Rounding

Chart Check:

Vitals

• hold things that need holding
  Labs

Glucose

• any diabetes management

Short Report

Subjective:

• Name/Age/Sex
• c/c
• Post op day __
• Overnight events
• Brief/pertinent ROS and reported concerns

Objective

• Vitals (pertinent)
  • good verbiage: “within normal limits”, “unremarkable”, or “stable”
    • be careful with “stable” - can be terrible and also stable
• Electrolytes and Friends (pertinent)
  • TOP 3: Cr, Hgb, WBC
  • T bili, ALP, other
• I/O
  • Urine output is a decision by the body
  • Ideal max diuresis = 1L / day
• PE:
  • ABD
  • distension, tenderness, ascites (fluid wave?), percussion (dull?), protuberant

Assessment

• What is going on?
  • diet
  • pain
  • activity
  • bowel/bladder
  • tubes/drains/ostomy rods/anticoags

Plan:
Next steps: pharm, diet, procedures, diagnostics
What are they attached to? (Start, stop, change)
Medications
Fluids
Diet
Upcoming procedure
Why are they in hospital? (TOP 3)
- Home life
- Wound
- Eating
- Unstable?
Discharge:
- wound care
- appointments
- cost of discharge meds
- transportation
- is it safe and feasible?