The 24-Hour Patient Care Flowsheet (5AB) is used for patients who are not on a pathway (Cardiac Surgery Pathway).
Patient label and date are required on both pages of the form. The assessment sections contain “normal” findings for a patient. If your patient meets this stated criteria a check is all that is required. If the patient deviates from any of the stated criteria, a variance should be documented and elaborated upon.
When documenting about a variance the Data Action Response, or similar format, is to be used.
0700 Heart rate increased at 112 bpm. Patient denies SOB, chest pain. Skin warm and dry. Dr. Sam informed of patient status at 0730. Order received to give scheduled beta blocker STAT.RN
0720 Scheduled beta blocker given at 0715. Will reassess heart rate in one hour. RN
0915 Heart rate at 88 bpm. Will continue to monitor. RN
Data: Subjective and/or objective information that supports the assessment
Action: Completed or planned nursing interventions based on the nurse’s assessment
Response: Description of the impact of the interventions on client outcomes.
A Closer Look at the 24 Hr Flowsheet
Vital Signs/MEWS: Completed as per protocol – beginning of every shift, change in status, prn. MEWS must be completed with every set of VS, not just at the beginning of the shift. MEWS is effective at highlighting patient deterioration because it demonstrates a trend. A trend cannot be seen if the MEWS is not completed with every set of VS.
Vascular/Orthopedic: Completed with baseline patient assessment each shift and prn
Central Nervous System: Completed with baseline patient assessment each shift and prn
Pain: Document presence and location of non-cardiac pain using pain scale of 0 to 10, or other pain indicator. If a patient is pain free there is no need to document that. If a pain complains of pain the Pain SBAR requires completion. If a patient is on a 24 hr pain management flowsheet make sure to note that on the 24 hr flowsheet in the indicated space.
Neurological: The Delirium Screening and Care Plan (PHC-NF351) must be completed on all patients each shift. Risk Factors must be indicated, the screen signed and dated, timed.
Each line of the CAM screening must indicate ‘+’ or ‘-‘. A line from the top of the column to the bottom is not acceptable. If a patient is CAM positive, PRISME interventions must be indicated.
Respiratory: Respiratory rate is to be counted for a full minute to determine an accurate rate, as respiratory rate is an important indicator in patient deterioration (MEWS).
Cardiovascular: Indicate whether patient is on telemetry by checking the ECG strip flowsheet box. There is no need to document findings that meet the criteria indicated, only variances. Variances are to use the DAR format.
Gastrointestinal: Diet type and last bowel movement are to be documented where indicated.
Genitourinary: If patient has a urinary catheter in situ this needs to be indicated, as well as the reason for the catheter.
Integumentary: Indicate specialty surface if one is used. Braden scale is completed q48 hr, therefore check Braden tool to see if reassessment is required and complete if needed.
Musculoskeletal: Activity level refers to the ordered activity i.e. AAT, bedrest. If a patient is on bedrest indicate the frequency of turning where indicated. Hygiene refers to the type of activity undertaken (sponge bath, shower) and not the amount of assistance required. Baseline criteria is patient is independent with these activities. Document a variance if the patient requires assistance and how much.
Psychosocial: Document any variances from baseline.
Safety: Assess safety and document only if all aspects are met. If something in the safety check is missing, rectify and document.
Dressings/Incisions: Applies to any wounds or incisions the patient has. If does not include central line dressings which are documented on page 4. Indicate site of the wound(s). If the wound/incision is uncomplicated documenting on the 24-Hr flowsheet is appropriate, however, if the wound/incision is complex, complete the Wound Assessment/Documentation Flowsheet (PHC-NF099). Refer to this additional flowsheet when documenting.
0930 Refer to Wound Assessment flowsheet RN
Drainage Tubes: Document site as well as any additional flowsheets associated with tube (Chest tube flowsheet). Indicate location of tube(s). If no drainage tubes present document ‘n/a’.
Patient Teaching: Patient/family teaching happens every day; therefore this section should not be left blank. Indicate what was taught and to whom, any teaching materials given and patient/family’s level of understanding, or lack of understanding.
Other: Document any tests, admissions, discharges, or other items that do not fit into the other categories here.
Fluid Balance: Indicate amount of fluid restriction if applicable. If fluid balance is ordered any fluids that go into or out of the patient require documentation. Intake includes IV fluids/meds, PO fluids, parenteral fluids. Output includes, urine, emesis, blood, chest tube volumes, drain volumes. The 24 Hr fluid balance is to be calculated at 0600 each day.
If a patient is recording their own ins and outs it can be noted on the fluid balance to refer to this sheet for details.
IV/CVC Assessments and Procedures: Any assessments and interventions involving IV access are documented here. The Legend for documenting in this section is located at the bottom of the form.