Red Flag Reporting CNA 2 OSBN Curriculum VITAL

Red Flag Reporting CNA 2 OSBN Curriculum

VITAL SIGNS �Temp > 38 degrees C or 100. 4 F �SBP > 170 or < 90 ◦ Retake manually if done with machine �DBP > 90 or < 50 ◦ Retake manually is done with machine �Respirations > 24 or < 12 �HR >110 or < 50 http: //www. medcomrn. com/dev/flash/ flvplayer/movie. php? movie=http: //ss 1. medcomrn. com/flv/cna 515 r_sec 02_300 k. flv&title=&detectflash=false

INTAKE/OUTPUT �Intake ◦ Decreased due to N/V �Output ◦ UOP �<30 ml/hr or 240 ml/8 hr �Appearance ◦ ◦ Emesis Sputum Urine Stool of Blood

General �ADL’s �Movement

ENDOCRINE �Blood Glucose ◦ • If < 40 or > 400 ◦ NOTIFY NURSE IMMEDIATELY!!!

RESPIRATORY �SOB �Dyspnea �Cough �Sputum ◦ Note Color ◦ Note Changes

GI/GU �N/V �Poor Appetite �Difficulty Swallowing/Eating �Urine ◦ ◦ Sediment Foul Odor Pink Colored Dark Tea Colored �Stool ◦ Melena ◦ Frank Blood

MENTATION �Excessive �LOC �New Drowsiness Onset ◦ Confusion ◦ Weakness ◦ Agitation �New ◦ Inability to Communicate ◦ Drooling while Awake ◦ Facial Droop

PAIN �Location �Intensity �Onset �Duration �Chest Pain �Sudden Change in Pain Level

SKIN �Cyanosis �Pallor �Chills �Diaphoresis �Edema �Any Drainage �Rashes/Bumps/Sores

OTHER �Dislodgment of any Tubes/Drains �Physical Signs of Abuse �Verbalization of Abuse �Pt. Expressing Concerns ◦ Code Status