[NOTE: If you observe any general precursors to seizure activity during your shift, enter notes below. If he has a seizure during your shift, refer below to "Emergent Reports" under Procedures.]

•  I used the cough assist as a therapy
  • Time 
    
•  I used the cough assist as an intervention
  • Time 
    

• [NOTE: For information on adminstering Budesonide, Xopenex, or Sodium Chloride properly, refer to the "Medication Administration Routines"]

•  I administered Budesonide via nebulizer
  •  Awake
  •  Asleep
  •  •  Time 
•  I administered Xopenex via nebulizer
  •  Awake
  •  Asleep
  •  •  Time 
•  I administered Sodium Chloride via nebulizer
  •  Awake
  •  Asleep
  •  •  Time 

• I did change the G-tube balloon water
• I put the G-tube balloon water back in (not recommended)

• First time today 
  He had stomach gas.
  He did not have stomach gas.
• Second time today 
  He had stomach gas.
  He did not have stomach gas.
• Third time today 
  He had stomach gas.
  He did not have stomach gas.

[NOTE: For specifics on administering Ondansetron (Zofran), refer to Medication Administration Routines]

• Time Ondansetron given • 
  The Ondansetron prevented the emesis
  Emesis happened despite the Ondansetron
  • Time of emesis • 
  • Location of emesis 
  • Volume of emesis 

• Time of seizure  • 
  Seizure duration and description
  

[NOTE: If any seizure lasts more than three minutes or he has four seizures in one hour, administer Nayzilam. See also Seizure Monitoring and use the Seizure Log (PDF) to keep track of seizure details.]

• I did adminster the first dose of Nyazilam at  • 

• I did administer the second dose of Nayzilam at • 
  I did call 911

1. Reason for first recovery position
   
   Time of first recovery position • 
2. Reason for second recovery position
   
   Time of second recovery position • 
3. Reason for third recovery position
   
   Time of third recovery position • 

• Cause and severity of the injury
  
  Time of the injury • 
  Injury remedy and outcome
  
  Suggestions for future prevention
  

• Cause and severity of the injury
  
  Time of the injury • 
  Injury remedy and outcome
  
  Suggestions for future prevention
  

• Cause and severity of the injury
  
  Time of the injury • 
  Injury remedy and outcome
  
  Suggestions for future prevention
  

• 1. Veg. meal amount •  • Time 01 
  2. Veg. meal amount •  • Time 02 
  3. Veg. meal amount •  • Time 03 

• 1. Animal meal amount •  • Time 01 
  2. Animal meal amount •  • Time 02 
  3. Animal meal amount •  • Time 03 

• 1. Veg. snack amount •  • Time 01 
  2. Veg. snack amount •  • Time 01 

• 1. Animal snack amount •  • Time 01 
  2. Animal snack amount •  • Time 01 

1. Amount •   • Time 01 
2. Amount •   • Time 02 
3. Amount •   • Time 03 
4. Amount •   • Time 04 
5. Amount •   • Time 05 
6. Amount •   • Time 06 

1. Sips
   •  Time 01 
2. Sips
   •  Time 02 
3. Sips
   •  Time 03 
4. Sips
   •  Time 04 
5. Sips
   •  Time 05 
6. Sips
   •  Time 06 

1. Tastes • Type  • Time 01 
2. Tastes • Type  • Time 02 

• In the bathroom
  • 1. Soiled with  Urine  Stool  • Time 
    2. Soiled with  Urine  Stool  • Time 
    3. Soiled with  Urine  Stool  • Time 
    4. Soiled with  Urine  Stool  • Time 
    5. Soiled with  Urine  Stool  • Time 
  • If any stool was in the brief, what was the general consistency?
    Too hard Firm Medium Medium-soft Soft Loose Watery/Diarrhea
• At the Rifton chair (soiled with urine only - no stool)
  • 1. Time 
    2. Time 
    3. Time 

• 1. We tried • Time    Go!  No go
  2. We tried • Time    Go!  No go
  3. We tried • Time    Go!  No go
  4. We tried • Time    Go!  No go

• 1. We tried • Time    Success!  No success
     If you had success, what was the consistency? Too hard Firm Medium Medium-soft Soft Loose Watery/Diarrhea
  2. We tried • Time    Success!  No success
     If you had success, what was the consistency? Too hard Firm Medium Medium-soft Soft Loose Watery/Diarrhea
  3. We tried • Time    Success!  No success
     If you had success, what was the general consistency of stool during your shift?
     Too hard Firm Medium Medium-soft Soft Loose Watery/Diarrhea

•  Comfort level
  

•  Comfort level
  

• With razor and shaving cream
• With electric shaver
•  Comfort level
  

• I trimmed his fingernails
• I trimmed his toenails
•  Comfort level
  

•  Comfort level
  

• No choking while brushing teeth
  He did choke during tooth brushing

• 1. Repositioned at
  2. Repositioned at
  3. Repositioned at

•  I did not use the BiPAP overnight
•  I made use of the BiPAP during sleep overnight
  • Duration of BiPAP use overnight 

• He woke up at • 

• He woke up at •
  He stayed in bed
  • He fell asleep again at  •  
    He stayed in bed sitting up until •  , and then got up for the day.
• He got out of bed too early
  • His baseline comfort level after getting up too early
    
    I tried to get him to void standing at the toilet
    • He did not void at the toilet after waking too early
    • He voided at the toilet after waking too early
      • He voided at • 
        I put him back in bed after he voided at the toilet
        • He did not fall back to sleep after voiding at the toilet
          After voiding at the toilet, he fell back to sleep at • 
  • I transferred him to the Rifton chair and gave him medications
    
    
    • Baseline pain (1-10) after being seated
      

      [NOTE: After administering one pain medication, before you administer any additional pain medications, wait at least 45 minutes and then rate his pain again.]

    • [NOTE: For specifics on administering Acetaminophen, refer to Medication Administration Routines]

       Acetaminophen
      •  • Dose   •  Time 
        Pain 45 minutes after Acetaminophen (1-10)
        

    • [NOTE: For specifics on administering Acetaminophen, refer to Medication Administration Routines]

       Oxycodone
      •  • Dose   •  Time 
        Pain 45 minutes after Oxycodone (1-10)
        

    • [NOTE: For specifics on administering Clonazepam, refer to Medication Administration Routines]

       Clonazepam
      •  • Dose   •  Time 

    • [NOTE: For specifics on administering Simethicone, refer to Medication Administration Routines]

       Simethicone (Gas-X)
      •  • Dose   •  Time 
        

        [NOTE: Administer Simethicone only after giving at least some food via G-tube; never on an empty stomach.]

    • His comfort level after treatements for getting up too early
      
      After treatments he stayed up for the day
      After treatments he went back to sleep at •  Time 

1. Time he fell asleep •
     Time he woke up •
2. Time he fell asleep •
     Time he woke up •

1. Transfer from the Rifton chair to the bedroom
   • Amount of time in the Rifton chair • 
2. Transfer from the Rifton chair to the bedroom
   • Amount of time in the Rifton chair • 
3. Transfer from the Rifton chair to the bedroom
   • Amount of time in the Rifton chair • 
4. Transfer from the Rifton chair to the bedroom
   • Amount of time in the Rifton chair • 

1. Transfer from the Rifton chair to the wheelchair
   • Amount of time in the Rifton chair • 
2. Transfer from the Rifton chair to the wheelchair
   • Amount of time in the Rifton chair • 
3. Transfer from the Rifton chair to the wheelchair
   • Amount of time in the Rifton chair • 
4. Transfer from the Rifton chair to the wheelchair
   • Amount of time in the Rifton chair • 

1. Transfer from the wheelchair to the bedroom
   • Amount of time in the wheelchair • 
2. Transfer from the wheelchair to the bedroom
   • Amount of time in the wheelchair • 
3. Transfer from the wheelchair to the bedroom
   • Amount of time in the wheelchair • 
4. Transfer from the wheelchair to the bedroom
   • Amount of time in the wheelchair • 

1. Transfer from the wheelchair to the Rifton
   • Amount of time in the wheelchair • 
2. Transfer from the wheelchair to the Rifton
   • Amount of time in the wheelchair • 
3. Transfer from the wheelchair to the Rifton
   • Amount of time in the wheelchair • 
4. Transfer from the wheelchair to the Rifton
   • Amount of time in the wheelchair •