Date: 

Assess Site for the Following: 

Shift 

Sunday 

Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

Vitals              BP             TPR 

11-7 

7-3 

3-11 

Bruit 

11-7 

          ( + ) Positive ( - ) Negative   

7-3 

           If negative notify MD 

3-11 

Thrill 

11-7 

          ( + ) Positive ( - ) Negative   

7-3 

           If negative notify MD 

3-11 

Scab Formation 

11-7 

          ( + ) Positive ( - ) Negative   

7-3 

           If negative notify MD 

3-11 

Pain at site or Moving  Arm 

          ( + ) Positive   ( - ) Negative 

          If positive, notify MD 

Signs & Symptoms of Infection (Pain, Redness, Swelling, Drainage, Fever) 

11-7 

          ( + ) Positive   ( - ) Negative 

7-3 

          If positive, notify MD 

3-11 

Signs & Symptoms of Fluid Deficit (Dizziness, Decrease BP, Increase P) or Fluid Overload (Shortness of Breath, Abnormal Lung Sounds, Increase in Edema) 

11-7 

          ( + ) Positive   ( - ) Negative 

7-3 

          If positive, notify MD 

3-11 

Initials of Nurse 

11-7 

Initials of Nurse 

7-3 

Initials of Nurse 

3-11