Chest pain/dyspnea Approximate ambient air temperature Nausea/vomiting Estimate exposure time Headache/mental status Type of environment (inside, outside, wet) Neuro Assessment Loss of consciousness Treatments/Reassessments Fluid intake Report given and signature of RN Skin turgor/condition ETOH/Substance abuse Treatments/reassessments Report and signature of RN INHALATION INJURY GAS/SMOKE) POISONING/DRUG INGESTION Type of gas Name of substance Duration of exposure Amount Area of exposure (enclosed room) Route of intake Heated environment How long ago Burns/singing (oral, nasal, facial area) Vomiting since ingestion as appropriate Treatments/reassessments Intentional vs. Unintentional Report given and signature of RN ETOH/substance use Oral mucosa burns if appropriate Treatments/reassessments Report given and signature of RN PREGNANCY/OB DELIVERY REFUSALS Separate report required for mother and each delivery Documentation of: Non-Delivery Competency Abdominal Pain MMSE Gravida/Para/Abortion Lack of Trauma Length of gestation/estimated due date Situation Edema (pedal)/BP/Headache/Visual Ability to make good decisions Disturbance Safety of patient is assured by caretakers, Vaginal bleeding/discharge if yes, family, etc. – describe Treatments/reassessments Report given and signature of RN Last time movement Delivery SEIZURES Multiple fetuses OPQRST and SAMPLE as appropriate Mucous plug resented Obvious injures (mouth, head, tongue) Membranes ruptured if yes, is amniotic Duration and number of events – clear? Incontinence Crowning as appropriate Level of consciousness (postictal) Treatments/reassessments Report given and signature of RN NEONATE STROKE/CVA/TIA Time of OPQRST and SAMPLE as appropriate Thoroughly dried and warmed Onset and duration of symptoms Oral and nasal suctioning Headache/Vision disturbances
Chest pain/dyspnea Nausea/vomiting Headache/mental status Neuro Assessment Treatments/Reassessments Report given and signature of RN Approximate ambient air temperature Estimate exposure time Type of environment (inside, outside, wet) Loss of consciousness Fluid intake Skin turgor/condition ETOH/Substance abuse Treatments/reassessments Report and signature of RN INHALATION INJURY GAS/SMOKE) Type of gas Duration of exposure Area of exposure (enclosed room) Heated environment Burns/singing (oral, nasal, facial area) Treatments/reassessments Report given and signature of RN POISONING/DRUG INGESTION Name of substance Amount Route of intake How long ago Vomiting since ingestion as appropriate Intentional vs. Unintentional ETOH/substance use Oral mucosa burns if appropriate Treatments/reassessments Report given and signature of RN PREGNANCY/OB DELIVERY Separate report required for mother and each delivery Non-Delivery Abdominal Pain Gravida/Para/Abortion Length of gestation/estimated due date Edema (pedal)/BP/Headache/Visual Disturbance Vaginal bleeding/discharge – if yes, describe Treatments/reassessments Report given and signature of RN Last time movement REFUSALS Documentation of: Competency MMSE Lack of Trauma Situation Ability to make good decisions Safety of patient is assured by caretakers, family, etc. Delivery Multiple fetuses Mucous plug resented Membranes ruptured – if yes, is amniotic clear? Crowning as appropriate SEIZURES OPQRST and SAMPLE as appropriate Obvious injures (mouth, head, tongue) Duration and number of events Incontinence Level of consciousness (postictal) Treatments/reassessments Report given and signature of RN NEONATE Time of Thoroughly dried and warmed Oral and nasal suctioning STROKE/CVA/TIA OPQRST and SAMPLE as appropriate Onset and duration of symptoms Headache/Vision disturbances
TN-Protocol-07282016.docx