Assessing

Here are 's current set of observations to review.

Airway	is aware of her surroundings and is maintaining her own airway.
Breathing	Respiratory rate is 27 bpm, SpO₂ 92% on air. No audible wheeze. Lactate level is 1.8 mmol/L.
Circulation	Heart rate 110 bpm, appears to be in sinus rhythm with ventricular ectopics, pulse feels weak and slightly irregular, BP 87/35, MAP 64, capillary refill time 3 seconds, skin temp cool, temp 38.1°C.
Disability	Pupils size 4 equal and reacting to light. Aware of surroundings, BM 11.5 mmol/L.
Exposure	Examined skin, cool to touch, sacrum no broken skin but red and blanching. Legs look oedematous and red, small blister on right leg.

MEDICINE PRESCRIPTION AND ADMINISTRATION RECORD
WARD Emergency Dept. WARD __________ WARD __________			CONSULTANT ____________________		DATE OF ADMISSION		NAME: AGE: HOSPITAL NUMBER: NHS NUMBER:
Card No 1 of 1		Chart rewritten By _____________ Date ________________________ Pharmacy check By _____________ Date ________________________			Weight _______(kg) Date ____________ Weight _______(kg) Date		NAME: AGE: HOSPITAL NUMBER: NHS NUMBER:
DRUG ALLERGY or ADVERSE EFFECT Medicine/Other Signature				If none know tick box [✔] Effect Date This section must be completed and signed by a prescriber or Pharmacist
ONCE ONLY MEDICINES
Date	Medicine	Dose	Route	Administration Instructions	Time Required	Prescriber's Sig, Print Name & Bleep	Time Given	Given By	Checked By	Pharm
	Tazocin	4.5g	I.V.	Give Immediately	18.00	A.BRN 1234	18.15	JE	AM
	Salbutamol	2.5mg	neb		18.00	A.BRN 1234	18.15	JE	AM
	Atrovent	500mg	neb		18.00	A.BRN 1234	18.15	JE	AM

Patient Details Patient Name: Age: Hospital Number:				FLUID CHART DATE: WARD: Emergency Dept.
INPUT (mLs)						OUTPUT (mLs)
Time	Intravenous fluid	Other (write)	DRUG (write) Noradrenaline	Hourly total	Running total	Urine	Hourly total	Running total	Balance (+ve or -ve)
01:00
...
18:00	500					++ incontinent
19:00	500	30 (tazocin)		1030	1030				+ve 1030
20:00	500, 500			1000	2030				+ve 2030
21:00
22:00
23:00
24:00

Patient Details Patient Name: Age: Hospital Number:				FLUID CHART Part One \| Part Two DATE: WARD: Emergency Dept. PREVIOUS DAY'S BALANCE: +ve 2533
INPUT (mLs)						OUTPUT (mLs)
Time	Intravenous fluid	Other (write)	DRUG (write) Noradrenaline	Hourly total	Running total	Urine	Hourly total	Running total	Balance (+ve or -ve)
01:00	250		10	260	260	30	30	30	+ve 230
02:00	250		10	260	520	35	35	65	+ve 455
03:00	250		10	260	780	40	40	105	+ve 675
04:00	250		10	260	1040	15	15	120	+ve 920
05:00	250	500 Hartman's	10	760	1800	25	25	145	+ve 1655
06:00	250		10	260	2060	30	30	175	+ve 1885
07:00	250		10	260	2320	30	30	205	+ve 2115
08:00	250		10	260	2580	20	20	225	+ve 2355
09:00	250		10	260	2840	10	10	235	+ve 2605
...

Haematology and CoagulopathyClinical Chemistry and Liver Function Tests
Test	Normal Values	18:30	20:15	06:00
HB	11.5 - 16.5 g/dL	10.0	9.8
Platelets	150 - 450 x 10^-9/L	120	114
WBC	4.0 - 11.0 x 10^-9/L	14.0	14.8
MCV	84 - 102 fL	85	84
Neutrophils	2.0 - 7.5 x 10^-9/L	9.0	9.2
ESR	1 - 20
APTT Ratio	0.85 - 1.14
INR	0.8 - 1.2
Prothrombin Time	10.0 - 12.0 sec's	12	12
APTT	21.0 - 29.0 sec's	32	32
Thrombin Time	17.0 - 21.0 sec's	21	21
D-Dimer	0 - 250 µg/L	200	202
Fibrinogen	1.8 - 4.0 g/L

Clinical Chemistry and Liver Function TestsHaematology and Coagulopathy
Test	Normal Values	18:30	20:15	06:00
Sodium	134 - 145 mmol/L	140	138
Potassium	3.5 - 5.3 mmol/L	4.5	4.2
Urea	2.9 - 7.5 mmol/L	10.0	10.2
Creatinine	45 - 84 µmol/L	100	104
GFR	(ml/min)
Glucose	4.0 - 8.0 mmol/L	9.9	8.9
Amylase	0 - 110 U/L
CK	25 - 200 U/L
ALT	0 - 35 U/L	30	35
γGT	0 - 40 U/L	50	48
Bilirubin	0 - 21 µmol/L	40	45
Alk Phosphate	40 - 130 U/L	180	183
Albumin	30 - 50 g/L	24	18
CRP	0 - 10 mg/dL	110	121
Troponin	up to 0.1 µg/L
Bicarbonate	24 - 32 mmol/L
Calcium	2.2 - 2.6 mmol/L
Phosphate	0.8 - 1.45 mmol/L
Magnesium	0.7 - 1.0 mmol/L

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