Table 3 A sample of final nursing reporting MDS: the cardiovascular system assessment data elements
From: Development and evaluation of an electronic nursing documentation system
Data elements | Data values | ||
|---|---|---|---|
HR | |||
 BP | Invasive | ||
Non-invasive | |||
 Iv line | Peripheral | Angio cat Scalp | |
Central | Triple lumen Double lumen Port Cat down | ||
 Site of Iv line | Peripheral | Hand Leg Jugular | |
Central | Subclavian Jugular Limb | ||
 Serum | Dose / Ml/hr. / Gtt/min | ||
 Type of serum | Isotonic/ Hypertonic/ Hypotonic | ||
 The patient needs blood products | No | ||
Yes (if yes,) | FFP, Cryoprecipitate, Cryopoor Plasma (CPP), whole blood, platelet concentration, washed red blood cells, Low leukocyte red blood, Radiated red blood cells, Frozen red blood cells | ||
 Quality of pulse (power) | +, ++, +++, ++++ | ||
 Symptoms of dyspnea | PND (paroxysmal natural dyspnea), Orthopnea, dyspnea during exercise, dyspnea during rest, | ||
 chest pain | yes | Onset, Site Radiation, Quality of pain, Pain aggravating factors, Pain Reduction Factors, | |
no | |||
 Capillary Refill time | Brisk (> 2 s), Sluggish (< 2) | ||
Time to start the pain | |||
 CVP (central vein pressure) | Normal, abnormal | ||
 Rhythm | normal | ||
arrhythmia | Irregular | Atrium arrhythmia, Early Stimulation Syndromes, AV arrhythmia & blocks, Branch blocks, Ventricular arrhythmia, | |
Regular | SA node arrhythmia | ||
 patient needs a pacemaker | yes | Internal, External | |
no | |||
 Set up of pacemaker | Mode, Output, Rate | ||
 Does the patient need a monitor? | Yes, no | ||
 Does the patient need an IABP? | Yes, no | setup | |
 Edema | yes | Localize, general | |
no | |||
 Edema | yes | Pitting, Not pitting | |
no | |||
 CPCR | yes | onset start, duration, end time of CPCR, Time to announce resuscitation code, Drug are used, Type of rhythm, shock, | |
no | |||
 CPR successful | yes | post-CPR care | |
no | |||
 ventilate the patient during CPR | ETT, LMA, AMBO bag | ||