Admit (to floor X, Ward X, etc.)
Diagnosis
Condition (fair, stable, critical, etc.)
Vital frequency
Activity (up ad lib, bedrest, bathroom privileges, etc.)
Nursing (strict In’s & Out’s (all fluids in and all fluids out recorded), foley to gravity, etc.)
Diet (general, clear liquids, Nothing Per Os= Nothing by mouth, ADA (American Dietetic Association) diet, etc.)
Allergies
Labs
IV fluids (type & rate)
Special tests/studies
Meds
How to read a chest x-ray, systematicallyFirst confirm patient name/medical record number and date of films. Are the films the ones you ordered? Then assess the degree of penetration/exposure, rotation of the patient, whether patient was upright or lying in bed and degree of inspiration (adequate= 8-10 ribs seen). Then just follow your ABC’s... For the following ABC’s, have a system for each letter (ie. Look left to right and scan down for Airway, then same for bone)
Airway (is it straight?)
Bone (osteoporosis, thickening, fractures?)
Cardiac Shadow (is it larger than 1/2 diameter of the mediastinum, LA border visible?)
Diaphragm (proper elevation, sharp angles?)
Effusion/Edema (look for gravity dependent sharp fluid borders)
Fields (lung markings visible in all lung fields?)
Gadgets (are all chest tubes, NasoGastric tubes in place? any foreign objects?)