Kardex Finlay Watson DOB 15/06/1967
Shift Report
| Shift | Neuro | Cardio | Resp | GI | GU | Skin | Wound | Nutrition | In/Out |
| Day shift (2 days ago) | GCS 15 | Tele NSR | Clear | BSX4 | Urinal qs | Intact | none | Cardiac diet | IV |
| Adequate | |||||||||
| NOTES: | Admitted from ER @ 1830. Able to stand and transfer with no chest pain. Ate supper, wife into visit. | ||||||||
| Understands importance of using call bell if any CP/ Tightness/ SOB. Using urinal for voids. | |||||||||
| Shift | Neuro | Cardio | Resp | GI | GU | Skin | Wound | Nutrition | In/Out |
| Night Shift (2 days ago) | GCS 15 | No CP | Clear | BSX4 | Voids | Intact | None | no concern | IV |
| Adequate | |||||||||
| NOTES: | BP 155/90 pre cardiac meds deceased 125/75. Denies any CP. Slept intermittently. | ||||||||
| Up sitting @ bedside and wlaked to BR x 1 with no issues. | |||||||||
| Shift | Neuro | Cardio | Resp | GI | GU | Skin | Wound | Nutrition | In/Out |
| Day (y’day) | GCS 15 | Tele | Clear | no BM | Voids | no concerns | none | Cardiac | IV |
| Adequate | |||||||||
| NOTES: | Seems a bit anxious today- states he is worried about work. On the phone ++. BP increasing | ||||||||
| this morning but responded to meds. Denies any CP. Asking if he could go home then go for angio. | |||||||||
| Explained risks. Wife in x 1. Ambulating around room/ BR no concerns. | |||||||||
| Shift | Neuro | Cardio | Resp | GI | GU | Skin | Wound | Nutrition | In/Out |
| Night (last) | GCS 15 | Tele | clear | no BM | Voids | no concerns | none | Cardiac | IV X 1 |
| NOTES: | Slept poorly. No chest pain over night. Slept poorly d/t admission @0200, had zopiclone @ HS. | ||||||||
| Up to BR for voids. Wants to have a shower. New IV started to Lt arm. | |||||||||
