without complications.

Observed for 30 minutes post m edication infused. Normal saline250 mL infused during observation.

Final vital signs are: BP, P

No complications noted. Further vital signs in CareWeb -Continuity.IV discontinued.


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[ ] Labs drawn (specify):

DISPOSITION OF CARE AT D ISCHARGE FROM VISIT:

PLAN: Infusion every weeks

PATIENT INSTRUCTION:[ ] Reinforced post infusion instructions:Medication - Intravenous Immune Globulin: Given for problems withimmune system. Helps prevent infections or make the i nfectionless severe. Treats low platelets due to ITP.Possible Side Effects - Renal dysfunction and acute renalfailure.Notify Physician/Nurse - immediately if symptoms of decreasedurine output, sudden weight gain, fluid retention/edema, and/orshortness of breath occur.

[ ] Written Medication Information given[ ] Phone numbers of physician/nurse given



Injection/Medication (Pediatric Infusion)Nursing Note, Vr. 2.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

2/28/06 M. Wlodyga 3/2/06 Tori Niu 6/5/08 D. BrownC. Davies

INJECTION/MEDICATION (PEDIATRIC INFUSION) NURSING NOTE, Vr. 2.0

REASON FOR NURSING ENCOUNTER: ASSESSMENT: SUBJECTIVE:[ ] Side effects from previous administration of Medication:

OBJECTIVE:Weight: Height: Allergies:

NURSING IMPRESSION:

INTERVENTIONS DURING ENCOUNTER: A time-out was completed verifying correct patient,procedure, site, positioning, and implant(s) or specialequipment.[ ] Medication/Dose: [ ] Site: [ ] Patient tolerated procedure in manner appropriate to age.

DISPOSITION OF CARE: Next Injection due:


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PATIENT INSTRUCTION:[ ] Common side effects and their management reviewed withParent/Patient[ ] Patient advised to call Provider with question, concerns, orchange in symptoms.[ ] Other (specify):



Intravenous Infusion Nursing Note, Vr. 1.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

3/15/06 M. Brancheau 3/15/06 K Ford 6/5/08 D. BrownC. Davies

INTRAVENOUS INFUSION NURSING NOTE, Vr. 1.0

A time-out was completed verifying correct patient,

procedure and site for IV placement.

gauge angiocath started in , with brisk flow ofblood returned. ml of fluid infused over hours without complications. Infusion Start Time: FinishTime: IV discontinued.

Any IV medications given are recorded on the PSL. Vital Signstaken are documented in Continuity.

DISPOSITION OF CARE:[ ] Home[ ] Hospital


[ ] Patient advised to Call Provider with Questions, Concerns, orChange in Symptoms.


Lupron Depot Nursing Note, Vr. 2.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

8/17/2007 Y. Small 8/17/2007 H. Rodriguez 6/5/08LUPRON DEPOT NURSING NOTE, Vr. 2.0

Date of provider order:

History:Indication for Lupron Depot:[ ] Fibroids[ ] Bleeding / Anemia[ ] Endometriosis[ ] Postpone Puberty[ ] Prostate Cancer[ ] Other (specify):


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Date of most recent injection: [ ] Medication brought to clinic by Patient.Vital Signs: Weight: Blood Pressure: Pulse:

ASSESSMENT:[ ] No Unusual Findings[ ] Sharp chest pain, sudden SOB or hemoptysis[ ] Sudden severe headache, vomiting, fainting or dizziness[ ] Visual changes[ ] Difficulty with speech[ ] Extremity weakness or numbness[ ] Severe pain or swelling in the calf[ ] Unusually heavy bleeding[ ] Severe pain or tenderness in lower abdominal area[ ] Persistent pain, pus or bleeding at the injection site[ ] Other (specify):

NURSING IMPRESSION:

DISPOSITION OF CARE:[ ] Lupron Depot mg. Route and recorded inPSLLocation given:Lot#: Exp date: Next injection due: [ ] Patient given appointment information.[ ] Follow-up appointment with provider [ ] Patient verbali zed understanding and agrees to plan.

Patient Instruction:[ ] Review of side effects and risk of Lupron Depot. (Hotflashes, uncomfortable intercourse, osteoporosis, peripheral

edema, decreased libido)[ ] Patient provided with written information on Lup ron Depot[ ] From manufacturer[ ] Micromedex

[ ] Patient verbalized understanding of treatment and agrees toplan.

The patient was advised to call clinic if he/she had anyquestions, concerns or problems. He/she was given the pagingoperatornumber if questions, concerns or problems during after hours,weekend or holidays.


Methotrexate Injection Nurse Visit Note, Vr.1.0

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RevisedDate:

RevisedBy:

10/7/08 D. Czarnota 10/7/08 D. KowalczykMethotrexate Injection Nurse Visit Note, Vr. 1.0


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INTERVENTIONS DURING ENCOUNTER:Vital Signs:Weight: Blood pressure: Pulse:

[ ] HOLD parameters reviewed and the following labs are withinadministration limits:[ ] BHCG[ ] CBCP[ ] Creatinine[ ] LFTs[ ] RHA

[ ] A time-out was completed verifying correct patient andprocedure

[ ] Medication double check performed by signerand RN per UMHS policy.

[ ] Methotrexate mg administered intramuscularly using

two syringesSite(s):[ ] Left gluteus maximus[ ] Right gluteus maximus[ ] Left vastuslateralis[ ] Right vastuslateralis[ ] Other

DISPOSITION OF CARE AT DISCHARGE FROM VISIT:[ ] Labs to be drawn on and [ ] Requisitions given to patient to hand carry to lab.[ ] Follow up appointment with provider given[ ] Patient advised to call with questions, conc erns orchange in symptoms

PATIENT INSTRUCTION[ ] Patient instruction materials on Methotrexate provided andreviewed with the patient[ ] Patient able to state reason for methotrexateadministration, side effects and management,and follow up plan. Pa tient agrees with plan. Related URL orReferences:

Newborn Weight Check Visit Vr. 2.0 Back to Top

Creation

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NEWBORN WEIGHT CHECK VISIT Vr. 2.0

Patient returns today for check of weight and feeding per order

of .


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The newborn is fed [] Breast Milk [] formula, < ____> times a day,

with < ____> minutes or ounces at each feeding.

[ ] Yes [ ] No The newborn is stooling several times a day and

making at least one wet diaper every 6 hours. If no, RN or

provider notified:

The newborn weighed at bi rth and at the last visit

on .

Today the weight is .

[ ] Yes [ ] No The infant is pink, active and has a strong cry.

IMPRESSION: Failure to gain weight

DISPOSITION (Choose one):

[ ] The newborn has regained b irth weight and will be seen at the

2 month well child exam.

[ ] The newborn has gained 20 -30 grams/day since the last weight

check but is not yet at birth weight and will be scheduled for areturn visit in 4-7 days.

[ ] The newborn has not gained adequate weight and a physician

was asked to see the infant today.

PARENT INSTRUCTION:

The parent was given instructional information in feeding the

newborn from the on -line patient advisor resource:

For Breast-fed newborns: How Do I Know My Baby Is Getting Eno ugh

Milk? http://www.med.umich.edu/1libr/pa/pa_howdoikn_hhg.htm

or

For Bottle-fed newborns: Formula (Bottle) Feeding.

http://www.med.umich.edu/1libr/pa/pa_formula_hhg.htm

Name and title:

Related URL or

References:Breast-fed: http://www.med.umich.edu/1libr/pa/pa_howdoikn_hhg.htm

Bottle-fed: http://www.med.umich.edu/1libr/pa/pa_formula_hhg.htm

Nurse Visit Note, Vr. 2.0 Back to Top

Creation

Date:

Created

By:

Approved

Date:

Approved

By:

Revised

Date:

Revised

By:6/30/2004 C. Laughlin 6/30/2004 R. Whitehouse 6/5/08 D. BrownC. Davies

NURSE VISIT NOTE, Vr. 2.0

REASON FOR NURSING ENCOUNTER:


OBJECTIVE:


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NURSING IMPRESSION:

PLAN:

INTERVENTIONS DURING ENCOUNTER:

PATIENT EDUCATION/INSTRUCTION: Patient restates plan and agrees with the plan of care.

DISPOSITION OF CARE AT DISCHARGE FROM VISIT:[ ] Advice per protocol specify: [ ] Appointment advised[ ] Appointment made date: [ ] Emergency Room advised Facility:[ ] Provider consulted, recommendations:[ ] Patient advised to call with questions, concerns, or changein symptoms[ ] Other (specify):

Provider follow -up action requested[ ] Contact patient

[ ] Advise/prescribe:ALLERGIES: [ ] Review and sign[ ] Other (specify):

Related URL or

References:

Nursing Note (Pediatric Infusion),Vr. 2.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:


NURSING NOTE (PEDIATRIC INFUSION), Vr. 2.0

PRE INFUSION ASSESSMENT:SUBJECTIVE: Medication Response since last visit:

OBJECTIVE:Weight: Height: Body Surface Area (BSA) :

Allergies:

DIAGNOSIS:

INFUSION: A time-out was completed verifying correct patient,procedure, site, positioning, and implant( s) or specialequipment.[ ] Heplock placed: [ ] Premeds RequiredPremeds/dose: [ ] Access Type and location: Infusion Start Time: Finish Time:


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Vital Signs: Intake: Output:

OUTCOME:[ ] Infusion Tolerated[ ] Infusion NOT tolerated (Explain): [ ] Completed Infusion

[ ] Infusion Not Completed (Explain): [ ] Other (Specify):

DISPOSITION OF CARE:[ ] Next Infusion Appointment: [ ] Discharge Home[ ] Discharged to Hospital[ ] Other (Specify):

PLAN/INTERVENTIONS:[ ] Provider Consulted, Recommendations: [ ] Other specify:

PATIENT INSTRUCTION:[ ] Infusion protocol reviewed Family and Patient

[ ] Common side effects and their management reviewedFamily/Patient[ ] Monitor for side effects.[ ] Patient advised to Call Provider with Questions, Concerns, orChange in Symptoms[ ] Other (Specify):



Pediatric Blood Pressure Check, Vr. 2.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:



PEDIATRIC BLOOD PRES SURE (BP) CHECK, Vr. 2.0

Patient returns today for blood pressure (BP) check per order ofDiagnosis: Elevated blood pressure

The patients BP was measured today using [ ] Manual [ ]ElectronicA size cuff was used on the patients [ ] Left [ ] Right[ ] Arm [ ] Leg

BP: P: A size cuff was used on the patients [ ] Left [ ] Right[ ] Arm [ ] Leg

DISPOSITION:[ ] The patients blood pressure was normal for age today andthis will be reported to the requesting physician.[ ] The patients blood pressure was > 95% for age and a


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physician was asked to review today.

Name/Title:


Procedure (Pediatric Infusion) Nursing Note,Vr 2.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:


PROCEDURE (PEDIATRIC INFUSION) NURSING NOTE, Vr. 2.0

PROCEDURE:

ASSESSMENTSUBJECTIVE:

OBJECTIVE: Weight: Height:

ALLERGIES:

INTERVENTIONS TODAY: A time-out was completed verifying correct patient,procedure, site, positioning, and implant(s) or specialequipment.

OUTCOME:[ ] Procedure completed [ ] YES [ ] NO

If no, explain: [ ] Patient tolerated Procedure age appropriate[ ] Other (specify):

PATIENT/FAMILY INSTRUCTION:[ ] Procedure explained to Family and Patient[ ] Post Procedure Instructions given to patient /family.[ ] Patient/Family restates instructions and agrees to plan.

DISPOSITION OF CARE:[ ] Provider consulted, recommendations:[ ] Patient advised to call provider with questions, concerns, orchange in symptoms.[ ] Other (specify):


Remicade Infusion Nursing Note, Vr. 3.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

11/7/08 E. Edwardst 11/17/08 D. Kowalczykz 6/5/08 D. BrownC. Davies


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REMICADE INFUSION NURSING NOTE, Vr. 3.0

REASON FOR NURSING ENCOUNTER: Remicade infusion.


OBJECTIVE: Alert and oriented to time, place and person. Skin iswarm, dry and pink.

NURSING IMPRESSION:

PLAN: Remicade infusion every weeks per order of

INTERVENTIONS DURING ENCOUNTER:Premeds: Initial vital signs:Blood pressure , Pulse

gauge angio started in with brisk flow of bloodreturned. Remicade mg in 250 mL normal saline infused over2 hours.

LOT #: Expiration date:

Observed for 30 minutes post Remicade infusion. 250 mL normalsaline flush infused during observation.Final vital signs are: . Additional vital signs incontinuity.Total volume infused: [ ] Complications noted (specify):[ ] Labs drawn

[ ] Instructed About Resources or Number To Call With OngoingQuestion.


Remicade (Infliximab) Current Prescribing Information,Comprehensive Nursing Approach to Infliiximab InfusionTherapy,Journal of Infusion Nursing, vol. 26, Nov./Dec. 2003

Scheduling Request to East Ann Arbor InfusionCenter, Vr. 2.0

Back to Top

Created By / Date: Approved By / Date Revised By / Date: RecommendedDoc Type

M. Cano 11/2010 T. Jackson (HIM)/ 12/2010M. Cano/ 12/2010

T. Jackson (HIM)M. Cano/ 06/2011

SCHEDULING REQUEST TO EAST ANN ARBOR INFUSION CENTER, Vr. 2.0 Date: Main Diagnosis: ICD-9 Code: Ordering Provider Name: Provider Number and/or Pager Number: :

Backup Provider Coverage: (Physician to contact if orderingprovider is unavailable): Name: , Provider Number: Backup Coverage for GI: Ordering physician. If not available,page . If not available, then page GI consult fellow.Backup Coverage for Rheumatology: Ordering physician then


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Rheumatology fellow on -call.

Medication Ordered:Dose(s) :Frequency:

Has the patient ever received this medication before?

[ ] No [ ] Yes

If Yes, did patient experience any reaction?[ ] No [ ] Yes

If Yes, was the reaction: [ ] Mild [ ] Moderate [ ] Severe

Is a Port or PICC Line Present? [ ] No [ ] Yes

Mobility: [ ] Ambulatory [ ] Wheelchair Bound [ ] StretcherBound

If a patient has a physical or mental impairment, confirm acaregiver will accompany the patient? [ ] Confirmed Specifydate and caregiver name:

Will lift equipment be needed to assist patient intransferring?[ ] No [ ] Yes

Does the patient reside i n a care facility or requiresupervision?[ ] No [ ] Yes

Does the patient use supplemental oxygen?[ ] No [ ] Yes

Does the patient require any contact precautions?[ ] No [ ] Yes

If the patient requires an interpreter, indicate language :

Additional Medical Conditions not addressed above :


Sore Throat and Positive Strep ProtocolAdult Nursing Note, Vr. 1.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

3/30/09 Pam Szymanski 4/22/094/23/09 B. Myers HIMPro FeeSORE THROAT AND POSI TIVE STREP PROTOCOL ADULT NURSING NOTE, Vr1.0

ASSESSMENT[ ] Positive strep culture[ ] sore throat[ ] fever[ ] swollen glands


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[ ] Recent exposure to strep:

ALLERGIES:

NURSING IMPRESSION:[ ] Strep Throat[ ] Sore Throat

DISPOSITION OF CARE:[ ] RN advises antibiotic treatment according to UMHS PositiveStrep Throat protocol.If not allergic to Penicillin:[ ] Rx. Pen VK 500 mg. BID x 10 days

If unable to tolerate Pen VK:[ ] Rx Amoxicillin 1,000 mg. BID x 6 days.

If allergic to Penicillin:[ ] Erythromycin 333mg. TID x 10 days

[ ] If allergic to Penicillin and Erythromycin,consult Provider:

[ ] Faxed/Called to Pharmacy: [ ] Patient to pick up prescription[ ] Comfort measures

[ ] Patient does meet criteria for Sore Throat Telephone Protocol[ ] Comfort measuresPer Patient Preference:[ ] Acetaminophen 320 mg. every 6 -8 hoursor[ ] Ibuprofen 400 mg. every 6 -8 hours

PATIENT INSTRUCTION[ ] Avoid close contact with other people until you have been

taking antibiotic for 24 -48 hours so they will not be exposed tostreptococcal bacteria.

[ ] Comfort measures as follows: increase fluids, vaporizer, saltwater gargle, throat lozenges, avoid smoke, rest

[ ] Hand washing is the best prevention against spreadinginfections.

[ ] Patient instructed to complete all of prescribed treatment toensure prevention or rheumatic fever. If sor e throat recurs,patient should be seen and re -evaluated. If generalized rash orhives develop stop medication and notify clinic.

[ ] Patient restates plan and agrees to above plan. [ ] Yes, [ ]No; If no, explain:

[ ] Provider action requested[ ] None[ ] Contact Patient[ ] Advise/Prescribe



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Seizure Pediatric Nursing Assessment, Vr. 2.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

4/30/07 H. Murrel 4/30/07 D. Kowalczyk 6/5/08 D. BrownC. Davies

SEIZURE PEDIATRIC NURSING ASSESSMENT, Vr. 2.0

Return visit: Current seizure meds:[ ] Missed doses (specify medication) : When [ ]Adverse effects: description

DESCRIPTION OF SEIZURE ACTIVITY (ASSESSMENT):Seizure frequency: Duration of seizure activity: [ ] Concurrent illness(describe): Febrile [ ][ ] Typical seizure for this child. See CareWeb note dated:

PRIOR TO SEIZURE[ ] Cried out[ ] Jerking of arms[ ] Right [ ]Left[ ] Legs[ ] Right [ ] Left[ ] Confusion[ ] Headache[ ] Emesis[ ] Disturbed/behavior[ ] Other (specify): [ ] None of above

DURING SEIZURE[ ] Fell

[ ] Eyes turned [ ] Upward [ ] Right [ ]Left[ ] Body rigid [ ] Rhythmic Body Jerking[ ] Unconscious[ ] Cyanosis[ ] Emesis[ ] Response to stimuli present: (specify)[ ] Other (specify): [ ] None of above

POSTICTAL[ ] Soiled[ ] Urinated[ ] Bitten tongue[ ] Became confused

[ ] Need to Sleep. Duration [ ] Headache Afterwards[ ] Any injuries[ ] None of above

Duration of Seizure

Additional information:

NURSING IMPRESSION:


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Plan:[ ] Review with Physician[ ] Increase to: [ ] Decrease to: [ ] Start new medication [ ] Medication changes sent to pharmacy: Phone fax [ ] Labs repeat (specify):

[ ] day(s) [ ]week(s) [ ] month(s)

PATIENT EDUCATION:Drug information and dosing instructions[ ] Discussed[ ] Mailed copy [ ] date Seizure Emergency Care and Safety Issues Handout[ ] discussed [ ]Mailed date [ ] Emergency contact after office hours given[ ] Caregiver aware of plan and verbali zes understanding ofinstructions and agrees to plan.


Suture/Staple Removal, Vr. 3.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:



SUTURE/STAPLE REMOVAL, Vr. 3.0

This pt. returns today to have [ ] sutures [ ] staples removedper order of

[ ] Physician at an outside urgent center where the lacerationwas closed. Clinic provider consulted Name:

[ ] Physician at this facility Name:

The sutures/staples were placed days ago.

[ ] Yes [ ] No The patient states he/she is having pain ordrainage atthe wound site.If yes, RN or provider notified:

[ ] Yes [ ] No Wound is dry and edges of wound are togetherIf no, RN or provider notified:

[ ] Yes [ ] No Sutures /staples removed

Number removed:

Site(s): Appearance of wound: [ ] Steri-strips applied[ ] Dressing applied

Other:

Patient tolerated the procedure well. Signs and symptoms ofinfection reviewed per patient handout and patient instructedwhen to call clinic.


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Name/Title:


Travel Clinic Nursing Assessment, Vr. 2.0Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

3/15/06 S. Olsson 3/15/06 D. Kowalczyk 6/5/08 D. BrownC. Davies

TRAVEL CLINIC NURSING NOTE, Vr. 2.0

Daytime Phone (Home) #: Alternate Phone (Contact) #: Insurance:

DRUG ALLERGIES:

DESTINATION:

DEPARTURE DATE: DURATION OF TRIP:

PURPOSE OF TRIP:[ ] Missionary, School[ ] Vacation[ ] Adoption[ ] Agricultural[ ] Other

ACCOMMODATIONS:[ ] Camping[ ] Dormitory[ ] Hostel

[ ] Hotel[ ] Private Home[ ] Other (specify):

VACCINES GIVEN (See Immunization Record):[ ] Hepatitis A [ ]adult [ ]pediatric(1 -19 years old)[ ] Hepatitis B [ ]adul t [ ]pediatric(1-18 years old)[ ] IPV[ ] Japanese Encephalitis[ ] MMR[ ] MENINGOCOCCAL [ ] Medimmune [ ] Menactra (11 -55 years-old)[ ] Rabies[ ] Td [] Tdap[ ] Typhoid [ ] parenteral [ ] oral[ ] Varicella

[ ] Yellow Fever

NURSING IMPRESSION:

PRESCRIPTIONS GIVEN[ ] Rifaximin 200 mg. po TID x 3 days #9[ ] Ciprofloxacin HCL 500 mg. PO BID x 3 -5 days #10[ ] Azithromycin 500 mg. po daily x 3 days #3

[ ] Acetazolamide (Diamox) 250 mg. PO BID 24 hours prior to


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ascent, continue for 4 8 hours after.

ANTIMALARIALS[ ] Chloroquine Phosphate (Aralen) 500 mg. Take one tabletweekly. Begin one week before travel and continue until 4 weeksafter travel to malarious areas.[ ] Malarone (Atovaquone 250 mg. /Proguanil 100 mg.) Take one

tablet daily, starting one day before entering malarious areas.Continue until 7 days after leaving such areas.[ ] Doxycycline 100 mg. Begin 1 day prior to travel. Take onetablet daily and continue four weeks after return from malariousarea.[ ] Mefloquine (Larium) 250 mg Take one tablet weekly. Start oneweek before travel; continue during travel in malarious areas andfor 4 weeks after leaving such areas.

PATIENT INSTRUCTIONS[ ] Food and water precautions[ ] Mosquito avoidance[ ] Safety issues: (S un exposure, Crime, STD, HIV)[ ] Verbalized understanding, advised to call back withquestions, concerns, or vaccine reaction symptoms.

[ ] Appointment advised[ ] Patient advised to follow -up with primary care physician forcompletion of hepatitis A/B series.


Tuberculosis (TB) Screening Tool Nursing Note, Vr.1.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

4/10/09 Sue Olsson 4/27/09No response

HIM

BillingTUBERCULOSIS (TB) SCREENING TOOL NURSING NOTE, Vr. 1.0

REASON FOR CALL/VISIT:Patient has positive TB test

ASSESSMENT:Date of TB Test: Size of Induration:

CHEST X-RAYDate: Results:

CURRENT TB MEDICATIONS[ ] OralName of medication:Strength: Length of treatment:

SYMPTOMS[ ] Cough[ ] Fever[ ] Night sweats[ ] Fatigue


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[ ] Other:

ADDITIONAL INFORMATION:[ ] History of BCG vaccination or treatment[ ] Known exposure to someone with TB: [ ] Foreign-born or extensive travel to countries withendemic TB:

[ ] Immune-compromised: [ ] Other risk factors (Homelessness, Intravenous DrugAbuser, Incarceration):

NURSING IMPRESSION: TB Exposure

DISPOSITION:[ ] Advised to schedule appointment with Primary CarePhysician[ ] Appointment scheduled Date: [ ] Caller advised to call back with questions,concerns, or change in symptoms.[ ] Patient instructed to obtain a mask before comingtoclinic.


Urgent Care Cancer Center Nursing TriageNote, Vr. 3.0

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CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

11/06 A. Farless 11/6 T. Niu 6/5/08 D. BrownC. Davies

URGENT CARE CANCER C ENTER NURSING TRIAGE NOTE, Vr 3.0

Contact Phone Number: Diagnosis: Most recent Treatment (chemo, blood products, etc): < ____>Date of Last Treatment: Primary Provider Name and Contact Number:

ASSESSMENT:Chief Complaint:Quality/severity (Pain Scale, if appropriate): Onset: Duration: Modifying factor(s): Associated signs and symptoms: Comments:

NURSING ASSESSMENT:

PRESUMED DIAGNOSIS:

DIAGNOSTIC TEST(S):Laboratory:[ ] Complete Blood Count, Differential, Platelets (CDP)[ ] Basic[ ] Comprehensive Chemistry[ ] LDH


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[ ] Magnesium[ ] Lipase[ ] Amylase[ ] Protime (PT)[ ] PTT[ ] Blood Cultures[ ] Urinalysis (UA)

[ ] Urine Culture and Sensitivity (C&S)[ ] Other (Specify):

Radiology:[ ] CXR PA/Lateral[ ] CXR PA/Lateral, Decubitus[ ] Abdominal X-ray, flat/upright[ ] Acute Abdominal Serial X-ray[ ] Abdominal Ultrasound[ ] CT Scan/specify:[ ] Doppler[ ] Other (Specify):

PLAN:Appointment Time Requested :

[ ] 1300[ ] 1500[ ] Other (Specify):

Action Requested:[ ] Urgent Care will contact patient[ ] Urgent Care will schedule labs, test(s)[ ] Clinic will contact patient[ ] Clinic will schedule test(s)

Comments:

Disposition:Appointment Date:

Appointment Time:


Urinary Tract Infection (UTI), Non-PregnantAdult, Vr. 5.0

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CreatedBy/CreationDate: ApprovedBy/ApprovedDate: RevisedBy/RevisedDate:

C. Laughlin/4/29/2005 M. Kiss, K. Ford,E. Patrick-Dunlavey/4/29/2005

D. Brown, C. Davies/6/5/08 and12/13/10E. Patrick-Dunlavey (FGP), J. Pund,

PPC, T. Jackson (HIM)/

04/19/2011

URINARY TRACT INFECTION (UTI), NON -PREGNANT ADULT, Vr.5.0

ASSESSMENT:[ ] History of uncomplicated Urinary Tract Infection (UTI) withsimilar symptoms.If no, recommend physician appointmentIf yes, then date of last UTI:

Lower Tract Symptoms:[ ] dysuria[ ] urinary frequency


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[ ] urinary urgency

[ ] Symptoms of pyelonephritis: If any of these, recommend sameday appointment:[ ] flank or back pain[ ] fever[ ] nausea or vomiting

[ ] Pain (details):

[ ] Symptoms of vaginitis: If any of t hese, refer to adultvaginitis protocol:[ ] vaginal discharge[ ] itching[ ] external burning[ ] Other (specify):

HISTORY:Complicating Factors: If any of these, recommend same dayappointment[ ] Pregnancy[ ] Transplant[ ] Diabetic

[ ] Systemic steroid use[ ] Recent hospitalization[ ] Nursing home resident[ ] Chronic renal or urologic disease[ ] Other (specify):

[ ] Three or more UTI in the past 12 months. If yes, offer phonetriage nurse management AND schedule office visit in near futureto discuss management.

NURSING IMPRESSION: URINARY TRACT INFECTION

MEDICATION ALLERGIES:

Describe:

DISPOSITION OF CARE:If patient. meets criteria for phone treatment of urinarysymptoms, offer phone triage nurse management. If patient prefersoffice visit, schedule visit same day.[ ] The nurse advises phone treatment as follows:[ ] Bactrim DS (Sulfamethoxazole/Trimethoprim) 1 tab twice a dayfor 3 days, if no Sulfa allergy, or Macrobid (Nitrofuranto in) 100mg BID for 5-7 days[ ] Ciprofloxin 250 mg twice a day for 3 days (not in pregnantwomen)[ ] Macrobid 100 mg twice a day for 7 days[ ] Amoxicillin 500 mg three times a day for 7 days

To relieve discomfort, offer[ ] Pyridium 100 mg three times a day #10 no refills, prndiscomfort

[ ] Faxed/called to pharmacy:[ ] Patient to pick up prescription

PATIENT INSTRUCTION GIVEN:Call office if:1. Symptoms persist or worsen after 48 hrs


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2. Fever, vomiting or rash develop3. Symptoms recur after medica tion is finished

If using Pyridium, inform patient that urine and tears turnorange (risk of staining soft contact lenses).

Strategies for prevention of UTI per nursing protocol: urinate

after intercourse, drink plenty of fluids

[ ] Patient verbalized u nderstanding, states plan and agrees toabove plan.If No, explain:

PROVIDER ACTION REQU ESTED:[ ] None[ ] Contact patient[ ] Advise/prescribe


Work/School Excuse Note, Vr. 3.0 Back to TopCreation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:7/24/06 P. Szymanski 7/24/06 T. Niu 6/5/08 D. Brown

C. DaviesWORK / SCHOOL EXCUSE NOTE, Vr. 3.0

University of Michigan Healthcare System

WORK /SCHOOL EXCUSE NOTE

Health Center:

FIRST DAY UNABLE TO WORK OR ATTEND SCHOOL:

RETURN TO WORK / SCHOOL DATE:

ILLNESS / INJURY RELATED TO WORK / SCHOOL: YesNo

RESTRICTIONS:

SIGNATURE:



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ABNORMAL LAB TEST


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Abnormal Lab-Hematocrit (HCT) OBResults Management Note, Vr. 2.0

Back to Top

Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

10/1/2007 Mary Wieszczyk and

Barb Getty

10/1/2007 H. Rodriguez 6/5/08 D. Brown

C. Davies

ABNORMAL LAB-HEMATOCRIT (HCT) OB - RESULTS MANAGEMENT NOTE, Vr

2.0

ASSESSMENT

Gravida: Para:

Last Menstrual Period:

Estimated Date of Delivery:

Allergies:

Maternal illness/complications:

ABNORMAL LAB

[ ] HCT:

NURSING IMPRESSION: Abnormal Hematocrit Result

PLAN: PER UMHS Abnormal OB Laboratory Results Protocol, HCT

section

[ ] Patient notified of HCT value and pre scribed treatment

[ ] Treat with Ferrous Sulfate 325mg

[ ] For HCT 32-35, take one tablet daily

[ ] For HCT 30-32, take one tablet, twice daily

[ ] For HCT


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PROCEDURE TEMPLATE


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Internal Medicine Procedure Templates

Code Note, Vr. 1.0

Procedure Note: Arterial Blood Gas, Vr. 1.0

Procedure Note: Arterial Line Placement, Vr. 3.0

Procedure Note: Central Line, Vr 1.0

Procedure Note: Intubation, Vr. 1.0

Procedure Note: Lumbar Puncture,,Vr. 1.0

Procedure Note: Patency Capsule, Vr. 1.0

Procedure Note: Paracentesis, Vr. 1.0

Procedure Note: Thoracentesis, Vr. 1.0

Code Note, Vr. 1.0 Back to Top

Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

9/7/2010 B Stein 5/21/2007 M KissK Ford

CODE NOTE, Vr 1.0

Called to patients bedside via code blue pager.

Patient with past medical history significant for

evaluated and found to have condition.

.

PROCEDURES PERFORMED:

Intubation:

CPR:

Access Placement: ABG:

Arterial Line:

Post Code Status:

Related URL or

References:


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Procedure Note: Arterial Blood Gas, Vr. 1.0 Back to Top

Creation

Date:Created

By:Approved

Date:Approved

By:Revised

Date:Revised

By:

9/7/2010 B Stein 5/21/2007 M KissK Ford 9/7/2010 T. Jackson (HIM)

PROCEDURE NOTE: ARTERIAL BLOOD GAS, Vr. 1.0


procedure, site, positioning, and implant(s) or special equipment

if applicable.

Allens test was performed to ensure adequate perfusion.

Patients rightleft wrist was prepped and draped in usual

sterile fashion. Lidocaine was not used to anesthetize the

area. A gage needle was introduced into the artery with

appropriate blood return. Estimated blood loss was


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was threaded over the guide wire and the needle was removed with

appropriate pulsatile blood return. Blood loss was minimal. The

catheter was then sutured in place to the skin and a sterile

dressing applied. Perfusion to the extremity distal to the point

of the catheter insertion was checked and found to be adequate.

Estimated Blood Loss :

Patient tolerated the procedure


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K Ford

PROCEDURE NOTE: INTUBATION, Vr. 1.0


procedure, site, positioning, and implant(s) or special equipment

if applicable.

Patient was evaluated and required intubation for .

The patient was prepared in the usual fashion and a French

endotrachial tube was placed under direct visualization to

inches at the teeth. Bilateral breath sounds were heard without

air sounds in the abdomen. An end -tital Co2 monitor was used to

confirm tracheal placement of the ET tube. Estimated blood loss

was .

Sedation/Paralyzation:

Chest xray was ordered to assess for pneumothorax andendotracheal tube placement.

Patient tolerated the proc edure


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Sent for:


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if applicable

Ultrasound guidance wasnot used and appropriate fluid

pocket was identified.

Patient positioned, prepped and draped in usual sterile fashion.

1% Lidocaine wasnot used to anesthetize the area.

A gage needleangi ocath was introduced into the

peritoneal space and fluid was removed. Blood loss was


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complications.

Related URL or

References:


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PROCEDURE TEMPLATE


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Nursing Discharge Note, Vr. 1.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

2/28/06 J. Shlafer 3/2/06 Tori NiuNURSING DISCHARGE NOTE, Vr. 1.0

SUBJECTIVE:

OBJECTIVE: Pt discharged at , with , to:[] Home Health Care with Services[] Home Self Care[] Extended Care Facility[] Acute Care Facility

Temperature: Heart Rate: Blood pressure: O2 Sat (if applicable): Weight:

1. Nursing Diagnosis: Analysis: Plan:



4. Nursing Diagnosis: Analysis:

Plan:



Nursing Event Note, Vr. 1.0 Back to Top

CreationDate: CreatedBy: ApprovedDate: ApprovedBy: RevisedDate: RevisedBy:2/28/06 J. Shlafer 3/2/06 Tori Niu

NURSING EVENT NOTE, Vr. 1.0

EVENT:

SUBJECTIVE:

OBJECTIVE:


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ANALYSIS:

PLAN:

Related URL or

References:

Nursing Event Note Blood, Vr. 2.0 Back to Top

CreationDate:

CreatedBy:

ApprovedDate:

ApprovedBy:

RevisedDate:

RevisedBy:

10/06 J. Shalfer 10/06 T. Niu 7/1/09 D. WillisB. Myers HIM

NURSING EVENT NOTE BLOOD, Vr. 2.0

SUBJECTIVE:

[ ] no complaints related to transfusion[ ] complained of

OBJECTIVE:

Type of Blood Product Administered:Also see Transfusion Record and eMAR[ ] PRBC: # of units: < ____>[ ] Platelets: # of 5 packs: [ ] FFP: # of units: [ ] Other (Specify type and # of units):

Premedications Given:[ ] Tylenol see eMAR

[ ] Benadryl see eMAR[ ] None ordered[ ] Other:

Patient and/or Family Instructe d re:[ ] Rationale for transfusion[ ] Signs/symptoms of potential reaction and to notifynurse[ ] Post-Transfusion Instructions handout provided/reviewed;instructed to notify primary care provider if symptomsdevelop following dischargehttp://www.pathology.med.umich.edu/bloodbank/POD0271PostTransfusionInstructions109.pdf [ ] No instruction given due to:[ ] Confused[ ] Comatose[ ] Previously instructed[ ] Other (specify):

Patient Observation:[ ] Vital signs stable throughout see [ ] TransfusionRecord or [ ] Flowsheet[ ] No adverse signs/symptoms noted (e.g. chest pain,SOB, fever, chills, diaphoresis, hives, rash, pruritus)


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[ ] Noted Signs/Symptoms of . Treatment/follow -updone: [ ] Other (Specify):

ANALYSIS:[ ] Patient tolerated transfusion w/o complication[ ] Possible reaction noted Dr. aware (primary

team); Blood Bank following[ ] Unable to com

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