2001020051269Skin Integrity Care PlanAAAA128064255255255000000000000000002550001Arial140135501018421504000000000200102005126900000000000000000000000000000000000000000000000200102005126900010000000000000000000000000000000000000000000000000010000000000000000200102005126900000000000000000000000000000000000000000002001020051359^ Goal / Goal TimeAAAB22422417500000000001000000001105251021000Arial8000001842150400000000020010200513590000000000000000000000000000000000000000000000020010200513590001000000000000000001000000000000000000000000000000901000000000000000020010200513590000000000000000000000000000000000000000000200102005135912001020051276-100102001020051357TCP (PRESSURE 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skin integrityABAD025525500000100000000000001105251020000Arial8000001842150400000000020010200511000000000000000000000000000000000000000000000002001020051100000000000000000000000000000000000000000000000000000010000000000000000200102005110000000000000000000000000000000000000000000200102005131Very high risk (Braden 9 or <)VmVyeSBoaWdoIHJpc2sgZm9yIHNraW4gYnJlYWtkb3duIA==ABAE025525500000100000000000001105251020000Arial80000018421504000000000200102005131000000000000000000000000000000000000000000000002001020051310000000000000000000000000000000000000000000000000000001000000000000000020010200513100000000000000000000000000000000000000000002001020051333High risk (Braden 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programQWN0aXZlIG51cnNpbmcgcmVoYWIgb3IgcmVoYWIgcHJvZ3JhbSA=ABAK22122120000000000000000000001105251020010Arial8000111419443200000000020010200516800000000000000000000000000000000000000000000000200102005168000000000000000000000000000000000000000000000000000000100000000000000002001020051680000000000000000000000000000000000000000000200102005110Potential 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TO:ACAB21220820000010100000000000001105251020000Arial8000001842150400000000020010200512470000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200512470000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200512470000000000000000000000000000000000000000000000020010200512470000010000000000000000000000000000000000000000000000001000000000000000020010200512470000000000000000000000000000000000000000000200102005111Extrinsic factorsACAC025525500000100100000000001105251020000Arial8000001842150400000000020010200511100000000000000000000000000000000000000000000000200102005111000000000000000000000001000000000000000000000000000000100000000000000002001020051110000000000000000000000000000000000000000000200102005111120010200512473200102005111120010200512473200102005112Intrinsic 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incontinenceACAJ025525500000100100000000001105251020000Arial80000018421504000000000200102005114000000000000000000000000000000000000000000000002001020051140000000000000000000000010000000000000000000000000000001000000000000000020010200511400000000000000000000000000000000000000000002001020051141200102005124732001020051141200102005124732001020051345needACBC025525500000100000000000001105251020000Arial80000018421504000000000200102005134500000000000000000000000000000000000000000000000200102005134500000000000000000000000000000000000000000000000000000010000000000000000200102005134500000000000000000000000000000000000000000002001020051346likeACBD025525500000100000000000001105251020000Arial80000018421504000000000200102005134600000000000000000000000000000000000000000000000200102005134600000000000000000000000000000000000000000000000000000010000000000000000200102005134600000000000000000000000000000000000000000002001020051347wantACBE025525500000100000000000001105251020000Arial80000018421504000000000200102005134700000000000000000000000000000000000000000000000200102005134700000000000000000000000000000000000000000000000000000010000000000000000200102005134700000000000000000000000000000000000000000002001020051348preferACBF025525500000100000000000001105251020000Arial80000018421504000000000200102005134800000000000000000000000000000000000000000000000200102005134800000000000000000000000000000000000000000000000000000010000000000000000200102005134800000000000000000000000000000000000000000002001020051349hope forACBG025525500000100000000000001105251020000Arial80000018421504000000000200102005134900000000000000000000000000000000000000000000000200102005134900000000000000000000000000000000000000000000000000000010000000000000000200102005134900000000000000000000000000000000000000000002001020051272ADAA12812864255255255000000000000000002550001Arial140050101842150400000000020010200512720000000000000000000000000000000000000000000000020010200512720001000000000000000000000000000000000000000000000000001000000000000000020010200512720000000000000000000000000000000000000000000200102005116Peripheral vascular diseaseADAC025525500000100100000000001105251020000Arial8000001842150400000000020010200511600000000000000000000000000000000000000000000000200102005116000000000000000000000001000000000000000000000000000000100000000000000002001020051160000000000000000000000000000000000000000000200102005116120010200512473200102005116120010200512473200102005117DiabetesADAD025525500000100100000000001105251020000Arial8000001842150400000000020010200511700000000000000000000000000000000000000000000000200102005117000000000000000000000001000000000000000000000000000000100000000000000002001020051170000000000000000000000000000000000000000000200102005117120010200512473200102005117120010200512473200102005119Poor nutritional statusADAE025525500000100100000000001105251020000Arial8000001842150400000000020010200511900000000000000000000000000000000000000000000000200102005119000000000000000000000001000000000000000000000000000000100000000000000002001020051190000000000000000000000000000000000000000000200102005119120010200512473200102005119120010200512473200102005118DehydrationADAF025525500000100100000000001105251020000Arial8000001842150400000000020010200511800000000000000000000000000000000000000000000000200102005118000000000000000000000001000000000000000000000000000000100000000000000002001020051180000000000000000000000000000000000000000000200102005118120010200512473200102005118120010200512473200102005129Poor tissue perfusionADAG025525500000100100000000001105251020000Arial8000001842150400000000020010200512900000000000000000000000000000000000000000000000200102005129000000000000000000000001000000000000000000000000000000100000000000000002001020051290000000000000000000000000000000000000000000200102005129120010200512473200102005129120010200512473200102005120Impaired tactile sensationADAH025525500000100100000000001105251020000Arial8000001842150400000000020010200512000000000000000000000000000000000000000000000000200102005120000000000000000000000001000000000000000000000000000000100000000000000002001020051200000000000000000000000000000000000000000000200102005120120010200512473200102005120120010200512473200102005121Use of psychotropic medicationVXNlIG9mIHBzeWNob3Ryb3BpYyBtZWRpY2F0aW9ucyA=ADAI025525500000100100000000001105251020000Arial80000018421504000000000200102005121000000000000000000000000000000000000000000000002001020051210000000000000000000000010000000000000000000000000000001000000000000000020010200512100000000000000000000000000000000000000000002001020051211200102005124732001020051211200102005124732001020051297Use of steroid medicationsADAJ025525500000100100000000001105251020000Arial8000001842150400000000020010200512970000000000000000000000000000000000000000000000020010200512970000000000000000000000010000000000000000000000000000001000000000000000020010200512970000000000000000000000000000000000000000000200102005129712001020051247320010200512971200102005124732001020051273AEAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005127300000000000000000000000000000000000000000000000200102005127300010000000000000000000000000000000000000000000000000010000000000000000200102005127300000000000000000000000000000000000000000002001020051118Use of narcotic medicationsAEAC025525500000100100000000001105251020000Arial8000001797457400000000020010200511180000000000000000000000000000000000000000000000020010200511180000000000000000000000010000000000000000000000000000001000000000000000020010200511180000000000000000000000000000000000000000000200102005111812001020051247320010200511181200102005124732001020051119Non-removable deviceAEAD025525500000100100000000001105251020000Arial8000001797457400000000020010200511190000000000000000000000000000000000000000000000020010200511190000000000000000000000010000000000000000000000000000001000000000000000020010200511190000000000000000000000000000000000000000000200102005111912001020051247320010200511191200102005124732001020051302Inability to lie flatAEAE025525500000100100000000001105251020000Arial80000018421504000000000200102005130200000000000000000000000000000000000000000000000200102005130200000000000000000000000100000000000000000000000000000010000000000000000200102005130200000000000000000000000000000000000000000002001020051302120010200512473200102005130212001020051247320010200515Disease processAEAF025525500000100100000000001105251020000Arial80000018421504000000000200102005150000000000000000000000000000000000000000000000020010200515000000000000000000000001000000000000000000000000000000100000000000000002001020051500000000000000000000000000000000000000000002001020051512001020051247320010200515120010200512473200102005130ChemotherapyAEAG025525500000100100000000001105251020000Arial80000018421504000000000200102005130000000000000000000000000000000000000000000000002001020051300000000000000000000000010000000000000000000000000000001000000000000000020010200513000000000000000000000000000000000000000000002001020051301200102005124732001020051301200102005124732001020051298Radiation therapyAEAH025525500000100100000000001105251020000Arial8000001842150400000000020010200512980000000000000000000000000000000000000000000000020010200512980000000000000000000000010000000000000000000000000000001000000000000000020010200512980000000000000000000000000000000000000000000200102005129812001020051247320010200512981200102005124732001020051300Renal dialysisAEAI025525500000100100000000001105251020000Arial8000001842150400000000020010200513000000000000000000000000000000000000000000000000020010200513000000000000000000000000010000000000000000000000000000001000000000000000020010200513000000000000000000000000000000000000000000000200102005130012001020051247320010200513001200102005124732001020051318SurgeryAEAJ025525500000100100000000001105251020000Arial8000001842150400000000020010200513180000000000000000000000000000000000000000000000020010200513180000000000000000000000010000000000000000000000000000001000000000000000020010200513180000000000000000000000000000000000000000000200102005131812001020051247320010200513181200102005124732001020051317AFAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005131700000000000000000000000000000000000000000000000200102005131700010000000000000000000000000000000000000000000000000010000000000000000200102005131700000000000000000000000000000000000000000002001020051274AGAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005127400000000000000000000000000000000000000000000000200102005127400010000000000000000000000000000000000000000000000000010000000000000000200102005127400000000000000000000000000000000000000000002001020051248MANIFESTED BY:AGAB21220820000010100000000000001105251020000Arial8000001842150400000000020010200512480000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200512480000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200512480000000000000000000000000000000000000000000000020010200512480000010000000000000000000000000000000000000000000000001000000000000000020010200512480000000000000000000000000000000000000000000200102005132Stasis ulcer presentAGAC025525500000100100000000001105251020000Arial8000001842150400000000020010200513200000000000000000000000000000000000000000000000200102005132000000000000000000000001000000000000000000000000000000100000000000000002001020051320000000000000000000000000000000000000000000200102005132120010200512483200102005132120010200512483200102005133Discolored areaAGAD025525500000100100000000001105251020000Arial8000001842150400000000020010200513300000000000000000000000000000000000000000000000200102005133000000000000000000000001000000000000000000000000000000100000000000000002001020051330000000000000000000000000000000000000000000200102005133120010200512483200102005133120010200512483200102005134Fragile skinAGAE025525500000100100000000001105251020000Arial8000001842150400000000020010200513400000000000000000000000000000000000000000000000200102005134000000000000000000000001000000000000000000000000000000100000000000000002001020051340000000000000000000000000000000000000000000200102005134120010200512483200102005134120010200512483200102005135RashAGAF025525500000100100000000001105251020000Arial8000001842150400000000020010200513500000000000000000000000000000000000000000000000200102005135000000000000000000000001000000000000000000000000000000100000000000000002001020051350000000000000000000000000000000000000000000200102005135120010200512483200102005135120010200512483200102005136Complaints of itchingAGAG025525500000100100000000001105251020000Arial8000001842150400000000020010200513600000000000000000000000000000000000000000000000200102005136000000000000000000000001000000000000000000000000000000100000000000000002001020051360000000000000000000000000000000000000000000200102005136120010200512483200102005136120010200512483200102005137Poor skin turgorAGAH025525500000100100000000001105251020000Arial80000018421504000000000200102005137000000000000000000000000000000000000000000000002001020051370000000000000000000000010000000000000000000000000000001000000000000000020010200513700000000000000000000000000000000000000000002001020051371200102005124832001020051371200102005124832001020051336Cool skinAGAI025525500000100100000000001105251020000Arial8000001842150400000000020010200513360000000000000000000000000000000000000000000000020010200513360000000000000000000000010000000000000000000000000000001000000000000000020010200513360000000000000000000000000000000000000000000200102005133612001020051248320010200513361200102005124832001020051169Abnormal lab valuesAGAJ025525500000100100000000001105251020000Arial8000001842150400000000020010200511690000000000000000000000000000000000000000000000020010200511690000000000000000000000010000000000000000000000000000001000000000000000020010200511690000000000000000000000000000000000000000000200102005116912001020051248320010200511691200102005124832001020051275AHAA12812864255255255000000000000000002550001Arial14005010184215040000000002001020051275000000000000000000000000000000000000000000000002001020051275000100000000000000000000000000000000000000000000000000100000000000000002001020051275000000000000000000000000000000000000000000020010200517Stage 1 pressure ulcerAHAC22122120000000000100000000001105251020010Arial8000011419443200000000020010200517000000000000000000000000000000000000000000000002001020051700000000000000000000000100000000000000000000000000000010000000000000000200102005170000000000000000000000000000000000000000000200102005171200102005124832001020051712001020051248320010200518Stage 2 pressure ulcerAHAD22122120000000000100000000001105251020010Arial8000011419443200000000020010200518000000000000000000000000000000000000000000000002001020051800000000000000000000000100000000000000000000000000000010000000000000000200102005180000000000000000000000000000000000000000000200102005181200102005124832001020051812001020051248320010200519Stage 3 pressure ulcerAHAE22122120000000000100000000001105251020010Arial80000114194432000000000200102005190000000000000000000000000000000000000000000000020010200519000000000000000000000001000000000000000000000000000000100000000000000002001020051900000000000000000000000000000000000000000002001020051912001020051248320010200519120010200512483200102005139Stage 4 pressure ulcerAHAF22122120000000000100000000001105251020010Arial8000011419443200000000020010200513900000000000000000000000000000000000000000000000200102005139000000000000000000000001000000000000000000000000000000100000000000000002001020051390000000000000000000000000000000000000000000200102005139120010200512483200102005139120010200512483200102005140Burns- 2nd or 3rd degreeQnVybiAoMm5kIG9yIDNyZCBkZWdyZWUpICA=AHAG22122120000000000100000000001105251020010Arial80000114194432000000000200102005140000000000000000000000000000000000000000000000002001020051400000000000000000000000010000000000000000000000000000001000000000000000020010200514000000000000000000000000000000000000000000002001020051401200102005124832001020051401200102005124832001020051328unstageable - non-remove drsgVW5zdGFnZWFibGUgdWxjZXIgKG5vbi1yZW1vdmFibGUgZHJlc3Npbmcgb3IgZGV2aWNlKSAgAHAH22122120000000000100000000001105251020010Arial8000111419443200000000020010200513280000000000000000000000000000000000000000000000020010200513280000000000000000000000010000000000000000000000000000001000000000000000020010200513280000000000000000000000000000000000000000000200102005132812001020051248320010200513281200102005124832001020051328301-1-14.020010200513283012-11200102005132830116-112001020051329unstageable - slough/escharVW5zdGFnZWFibGUgdWxjZXIgKHdvdW5kIGJlZCBjb3ZlcmVkIGJ5IHNsb3VnaCBhbmQvb3IgZXNj aGFyKSAgIA==AHAI22122120000000000100000000001105251020010Arial8000111419443200000000020010200513290000000000000000000000000000000000000000000000020010200513290000000000000000000000010000000000000000000000000000001000000000000000020010200513290000000000000000000000000000000000000000000200102005132912001020051248320010200513291200102005124832001020051329301-1-14.020010200513293012-11200102005132930116-112001020051330unstageable - deep tissueVW5zdGFnZWFibGUgdWxjZXIgKHN1c3BlY3RlZCBkZWVwIHRpc3N1ZSBpbmp1cnkgaW4gZXZvbHV0 aW9uKSAgAHAJ22122120000000000100000000001105251020010Arial8000111419443200000000020010200513300000000000000000000000000000000000000000000000020010200513300000000000000000000000010000000000000000000000000000001000000000000000020010200513300000000000000000000000000000000000000000000200102005133012001020051248320010200513301200102005124832001020051330301-1-14.020010200513303012-11200102005133030116-112001020051331AIAA12812864255255255000000000000000002550001Arial140050101842150400000000020010200513310000000000000000000000000000000000000000000000020010200513310001000000000000000000000000000000000000000000000000001000000000000000020010200513310000000000000000000000000000000000000000000200102005141Other open lesion(s)T3BlbiBsZXNpb24ocykgb3RoZXIgdGhhbiB1bGNlciwgcmFzaCwgY3V0LiAgAIAC22122120000000000100000000001105251020010Arial8000011419443200000000020010200514100000000000000000000000000000000000000000000000200102005141000000000000000000000001000000000000000000000000000000100000000000000002001020051410000000000000000000000000000000000000000000200102005141120010200512483200102005141120010200512483200102005142Surgical WoundAIAD22122120000000000100000000001105251020010Arial8000011419443200000000020010200514200000000000000000000000000000000000000000000000200102005142000000000000000000000001000000000000000000000000000000100000000000000002001020051420000000000000000000000000000000000000000000200102005142120010200512483200102005142120010200512483200102005143Infection of the footAIAE22122120000000000100000000001105251020010Arial8000011419443200000000020010200514300000000000000000000000000000000000000000000000200102005143000000000000000000000001000000000000000000000000000000100000000000000002001020051430000000000000000000000000000000000000000000200102005143120010200512483200102005143120010200512483200102005144Open lesions on the footAIAF22122120000000000100000000001105251020010Arial80000114194432000000000200102005144000000000000000000000000000000000000000000000002001020051440000000000000000000000010000000000000000000000000000001000000000000000020010200514400000000000000000000000000000000000000000002001020051441200102005124832001020051441200102005124832001020051320venous ulcer, partial thicknesUGFydGlhbCB0aGlja25lc3MgdmVub3VzIHVsY2VyICAgAIAG025525500000100100000000001105251020000Arial8000001797457400000000020010200513200000000000000000000000000000000000000000000000020010200513200000000000000000000000010000000000000000000000000000001000000000000000020010200513200000000000000000000000000000000000000000000200102005132012001020051248320010200513201200102005124832001020051321venous ulcer, full thicknessRnVsbCB0aGlja25lc3MgdmVub3VzIHVsY2VyICAgAIAH025525500000100100000000001105251020000Arial8000001797457400000000020010200513210000000000000000000000000000000000000000000000020010200513210000000000000000000000010000000000000000000000000000001000000000000000020010200513210000000000000000000000000000000000000000000200102005132112001020051248320010200513211200102005124832001020051322arterial ulcer, partial thickUGFydGlhbCB0aGlja25lc3MgYXJ0ZXJpYWwgdWxjZXIgIA==AIAI025525500000100100000000001105251020000Arial8000001797457400000000020010200513220000000000000000000000000000000000000000000000020010200513220000000000000000000000010000000000000000000000000000001000000000000000020010200513220000000000000000000000000000000000000000000200102005132212001020051248320010200513221200102005124832001020051323arterial ulcer, full thicknessRnVsbCB0aGlja25lc3MgYXJ0ZXJpYWwgdWxjZXIgICA=AIAJ025525500000100100000000001105251020000Arial8000001797457400000000020010200513230000000000000000000000000000000000000000000000020010200513230000000000000000000000010000000000000000000000000000001000000000000000020010200513230000000000000000000000000000000000000000000200102005132312001020051248320010200513231200102005124832001020051279ApproachAKAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005127900000000000000000000000000000000000000000000000200102005127900010000000000000000000000000000000000000000000000000010000000000000000200102005127900000000000000000000000000000000000000000002001020051251Nurses ---AKAB21220820000010100000000000001105251020000Arial80000018421504000000000200102005125100000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125100000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125100000000000000000000000000000000000000000000000200102005125100000100000000000000000000000000000000000000000000000010000000000000000200102005125100000000000000000000000000000000000000000002001020051138Skin assessment per policyAKAC025525500000100100000000001105251020000Arial8000001797457400000000020010200511380000000000000000000000000000000000000000000000020010200511380000000000000000000000010000000000000000000000000000001000000000000000020010200511380000000000000000000000000000000000000000000200102005113812001020051251320010200511381200102005125132001020051139ID changes / minimize factorsTm90ZSBjaGFuZ2VzIGluIGxldmVsIG9mIHJpc2sgZm9yIHNraW4gYnJlYWtkb3duIGFuZCBtaW5p bWl6ZSBmYWN0b3JzLCA=AKAD025525500000100100000000001105251020000Arial800000179745740000000002001020051139000000000000000000000000000000000000000000000002001020051139000000000000000000000001000000000000000000000000000000100000000000000002001020051139000000000000000000000000000000000000000000020010200511391200102005125132001020051139120010200512513200102005172Minimize mech/chem irritantsSWRlbnRpZnkgYW5kIG1pbmltaXplIGV4cG9zdXJlIHRvIG1lY2hhbmljYWwgYW5kIGNoZW1pY2Fs IHNraW4gaXJyaXRhbnRzIA==AKAE025525500000100100000000001105251020000Arial800000184215040000000002001020051720000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517200000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005172000000001000000000000000000000000000000000000002001020051720000000000000000000000010000000000000000000000000000001000000000000000020010200517200000000000000000000000000000000000000000002001020051721200102005125132001020051721200102005125132001020051129Daily skin assessmentAKAF025525500000100100000000001105251020000Arial8000001797457400000000020010200511290000000000000000000000000000000000000000000000020010200511290000000000000000000000010000000000000000000000000000001000000000000000020010200511290000000000000000000000000000000000000000000200102005112912001020051251320010200511291200102005125132001020051140Weekly skin assessmentAKAG025525500000100100000000001105251020000Arial8000001797457400000000020010200511400000000000000000000000000000000000000000000000020010200511400000000000000000000000010000000000000000000000000000001000000000000000020010200511400000000000000000000000000000000000000000000200102005114012001020051251320010200511401200102005125132001020051148Evaluate healing progressRXZhbHVhdGUgaGVhbGluZyBwcm9jZXNzIGFuZCByZXZpc2UgY2FyZSBwbGFuIGFzIG5lZWRlZCwg AKAH025525500000100100000000001105251020000Arial8000001797457400000000020010200511480000000000000000000000000000000000000000000000020010200511480000000000000000000000010000000000000000000000000000001000000000000000020010200511480000000000000000000000000000000000000000000200102005114812001020051251320010200511481200102005125132001020051149Due to darker pigment...RHVlIHRvIGRhcmtlciBza2luIHBpZ21lbnQsIHVzZSBoYWxvZ2VuIGxpZ2h0IHRvIGFzc2VzcyBm b3IgY29sb3IgY2hhbmdlcyBbbm90ZSBwdXJwbGUgaHVlc10uIENvbXBhcmUgc2tpbiBvdmVyIGJv bnkgcHJvbWluZW5jZXMgdG8gc3Vycm91bmRpbmcgc2tpbiBbbm90ZSBib2dnaW5lc3MsIHN0aWZm bmVzcywgb3IgdGVtcGVyYXR1cmUgdmFyaWF0aW9uc30uIA==AKAI025525500000100100000000001105251020000Arial8000001797457400000000020010200511490000000000000000000000000000000000000000000000020010200511490000000000000000000000010000000000000000000000000000001000000000000000020010200511490000000000000000000000000000000000000000000200102005114912001020051251320010200511491200102005125132001020051350ALAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005135000000000000000000000000000000000000000000000000200102005135000010000000000000000000000000000000000000000000000000010000000000000000200102005135000000000000000000000000000000000000000000002001020051150Note daily care regimenTm90ZSBhcHByb3ByaWF0ZW5lc3Mgb2YgZGFpbHkgc2tpbiBjYXJlIHJlZ2ltZW4gdG8gY3VycmVu dCBza2luIHN0YXR1czogbm8gaG90IHdhdGVyLCBubyBza2luIGlycml0YW50cywgdXNlIG1vaXN0 dXJpemVyIGFuZC9vciBza2luIGJhcnJpZXIgY3JlYW0gYXMgaW5kaWNhdGVkLiBSZXZpc2UgcmVn aW1lbiBQUk4uICA=ALAC025525500000100100000000001105251020000Arial8000001797457400000000020010200511500000000000000000000000000000000000000000000000020010200511500000000000000000000000010000000000000000000000000000001000000000000000020010200511500000000000000000000000000000000000000000000200102005115012001020051251320010200511501200102005125132001020051153Educate resident/family/staffRWR1Y2F0ZSByZXNpZGVudC9mYW1pbHkvc3RhZmYgcmVnYXJkaW5nIHRyZWF0bWVudCBhbmQgcHJl dmVudGl2ZSBtZWFzdXJlcy4gALAD025525500000100100000000001105251020000Arial8000001797457400000000020010200511530000000000000000000000000000000000000000000000020010200511530000000000000000000000010000000000000000000000000000001000000000000000020010200511530000000000000000000000000000000000000000000200102005115312001020051251320010200511531200102005125132001020051154Assess need for debridementALAE025525500000100100000000001105251020000Arial800000179745740000000002001020051154000000000000000000000000000000000000000000000002001020051154000000000000000000000001000000000000000000000000000000100000000000000002001020051154000000000000000000000000000000000000000000020010200511541200102005125132001020051154120010200512513200102005152Meds/treatment as orderedQWRtaW5pc3RlciBtZWRpY2F0aW9ucy90cmVhdG1lbnQgYXMgb3JkZXJlZCBhbmQgZXZhbHVhdGUg Zm9yIGVmZmVjdGl2ZW5lc3MuIA==ALAF025525500000100100000000001105251020000Arial8000001842150400000000020010200515200000000000000000000000000000000000000000000000200102005152000000000000000000000001000000000000000000000000000000100000000000000002001020051520000000000000000000000000000000000000000000200102005152120010200512513200102005152120010200512513200102005153Request pharmacy reviewALAG025525500000100100000000001105251020000Arial80000018421504000000000200102005153000000000000000000000000000000000000000000000002001020051530000000000000000000000010000000000000000000000000000001000000000000000020010200515300000000000000000000000000000000000000000002001020051531200102005125132001020051531200102005125132001020051178Request therapy evaluationALAH025525500000100100000000001105251020000Arial8000001797457400000000020010200511780000000000000000000000000000000000000000000000020010200511780000000000000000000000010000000000000000000000000000001000000000000000020010200511780000000000000000000000000000000000000000000200102005117812001020051251320010200511781200102005125132001020051179Request dietary evaluationALAI025525500000100100000000001105251020000Arial8000001797457400000000020010200511790000000000000000000000000000000000000000000000020010200511790000000000000000000000010000000000000000000000000000001000000000000000020010200511790000000000000000000000000000000000000000000200102005117912001020051251320010200511791200102005125132001020051351AMAA12812864255255255000000000000000002550001Arial140050101842150400000000020010200513510000000000000000000000000000000000000000000000020010200513510001000000000000000000000000000000000000000000000000001000000000000000020010200513510000000000000000000000000000000000000000000200102005123Multidisciplinary nutrit evalUmVxdWVzdCByZXZpZXcgYnkgbXVsdGlkaXNjaXBsaW5hcnkgbnV0cml0aW9uYWwgdGVhbSA=AMAC025525500000100100000000001105251020000Arial80000018421504000000000200102005123000000000000000000000000000000000000000000000002001020051230000000000000000000000010000000000000000000000000000001000000000000000020010200512300000000000000000000000000000000000000000002001020051231200102005125132001020051231200102005125132001020051130Reduce pressure and frictionAMAD025525500000100100000000001105251020000Arial8000001797457400000000020010200511300000000000000000000000000000000000000000000000020010200511300000000000000000000000010000000000000000000000000000001000000000000000020010200511300000000000000000000000000000000000000000000200102005113012001020051251320010200511301200102005125132001020051181Limit sitting to 60 minTGltaXQgc2l0dGluZyB0byA2MCBtaW51dGVzIGF0IGEgdGltZSA=AMAE025525500000100100000000001105251020000Arial800000179745740000000002001020051181000000000000000000000000000000000000000000000002001020051181000000000000000000000001000000000000000000000000000000100000000000000002001020051181000000000000000000000000000000000000000000020010200511811200102005125132001020051181120010200512513200102005157Instruct to shift wt q15 minSW5zdHJ1Y3QgdG8gc2hpZnQgd2VpZ2h0IGV2ZXJ5IDE1IG1pbnV0ZXMgAMAF025525500000100100000000001105251020000Arial8000001842150400000000020010200515700000000000000000000000000000000000000000000000200102005157000000000000000000000001000000000000000000000000000000100000000000000002001020051570000000000000000000000000000000000000000000200102005157120010200512513200102005157120010200512513200102005161Admin supplements betw mealsQWRtaW5pc3RlciBzdXBwbGVtZW50cyBiZXR3ZWVuIG1lYWxzIA==AMAG025525500000100100000000001105251020000Arial80000018421504000000000200102005161000000000000000000000000000000000000000000000002001020051610000000000000000000000010000000000000000000000000000001000000000000000020010200516100000000000000000000000000000000000000000002001020051611200102005125132001020051611200102005125132001020051157Med for pain before activ/txTWVkaWNhdGUgZm9yIHBhaW4gYmVmb3JlIGFjdGl2aXRpZXMgYW5kIHRyZWF0bWVudHMgAMAH025525500000100100000000001105251020000Arial800000179745740000000002001020051157000000000000000000000000000000000000000000000002001020051157000000000000000000000001000000000000000000000000000000100000000000000002001020051157000000000000000000000000000000000000000000020010200511571200102005125132001020051157120010200512513200102005156Develop repositioning scheduleRGV2ZWxvcCBhbmQgbW9uaXRvciByZXBvc2l0aW9uaW5nIHNjaGVkdWxlIGJhc2VkIG9uIHN0YXR1 cyBhbmQgc3VwcG9ydCBzdXJmYWNlcyBwcm92aWRlZCA=AMAI025525500000100100000000001105251020000Arial8000001842150400000000020010200515600000000000000000000000000000000000000000000000200102005156000000000000000000000001000000000000000000000000000000100000000000000002001020051560000000000000000000000000000000000000000000200102005156120010200512513200102005156120010200512513200102005124Elevate heels in bedAMAJ025525500000100100000000001105251020000Arial80000018421504000000000200102005124000000000000000000000000000000000000000000000002001020051240000000000000000000000010000000000000000000000000000001000000000000000020010200512400000000000000000000000000000000000000000002001020051241200102005125132001020051241200102005125132001020051281ANAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005128100000000000000000000000000000000000000000000000200102005128100010000000000000000000000000000000000000000000000000010000000000000000200102005128100000000000000000000000000000000000000000002001020051180Limit HOB elevation to 30 degTGltaXQgaGVhZCBvZiBiZWQgZWxldmF0aW9uIHRvIDMwIGRlZ3JlZXMgYW5kIGVuY291cmFnZSAz MC1kZWdyZWUgc2lkZWx5aW5nIHBvc2l0aW9uIHdoZW4gaW4gYmVkLiBEbyBub3QgcG9zaXRpb24g ZGlyZWN0bHkgb24gdHJvY2hhbnRlci4gANAC025525500000100100000000001105251020000Arial800000179745740000000002001020051180000000000000000000000000000000000000000000000002001020051180000000000000000000000001000000000000000000000000000000100000000000000002001020051180000000000000000000000000000000000000000000020010200511801200102005125132001020051180120010200512513200102005162Position flat on back in bedANAD025525500000100100000000001105251020000Arial8000001842150400000000020010200516200000000000000000000000000000000000000000000000200102005162000000000000000000000001000000000000000000000000000000100000000000000002001020051620000000000000000000000000000000000000000000200102005162120010200512513200102005162120010200512513200102005163Use lifting devices:ANAE025525500000100100000000001105251020000Arial8000001842150400000000020010200516300000000000000000000000000000000000000000000000200102005163014UGxlYXNlIGxpc3Q6IA==0000000000000000000010000000000000000000000000000001000000000000000020010200516300000000000000000000000000000000000000000002001020051631200102005125132001020051631200102005125132001020051160Use pressure reducing devices:ANAF025525500000100100000000001105251020000Arial800000179745740000000002001020051160000000000000000000000000000000000000000000000002001020051160014UGxlYXNlIGxpc3Q6IA==000000000000000000001000000000000000000000000000000100000000000000002001020051160000000000000000000000000000000000000000000020010200511601200102005125132001020051160120010200512513200102005126Use skin protective devices:ANAG025525500000100100000000001105251020000Arial8000001842150400000000020010200512600000000000000000000000000000000000000000000000200102005126014UGxlYXNlIGxpc3Q6IA==000000000000000000001000000000000000000000000000000100000000000000002001020051260000000000000000000000000000000000000000000200102005126120010200512513200102005126120010200512513200102005164Monitor lab valuesANAH025525500000100100000000001105251020000Arial8000001842150400000000020010200516400000000000000000000000000000000000000000000000200102005164000000000000000000000001000000000000000000000000000000100000000000000002001020051640000000000000000000000000000000000000000000200102005164120010200512513200102005164120010200512513200102005183Eval skin under tubing/devicesRXZhbHVhdGUgc2tpbiB1bmRlciB0dWJpbmcgYW5kIG90aGVyIGRldmljZXMgdGhhdCBhcmUgaW4g ZGlyZWN0IGNvbnRhY3Qgd2l0aCBza2luIA==ANAI025525500000100100000000001105251020000Arial8000001797457400000000020010200518300000000000000000000000000000000000000000000000200102005183000000000000000000000001000000000000000000000000000000100000000000000002001020051830000000000000000000000000000000000000000000200102005183120010200512513200102005183120010200512513200102005125Note nutrition/hydr statusTm90ZSBudXRyaXRpb24gYW5kIGh5ZHJhdGlvbiBzdGF0dXMgYW5kIGFkZHJlc3Mgc291cmNlcyBv ZiBkZWZpY2llbmN5IA==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 relieving - chairUHJlc3N1cmUgcmVsaWV2aW5nIGRldmljZShzKSBmb3IgY2hhaXIgIA==AOAC22122120000000000100000000001105251020010Arial800011112800000000020010200514500000000000000000000000000000000000000000000000200102005145000000000000000000000001000000000000000000000000000000100000000000000002001020051450000000000000000000000000000000000000000000200102005145120010200512513200102005145120010200512513200102005146Pressure relieving- bedUHJlc3N1cmUgcmVsaWV2aW5nIGRldmljZShzKSAgZm9yIGJlZCAgAOAD22122120000000000100000000001105251020010Arial800011112800000000020010200514600000000000000000000000000000000000000000000000200102005146000000000000000000000001000000000000000000000000000000100000000000000002001020051460000000000000000000000000000000000000000000200102005146120010200512513200102005146120010200512513200102005147Monitor turning/repositioningTW9uaXRvciB0dXJuaW5nL3JlcG9zaXRpb24gcHJvZ3JhbSAgIA==AOAE22122120000000000100000000001105251020010Arial800011112800000000020010200514700000000000000000000000000000000000000000000000200102005147000000000000000000000001000000000000000000000000000000100000000000000002001020051470000000000000000000000000000000000000000000200102005147120010200512513200102005147120010200512513200102005150Monitor nutrition/hydrationTW9uaXRvciBudXRyaXRpb24gb3IgaHlkcmF0aW9uIGludGVydmVudGlvbnMgdG8gbWFuYWdlIHNr aW4gcHJvYmxlbXMsIA==AOAF22122120000000000100000000001105251020010Arial800011112800000000020010200515000000000000000000000000000000000000000000000000200102005150000000000000000000000001000000000000000000000000000000100000000000000002001020051500000000000000000000000000000000000000000000200102005150120010200512513200102005150120010200512513200102005148Provide ulcer careAOAG22122120000000000100000000001105251020010Arial8000111128000000000200102005148000000000000000000000000000000000000000000000002001020051480000000000000000000000010000000000000000000000000000001000000000000000020010200514800000000000000000000000000000000000000000002001020051481200102005125132001020051481200102005125132001020051352APAA12812864255255255000000000000000002550001Arial140050101842150400000000020010200513520000000000000000000000000000000000000000000000020010200513520001000000000000000000000000000000000000000000000000001000000000000000020010200513520000000000000000000000000000000000000000000200102005149Provide surgical wound careAPAC22122120000000000100000000001105251020010Arial800011112800000000020010200514900000000000000000000000000000000000000000000000200102005149000000000000000000000001000000000000000000000000000000100000000000000002001020051490000000000000000000000000000000000000000000200102005149120010200512513200102005149120010200512513200102005166Apply drsgs other than feetQXBwbHkgZHJlc3NpbmdzICh3aXRoIG9yIHdpdGhvdXQgdG9waWNhbCBtZWRpY2F0aW9ucykgb3Ro ZXIgdGhhbiB0byBmZWV0ICAgAPAD22122120000000000100000000001105251020010Arial800011112800000000020010200516600000000000000000000000000000000000000000000000200102005166000000000000000000000001000000000000000000000000000000100000000000000002001020051660000000000000000000000000000000000000000000200102005166120010200512513200102005166120010200512513200102005167Apply oints/rx other than feetQXBwbHkgb2ludG1lbnRzL21lZGljYXRpb25zIChvdGhlciB0aGFuIHRvIGZlZXQpICA=APAE22122120000000000100000000001105251020010Arial800011112800000000020010200516700000000000000000000000000000000000000000000000200102005167000000000000000000000001000000000000000000000000000000100000000000000002001020051670000000000000000000000000000000000000000000200102005167120010200512513200102005167120010200512513200102005169Apply drsg to feetQXBwbHkgZHJlc3NpbmcgKHdpdGggb3Igd2l0aG91dCB0b3BpY2FsIG1lZGljYXRpb25zKSAgIA== APAF22122120000000000100000000001105251020010Arial8000111128000000000200102005169000000000000000000000000000000000000000000000002001020051690000000000000000000000010000000000000000000000000000001000000000000000020010200516900000000000000000000000000000000000000000002001020051691200102005125132001020051691200102005125132001020051280AQAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005128000000000000000000000000000000000000000000000000200102005128000010000000000000000000000000000000000000000000000000010000000000000000200102005128000000000000000000000000000000000000000000002001020051283ARAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005128300000000000000000000000000000000000000000000000200102005128300010000000000000000000000000000000000000000000000000010000000000000000200102005128300000000000000000000000000000000000000000002001020051252Nurse Aide ---ARAB12806425525525510100000000000001105251021010Arial8000111000000000020010200512520000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200512520000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200512520000000000000000000000000000001000000000000000020010200512520000010000000000000000000000000000000000000000000000001000000000000000020010200512520000000000000000000000000000000000000000000200102005171Assist with hygiene/skin careQXNzaXN0IHdpdGggaHlnaWVuZSBhbmQgZ2VuZXJhbCBza2luIGNhcmUuIEF2b2lkIHVzaW5nIGhv dCB3YXRlciBmb3IgY2xlYW5zaW5nLiA=ARAC025525500000100100000000001105251020000Arial80000018421504000000000200102005171000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051710000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517100000000100000000000000000000000000000000000000200102005171000000000000000000000001000000000000000000000000000000100000000000000002001020051710000000000000000000000000000000000000000000200102005171120010200512523200102005171120010200512523200102005173Repos q2h when in bedUmVwb3NpdGlvbiBldmVyeSB0d28gaG91cnMgd2hpbGUgaW4gYmVkIA==ARAD025525500000100100000000001105251020000Arial800000184215040000000002001020051731200122002816002001020051732200082001230002001020051730000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517300000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005173000000001000000000000000000000000000000000000002001020051730000000000000010000000010001000000000000000000000000001000000000000000020010200517300000000000000000000000000000000000000000002001020051731200102005125232001020051731200102005125232001020051112Reposition q1h in chairUmVwb3N0aXRpb24gZXZlcnkgaG91ciB3aGVuIHVwIA==ARAE025525500000100100000000001105251020000Arial80000018421504000000000200102005111212001220028160020010200511122200082001230002001020051112000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051112000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051112000000001000000000000000000000000000000000000002001020051112000000000000001000000001000100000000000000000000000000100000000000000002001020051112000000000000000000000000000000000000000000020010200511121200102005125232001020051112120010200512523200102005174Special repositioning scheduleU3BlY2lhbCByZXBvc2l0aW9uaW5nIHNjaGVkdWxlOiA=ARAF025525500000100100000000001105251020000Arial80000018421504000000000200102005174000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051740000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517400000000100000000000000000000000000000000000000200102005174014QnJpZWZseSBkZXNjcmliZTog000000000000000000001000000000000000000000000000000100000000000000002001020051740000000000000000000000000000000000000000000200102005174120010200512523200102005174120010200512523200102005175Minimize pressure on bony promTWluaW1pemUgcHJlc3N1cmUgb24gYm9ueSBwcm9taW5lbmNlcyA=ARAG025525500000100100000000001105251020000Arial80000018421504000000000200102005175000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051750000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517500000000100000000000000000000000000000000000000200102005175000000000000000000000001000000000000000000000000000000100000000000000002001020051750000000000000000000000000000000000000000000200102005175120010200512523200102005175120010200512523200102005176Offer fluids with position chgT2ZmZXIgZmx1aWRzIHdpdGggcG9zaXRpb24gY2hhbmdlcyA=ARAH025525500000100100000000001105251020000Arial80000018421504000000000200102005176000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051760000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517600000000100000000000000000000000000000000000000200102005176000000000000000000000001000000000000000000000000000000100000000000000002001020051760000000000000000000000000000000000000000000200102005176120010200512523200102005176120010200512523200102005177Encourage ambulationARAI025525500000100100000000001105251020000Arial800000184215040000000002001020051770000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517700000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005177000000001000000000000000000000000000000000000002001020051770000000000000000000000010000000000000000000000000000001000000000000000020010200517700000000000000000000000000000000000000000002001020051771200102005125232001020051771200102005125232001020051353ASAA12812864255255255000000000000000002550001Arial140050101842150400000000020010200513530000000000000000000000000000000000000000000000020010200513530001000000000000000000000000000000000000000000000000001000000000000000020010200513530000000000000000000000000000000000000000000200102005192TED hose on in AM, off at HSASAC025525500000100100000000001105251020000Arial80000018421504000000000200102005192000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051920000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200519200000000100000000000000000000000000000000000000200102005192000000000000000000000001000000000000000000000000000000100000000000000002001020051920000000000000000000000000000000000000000000200102005192120010200512523200102005192120010200512523200102005155Report changes to nurseASAD025525500000100100000000001105251020000Arial8000001797457400000000020010200515500000000000000000000000000000000000000000000000200102005155000000000000000000000001000000000000000000000000000000100000000000000002001020051550000000000000000000000000000000000000000000200102005155120010200512523200102005155120010200512523200102005178Use pillows for supportASAE025525500000100100000000001105251020000Arial800000184215040000000002001020051780000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517800000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005178000000001000000000000000000000000000000000000002001020051780000000000000000000000010000000000000000000000000000001000000000000000020010200517800000000000000000000000000000000000000000002001020051781200102005125232001020051781200102005125232001020051117Use moisturizer with caresASAF025525500000100100000000001105251020000Arial800000184215040000000002001020051117000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051117000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051117000000000000000000000000000000000000000000000002001020051117000000000000000000000001000000000000000000000000000000100000000000000002001020051117000000000000000000000000000000000000000000020010200511171200102005125232001020051117120010200512523200102005179Keep skin clean and dryASAG025525500000100100000000001105251020000Arial80000018421504000000000200102005179000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051790000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200517900000000100000000000000000000000000000000000000200102005179000000000000000000000001000000000000000000000000000000100000000000000002001020051790000000000000000000000000000000000000000000200102005179120010200512523200102005179120010200512523200102005180Use lift sheetVXNlIGxpZnQgc2hlZXQgd2hlbiBtb3ZpbmcgcmVzaWRlbnQgaW4gYmVkIA==ASAH025525500000100100000000001105251020000Arial80000018421504000000000200102005180000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051800000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200518000000000100000000000000000000000000000000000000200102005180000000000000000000000001000000000000000000000000000000100000000000000002001020051800000000000000000000000000000000000000000000200102005180120010200512523200102005180120010200512523200102005194Up with mechanical liftASAI025525500000100100000000001105251020000Arial800000184215040000000002001020051940000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200519400000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005194000000001000000000000000000000000000000000000002001020051940000000000000000000000010000000000000000000000000000001000000000000000020010200519400000000000000000000000000000000000000000002001020051941200102005125232001020051941200102005125232001020051354ATAA12812864255255255000000000000000002550001Arial140050101842150400000000020010200513540000000000000000000000000000000000000000000000020010200513540001000000000000000000000000000000000000000000000000001000000000000000020010200513540000000000000000000000000000000000000000000200102005193Keep elbows tucked inATAC025525500000100100000000001105251020000Arial80000018421504000000000200102005193000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051930000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200519300000000100000000000000000000000000000000000000200102005193000000000000000000000001000000000000000000000000000000100000000000000002001020051930000000000000000000000000000000000000000000200102005193120010200512523200102005193120010200512523200102005184Use incontinence padsATAD025525500000100100000000001105251020000Arial800000184215040000000002001020051840000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200518400000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005184000000001000000000000000000000000000000000000002001020051840000000000000000000000010000000000000000000000000000001000000000000000020010200518400000000000000000000000000000000000000000002001020051841200102005125232001020051841200102005125232001020051113Barrier cream to peri areaATAE025525500000100100000000001105251020000Arial800000184215040000000002001020051113000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051113000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051113000000001000000000000000000000000000000000000002001020051113000000000000000000000001000000000000000000000000000000100000000000000002001020051113000000000000000000000000000000000000000000020010200511131200102005125232001020051113120010200512523200102005188Keep bony prom from touchingVXNlIHBpbGxvd3MgdG8ga2VlcCBib255IHByb21pbmVuY2VzIGZyb20gZGlyZWN0IGNvbnRhY3Qg d2l0aCBlYWNoIG90aGVyLiA=ATAF025525500000100100000000001105251020000Arial80000018421504000000000200102005188000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051880000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200518800000000100000000000000000000000000000000000000200102005188000000000000000000000001000000000000000000000000000000100000000000000002001020051880000000000000000000000000000000000000000000200102005188120010200512523200102005188120010200512523200102005189Enc not to pick affected 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 not position on ulcer/redRG8gbm90IHBvc2l0aW9uIHJlc2lkZW50IGRpcmVjdGx5IG9uIHByZXNzdXJlIHVsY2VyIG9yIGFy ZWFzIG9mIHJlZG5lc3MuIA==ATAH025525500000100100000000001105251020000Arial80000017974574000000000200102005187000000000000000000000000000000000000000000000002001020051870000000000000000000000010000000000000000000000000000001000000000000000020010200518700000000000000000000000000000000000000000002001020051871200102005125232001020051871200102005125232001020051176Keep heels elevated in bedATAI025525500000100100000000001105251020000Arial8000001797457400000000020010200511760000000000000000000000000000000000000000000000020010200511760000000000000000000000010000000000000000000000000000001000000000000000020010200511760000000000000000000000000000000000000000000200102005117612001020051252320010200511761200102005125232001020051282AUAA12812864255255255000000000000000002550001Arial140050101842150400000000020010200512820000000000000000000000000000000000000000000000020010200512820001000000000000000000000000000000000000000000000000001000000000000000020010200512820000000000000000000000000000000000000000000200102005133830 deg lateral sidelyingMzAgZGVncmVlIGxhdGVyYWwgc2lkZWx5aW5nIHBvc2l0aW9uOyBkbyBub3QgcGxhY2UgZGlyZWN0 bHkgb24gaGlwLiA=AUAC025525500000100100000000001105251020000Arial8000001842150400000000020010200513380000000000000000000000000000000000000000000000020010200513380000000000000000000000010000000000000000000000000000001000000000000000020010200513380000000000000000000000000000000000000000000200102005133812001020051252320010200513381200102005125232001020051177Use pressure relief devices:AUAD025525500000100100000000001105251020000Arial800000179745740000000002001020051177000000000000000000000000000000000000000000000002001020051177014UGxlYXNlIGxpc3Q6IA==0000000000000000000010000000000000000000000000000001000000000000000020010200511770000000000000000000000000000000000000000000200102005117712001020051252320010200511771200102005125232001020051115Heel protectors,AUAE025525500000100100000000001105251020000000000184215040000000002001020051115000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051115000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051115000000001000000000000000000000000000000000000002001020051115000000000000000000000001000000000000000000000000000000000000000000000002001020051115000000000000000000000000000000000000000000020010200511151200102005125232001020051115120010200512523200102005186Elbow protectors,AUAF025525500000100100000000001105251020000000000184215040000000002001020051860000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200518600000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005186000000001000000000000000000000000000000000000002001020051860000000000000000000000010000000000000000000000000000000000000000000000020010200518600000000000000000000000000000000000000000002001020051861200102005125232001020051861200102005125232001020051116Protective sleeves,AUAG025525500000100100000000001105251020000Arial800000184215040000000002001020051116000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051116000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051116000000001000000000000000000000000000000000000002001020051116000000000010000000000001000000000000000000000000000000100000000000000002001020051116000000000000000000000000000000000000000000020010200511161200102005125232001020051116120010200512523200102005191Padded siderails,AUAH025525500000100100000000001105251020000Arial80000018421504000000000200102005191000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051910000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200519100000000100000000000000000000000000000000000000200102005191000000000000000000000001000000000000000000000000000000100000000000000002001020051910000000000000000000000000000000000000000000200102005191120010200512523200102005191120010200512523200102005181Linen clean /dry /no wrinklesS2VlcCBsaW5lbiBjbGVhbiwgZHJ5LCBhbmQgd3JpbmtsZSBmcmVlLCA=AUAI025525500000100100000000001105251020000Arial800000184215040000000002001020051810000000000000000000000000000000200000000000001101110000000000000000000000000000000020010200518100000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005181000000001000000000000000000000000000000000000002001020051810000000000000000000000010000000000000000000000000000001000000000000000020010200518100000000000000000000000000000000000000000002001020051811200102005125232001020051811200102005125232001020051284AVAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005128400000000000000000000000000000000000000000000000200102005128400010000000000000000000000000000000000000000000000000010000000000000000200102005128400000000000000000000000000000000000000000002001020051285AWAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005128500000000000000000000000000000000000000000000000200102005128500010000000000000000000000000000000000000000000000000010000000000000000200102005128500000000000000000000000000000000000000000002001020051253Restorative ---AWAB21220820000010100000000000001105251020000Arial80000018421504000000000200102005125300000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125300000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125300000000000000000000000000000000000000000000000200102005125300000100000000000000000000000000000000000000000000000010000000000000000200102005125300000000000000000000000000000000000000000002001020051101Restorative Nursing programUmVzdG9yYXRpdmUgTnVyc2luZyBwcm9ncmFtIHRvIG1heGltaXplIGZ1bmN0aW9uYWwgYWJpbGl0 eSAoc2VlIFJlc3RvcmF0aXZlIE51cnNpbmcgT3JkZXIpIA==AWAC025525500000100100000000001105251020000Arial8000001842150400000000020010200511010000000000000000000000000000000000000000000000020010200511010000000000000000000000010000000000000000000000000000001000000000000000020010200511010000000000000000000000000000000000000000000200102005110112001020051253320010200511011200102005125332001020051360Turning and Repositioning ProgVHVybmluZyBhbmQgUmVwb3NpdGlvbmluZyBQcm9ncmFtIA==AWAD025525500000100100000000001105251020000Arial8000001842150400000000020010200513600000000000000000000000000000000000000000000000020010200513600000000000000000000000010000000000000000000000000000001000000000000000020010200513600000000000000000000000000000000000000000000200102005136012001020051253320010200513601200102005125332001020051102Offer fluids before/afterT2ZmZXIgZmx1aWRzIGJlZm9yZSBhbmQgYWZ0ZXIgcHJvZ3JhbSA=AWAE025525500000100100000000001105251020000Arial8000001842150400000000020010200511020000000000000000000000000000000000000000000000020010200511020000000000000000000000010000000000000000000000000000001000000000000000020010200511020000000000000000000000000000000000000000000200102005110212001020051253320010200511021200102005125332001020051103Use special equipment:AWAF025525500000100100000000001105251020000Arial800000184215040000000002001020051103000000000000000000000000000000000000000000000002001020051103014UGxlYXNlIGRlc2NyaWJlOiA=0000000000000000000010000000000000000000000000000001000000000000000020010200511030000000000000000000000000000000000000000000200102005110312001020051253320010200511031200102005125332001020051104Note restrictions in positionTm90ZSByZXN0cmljdGlvbnMgaW4gcG9zaXRpb25pbmcgYW5kIHRyYW5zZmVycyA=AWAG025525500000100100000000001105251020000Arial8000001842150400000000020010200511040000000000000000000000000000000000000000000000020010200511040000000000000000000000010000000000000000000000000000001000000000000000020010200511040000000000000000000000000000000000000000000200102005110412001020051253320010200511041200102005125332001020051105Report changes to nurseAWAH025525500000100100000000001105251020000Arial8000001842150400000000020010200511050000000000000000000000000000000000000000000000020010200511050000000000000000000000010000000000000000000000000000001000000000000000020010200511050000000000000000000000000000000000000000000200102005110512001020051253320010200511051200102005125332001020051288AXAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005128800000000000000000000000000000000000000000000000200102005128800010000000000000000000000000000000000000000000000000010000000000000000200102005128800000000000000000000000000000000000000000002001020051106Report indicators of painAXAC025525500000100100000000001105251020000Arial8000001842150400000000020010200511060000000000000000000000000000000000000000000000020010200511060000000000000000000000010000000000000000000000000000001000000000000000020010200511060000000000000000000000000000000000000000000200102005110612001020051253320010200511061200102005125332001020051107Minimize friction/shearAXAD025525500000100100000000001105251020000Arial8000001842150400000000020010200511070000000000000000000000000000000000000000000000020010200511070000000000000000000000010000000000000000000000000000001000000000000000020010200511070000000000000000000000000000000000000000000200102005110712001020051253320010200511071200102005125332001020051108Do not position on press areaRG8gbm90IHBvc2l0aW9uIG9uIHdvdW5kIG9yIGFyZWFzIG9mIHByZXNzdXJlIA==AXAE025525500000100100000000001105251020000Arial8000001842150400000000020010200511080000000000000000000000000000000000000000000000020010200511080000000000000000000000010000000000000000000000000000001000000000000000020010200511080000000000000000000000000000000000000000000200102005110812001020051253320010200511081200102005125332001020051109Note time of position changeTm90ZSB0aW1lIG9mIHBvc2l0aW9uIGNoYW5nZSB0byBkaXJlY3QgY2FyZSBzdGFmZiA=AXAF025525500000100100000000001105251020000Arial8000001842150400000000020010200511090000000000000000000000000000000000000000000000020010200511090000000000000000000000010000000000000000000000000000001000000000000000020010200511090000000000000000000000000000000000000000000200102005110912001020051253320010200511091200102005125332001020051187Note skin around deviceTm90ZSBza2luIGNvbmRpdGlvbiBhcm91bmQgZWRnZXMgb2YgZGV2aWNlOyByZXBvcnQgY2hhbmdl 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 ---AZAB21220820000010100000000000001105251020000Arial80000018421504000000000200102005125400000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125400000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125400000000000000000000000000000000000000000000000200102005125400000100000000000000000000000000000000000000000000000010000000000000000200102005125400000000000000000000000000000000000000000002001020051158Dietary consultAZAC025525500000100100000000001105251020000Arial8000001797457400000000020010200511580000000000000000000000000000000000000000000000020010200511580000000000000000000000010000000000000000000000000000001000000000000000020010200511580000000000000000000000000000000000000000000200102005115812001020051254320010200511581200102005125432001020051126Monitor lab valuesAZAD025525500000100100000000001105251020000Arial8000001842150400000000020010200511260000000000000000000000000000000000000000000000020010200511260000000000000000000000010000000000000000000000000000001000000000000000020010200511260000000000000000000000000000000000000000000200102005112612001020051254320010200511261200102005125432001020051159Monitor weightAZAE025525500000100100000000001105251020000Arial8000001797457400000000020010200511590000000000000000000000000000000000000000000000020010200511590000000000000000000000010000000000000000000000000000001000000000000000020010200511590000000000000000000000000000000000000000000200102005115912001020051254320010200511591200102005125432001020051121Provide additional fluidsAZAF025525500000100100000000001105251020000Arial8000001842150400000000020010200511210000000000000000000000000000000000000000000000020010200511210000000000000000000000010000000000000000000000000000001000000000000000020010200511210000000000000000000000000000000000000000000200102005112112001020051254320010200511211200102005125432001020051127Provide nutrition supplementUHJvdmlkZSBudXRyaXRpb25hbCBzdXBwbGVtZW50IA==AZAG025525500000100100000000001105251020000Arial8000001842150400000000020010200511270000000000000000000000000000000000000000000000020010200511270000000000000000000000010000000000000000000000000000001000000000000000020010200511270000000000000000000000000000000000000000000200102005112712001020051254320010200511271200102005125432001020051122Monitor calorie intakeAZAH025525500000100100000000001105251020000Arial8000001842150400000000020010200511220000000000000000000000000000000000000000000000020010200511220000000000000000000000010000000000000000000000000000001000000000000000020010200511220000000000000000000000000000000000000000000200102005112212001020051254320010200511221200102005125432001020051290BAAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005129000000000000000000000000000000000000000000000000200102005129000010000000000000000000000000000000000000000000000000010000000000000000200102005129000000000000000000000000000000000000000000002001020051123Monitor protein intakeBAAC025525500000100100000000001105251020000Arial8000001842150400000000020010200511230000000000000000000000000000000000000000000000020010200511230000000000000000000000010000000000000000000000000000001000000000000000020010200511230000000000000000000000000000000000000000000200102005112312001020051254320010200511231200102005125432001020051124Identify favorite foodsBAAD025525500000100100000000001105251020000Arial8000001842150400000000020010200511240000000000000000000000000000000000000000000000020010200511240000000000000000000000010000000000000000000000000000001000000000000000020010200511240000000000000000000000000000000000000000000200102005112412001020051254320010200511241200102005125432001020051125Encourage family 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ZCBtb25pdG9yIGVmZmljYWN5IA==BAAG025525500000100100000000001105251020000Arial80000018421504000000000200102005122000000000000000000000000000000000000000000000002001020051220000000000000000000000010000000000000000000000000000001000000000000000020010200512200000000000000000000000000000000000000000002001020051221200102005125432001020051221200102005125432001020051339Maximize oral intakeBAAH025525500000100100000000001105251020000Arial8000001842150400000000020010200513390000000000000000000000000000000000000000000000020010200513390000000000000000000000010000000000000000000000000000001000000000000000020010200513390000000000000000000000000000000000000000000200102005133912001020051254320010200513391200102005125432001020051289BBAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005128900000000000000000000000000000000000000000000000200102005128900010000000000000000000000000000000000000000000000000010000000000000000200102005128900000000000000000000000000000000000000000002001020051291BCAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005129100000000000000000000000000000000000000000000000200102005129100010000000000000000000000000000000000000000000000000010000000000000000200102005129100000000000000000000000000000000000000000002001020051255SocServ ---BCAB025525500010100000000000001105251020000000000184215040000000002001020051255000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051255000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051255000000000000000000000000000000000000000000000002001020051255001001000000000000000000000000000000000000000000000000000000000000000002001020051131Clarify res concerns/goalsQ2xhcmlmeSByZXNpZGVudCdzIGNvbmNlcm5zIGFuZCBnb2FscyByZWdhcmRpbmcgc2tpbiBzdGF0 dXMgYW5kIGNhcmUgYXBwcm9hY2hlcyA=BCAC025525500000100100000000001105251020000Arial8000001842150400000000020010200511310000000000000000000000000000000000000000000000020010200511310000000000000000000000010000000000000000000000000000001000000000000000020010200511310000000000000000000000000000000000000000000200102005113112001020051255320010200511311200102005125532001020051132Determine advance directivesRGV0ZXJtaW5lIGFkdmFuY2UgZGlyZWN0aXZlcyByZWdhcmRpbmcgcGFyZW50ZXJhbCBzdXBwbGVt ZW50YXRpb24gBCAD025525500000100100000000001105251020000Arial8000001842150400000000020010200511320000000000000000000000000000000000000000000000020010200511320000000000000000000000010000000000000000000000000000001000000000000000020010200511320000000000000000000000000000000000000000000200102005113212001020051255320010200511321200102005125532001020051133Assist to obtain equipmentBCAE025525500000100100000000001105251020000Arial8000001842150400000000020010200511330000000000000000000000000000000000000000000000020010200511330000000000000000000000010000000000000000000000000000001000000000000000020010200511330000000000000000000000000000000000000000000200102005113312001020051255320010200511331200102005125532001020051134Enc family involvementRW5jb3VyYWdlIGZhbWlseSBpbnZvbHZlbWVudCA=BCAF025525500000100100000000001105251020000Arial8000001842150400000000020010200511340000000000000000000000000000000000000000000000020010200511340000000000000000000000010000000000000000000000000000001000000000000000020010200511340000000000000000000000000000000000000000000200102005113412001020051255320010200511341200102005125532001020051135Enc mobilization/activityRW5jb3VyYWdlIG1vYmlsaXphdGlvbiBhbmQgYWN0aXZpdHkgYXR0ZW5kYW5jZSBhcyB0b2xlcmF0 ZWQgBCAG025525500000100100000000001105251020000Arial8000001842150400000000020010200511350000000000000000000000000000000000000000000000020010200511350000000000000000000000010000000000000000000000000000001000000000000000020010200511350000000000000000000000000000000000000000000200102005113512001020051255320010200511351200102005125532001020051136Validate understandingBCAH025525500000100100000000001105251020000Arial8000001842150400000000020010200511360000000000000000000000000000000000000000000000020010200511360000000000000000000000010000000000000000000000000000001000000000000000020010200511360000000000000000000000000000000000000000000200102005113612001020051255320010200511361200102005125532001020051137Assist with referrals PRNQXNzaXN0IHdpdGggcmVmZXJyYWxzIGFzIG5lZWRlZCA=BCAI025525500000100100000000001105251020000Arial8000001842150400000000020010200511370000000000000000000000000000000000000000000000020010200511370000000000000000000000010000000000000000000000000000001000000000000000020010200511370000000000000000000000000000000000000000000200102005113712001020051255320010200511371200102005125532001020051186Facil dc needs r/t wound careRmFjaWxpdGF0ZSBkaXNjaGFyZ2UgbmVlZHMgcmVsYXRlZCB0byB3b3VuZCBjYXJlIGFuZCBwcmV2 ZW50aW9uIA==BCAJ025525500000100100000000001105251020000Arial8000001797457400000000020010200511860000000000000000000000000000000000000000000000020010200511860000000000000000000000010000000000000000000000000000001000000000000000020010200511860000000000000000000000000000000000000000000200102005118612001020051255320010200511861200102005125532001020051292BDAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005129200000000000000000000000000000000000000000000000200102005129200010000000000000000000000000000000000000000000000000010000000000000000200102005129200000000000000000000000000000000000000000002001020051293BEAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005129300000000000000000000000000000000000000000000000200102005129300010000000000000000000000000000000000000000000000000010000000000000000200102005129300000000000000000000000000000000000000000002001020051256Activity ---BEAB21220820000010100000000000001105251020000Arial80000018421504000000000200102005125600000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125600000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125600000000000000000000000000000000000000000000000200102005125600000100000000000000000000000000000000000000000000000010000000000000000200102005125600000000000000000000000000000000000000000002001020051141Identify interests/strengthsBEAC025525500000100100000000001105251020000Arial8000001842150400000000020010200511410000000000000000000000000000000000000000000000020010200511410000000000000000000000010000000000000000000000000000001000000000000000020010200511410000000000000000000000000000000000000000000200102005114112001020051256320010200511411200102005125632001020051142Invite/assist to activitiesSW52aXRlIGFuZCBhc3Npc3QgdG8gYWN0aXZpdGllcyA=BEAD025525500000100100000000001105251020000Arial8000001842150400000000020010200511420000000000000000000000000000000000000000000000020010200511420000000000000000000000010000000000000000000000000000001000000000000000020010200511420000000000000000000000000000000000000000000200102005114212001020051256320010200511421200102005125632001020051143Provide 1:1 activitiesBEAE025525500000100100000000001105251020000Arial8000001842150400000000020010200511430000000000000000000000000000000000000000000000020010200511430000000000000000000000010000000000000000000000000000001000000000000000020010200511430000000000000000000000000000000000000000000200102005114312001020051256320010200511431200102005125632001020051144Offer food during activitiesBEAF025525500000100100000000001105251020000Arial8000001842150400000000020010200511440000000000000000000000000000000000000000000000020010200511440000000000000000000000010000000000000000000000000000001000000000000000020010200511440000000000000000000000000000000000000000000200102005114412001020051256320010200511441200102005125632001020051145Enc fluids during activitiesRW5jb3VyYWdlIGZsdWlkIGludGFrZSBkdXJpbmcgYWN0aXZpdGllcyA=BEAG025525500000100100000000001105251020000Arial8000001842150400000000020010200511450000000000000000000000000000000000000000000000020010200511450000000000000000000000010000000000000000000000000000001000000000000000020010200511450000000000000000000000000000000000000000000200102005114512001020051256320010200511451200102005125632001020051146Encourage family involvementBEAH025525500000100100000000001105251020000Arial8000001842150400000000020010200511460000000000000000000000000000000000000000000000020010200511460000000000000000000000010000000000000000000000000000001000000000000000020010200511460000000000000000000000000000000000000000000200102005114612001020051256320010200511461200102005125632001020051147Note changes to nurseBEAI025525500000100100000000001105251020000Arial8000001842150400000000020010200511470000000000000000000000000000000000000000000000020010200511470000000000000000000000010000000000000000000000000000001000000000000000020010200511470000000000000000000000000000000000000000000200102005114712001020051256320010200511471200102005125632001020051184Avoid same position > 1 hrQXZvaWQgYWN0aXZpdGllcyB0aGF0IHByZXZlbnQgcG9zaXRpb24gY2hhbmdlcyBmb3Igb3ZlciBv bmUgaG91ciA=BEAJ025525500000100100000000001105251020000Arial8000001797457400000000020010200511840000000000000000000000000000000000000000000000020010200511840000000000000000000000010000000000000000000000000000001000000000000000020010200511840000000000000000000000000000000000000000000200102005118412001020051256320010200511841200102005125632001020051294BFAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005129400000000000000000000000000000000000000000000000200102005129400010000000000000000000000000000000000000000000000000010000000000000000200102005129400000000000000000000000000000000000000000002001020051295BGAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005129500000000000000000000000000000000000000000000000200102005129500010000000000000000000000000000000000000000000000000010000000000000000200102005129500000000000000000000000000000000000000000002001020051257P.T. ---BGAB21220820000010100000000000001105251020000Arial80000018421504000000000200102005125700000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125700000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125700000000000000000000000000000000000000000000000200102005125700000100000000000000000000000000000000000000000000000010000000000000000200102005125700000000000000000000000000000000000000000002001020051258O.T. ---BGAC21220820000010100000000000001105251020000Arial80000018421504000000000200102005125800000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125800000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125800000000000000000000000000000000000000000000000200102005125800000100000000000000000000000000000000000000000000000010000000000000000200102005125800000000000000000000000000000000000000000002001020051259S.L.P. ---BGAD21220820000010100000000000001105251020000Arial80000018421504000000000200102005125900000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125900000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005125900000000000000000000000000000000000000000000000200102005125900000100000000000000000000000000000000000000000000000010000000000000000200102005125900000000000000000000000000000000000000000002001020051111R.T. ---BGAE21220820000010100000000000001105251020000Arial80000018421504000000000200102005111100000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005111100000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005111100000000000000000000000000000000000000000000000200102005111100000100000000000000000000000000000000000000000000000010000000000000000200102005111100000000000000000000000000000000000000000002001020051151Evaluate/treat as indicatedBGAF025525500000100000000000001105251020000Arial80000018421504000000000200102005115100000000000000000000000000000000000000000000000200102005115100000000000000000000000000000000000000000000000000000010000000000000000200102005115100000000000000000000000000000000000000000002001020051152Maximize mobilityBGAG025525500000100000000000001105251020000Arial80000018421504000000000200102005115200000000000000000000000000000000000000000000000200102005115200000000000000000000000000000000000000000000000000000010000000000000000200102005115200000000000000000000000000000000000000000002001020051182Eval/provide pressure aidsRXZhbHVhdGUgYW5kIHByb3ZpZGUgcHJlc3N1cmUgcmVkdWNpbmcgYWlkcyBhcyBpbmRpY2F0ZWQg BGAH025525500000100000000000001105251020000Arial80000017974574000000000200102005118200000000000000000000000000000000000000000000000200102005118200000000000000000000000000000000000000000000000000000010000000000000000200102005118200000000000000000000000000000000000000000002001020051183Wound care as orderedUHJvdmlkZSB3b3VuZCBjYXJlIGFzIG9yZGVyZWQgBGAI025525500000100000000000001105251020000Arial80000017974574000000000200102005118300000000000000000000000000000000000000000000000200102005118300000000000000000000000000000000000000000000000000000010000000000000000200102005118300000000000000000000000000000000000000000002001020051340Instruct re repositioningSW5zdHJ1Y3QgcmVnYXJkaW5nIHRoZSBuZWVkIGZvciBmcmVxdWVudCByZXBvc2l0aW9uaW5nIA== BGAJ025525500000100000000000001105251020000Arial8000001842150400000000020010200513400000000000000000000000000000000000000000000000020010200513400000000000000000000000000000000000000000000000000000001000000000000000020010200513400000000000000000000000000000000000000000000200102005138Offer fluids before/after txT2ZmZXIgZmx1aWRzIGJlZm9yZSBhbmQgYWZ0ZXIgdHJlYXRtZW50cyA=BGAK025525500000100000000000001105251020000Arial80000018421504000000000200102005138000000000000000000000000000000000000000000000002001020051380000000000000000000000000000000000000000000000000000001000000000000000020010200513800000000000000000000000000000000000000000002001020051301Dev nursing restorative 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 Staff ---BIAB21220820000010100000000000001105251020000Arial800000184215040000000002001020051260000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051260000000000000000000000000000000020000000000000110111000000000000000000000000000000002001020051260000000000000000000000000000000000000000000000002001020051260000001000000000000000000000000000000000000000000000000100000000000000002001020051260000000000000000000000000000000000000000000020010200514Report changes to nurseBIAC025525500000100100000000001105251020000Arial8000001842150400000000020010200514000000000000000000000000000000000000000000000002001020051400000000000000000000000100000000000000000000000000000010000000000000000200102005140000000000000000000000000000000000000000000200102005141200102005126032001020051412001020051260320010200516Offer fluids frequentlyBIAD025525500000100100000000001105251020000Arial800000184215040000000002001020051600000000000000000000000000000000000000000000000200102005160000000000000000000000010000000000000000000000000000001000000000000000020010200516000000000000000000000000000000000000000000020010200516120010200512603200102005161200102005126032001020051276GoalBKAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005127600000000000000000000000000000000000000000000000200102005127600010000000000000000000000000000000000000000000000000010000000000000000200102005127600000000000000000000000000000000000000000002001020051263GOAL:BKAB21220820000010100000000000001105251020000Arial80000018421504000000000200102005126300000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005126300000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005126300000000000000000000000000000000000000000000000200102005126300000100000000000000000000000000000000000000000000000010000000000000000200102005126300000000000000000000000000000000000000000002001020051166No skin breakdownBKAC02552550000010010000000000110525102000000000018421504000000000200102005116600000000000000000000000000000000000000000000000200102005116600000000000000000000000100000000000000000000000000000000000000000000000200102005116612001020051263320010200511661200102005126332001020051167Normal skin turgorBKAD02552550000010010000000000110525102000000000018421504000000000200102005116700000000000000000000000000000000000000000000000200102005116700000000000000000000000100000000000000000000000000000000000000000000000200102005116712001020051263320010200511671200102005126332001020051168Regain skin integrityBKAE025525500000100100000000001105251020000Arial8000001842150400000000020010200511680000000000000000000000000000000000000000000000020010200511680000000000000000000000010000000000000000000000000000001000000000000000020010200511680000000000000000000000000000000000000000000200102005116812001020051263320010200511681200102005126332001020051162No skin tearsBKAF02552550000010010000000000110525102000000000018421504000000000200102005116200000000000000000000000000000000000000000000000200102005116200000000000000000000000100000000000000000000000000000000000000000000000200102005116212001020051263320010200511621200102005126332001020051165Decreased wound sizeBKAG025525500000100100000000001105251020000Arial8000001842150400000000020010200511650000000000000000000000000000000000000000000000020010200511650000000000000000000000010000000000000000000000000000001000000000000000020010200511650000000000000000000000000000000000000000000200102005116512001020051263320010200511651200102005126332001020051173No discoloration to skinBKAH025525500000100100000000001105251020000Arial8000001842150400000000020010200511730000000000000000000000000000000000000000000000020010200511730000000000000000000000010000000000000000000000000000001000000000000000020010200511730000000000000000000000000000000000000000000200102005117312001020051263320010200511731200102005126332001020051175Decreased riskRGVjcmVhc2VkIHJpc2sgb2Ygc2tpbiBicmVha2Rvd24gBKAI025525500000100100000000001105251020000Arial8000001842150400000000020010200511750000000000000000000000000000000000000000000000020010200511750000000000000000000000010000000000000000000000000000001000000000000000020010200511750000000000000000000000000000000000000000000200102005117512001020051263320010200511751200102005126332001020051163No sign/symptom of infectionTm8gc2lnbiBvciBzeW1wdG9tIG9mIGluZmVjdGlvbg==BKAJ025525500000100100000000001105251020000Arial8000001842150400000000020010200511630000000000000000000000000000000000000000000000020010200511630000000000000000000000010000000000000000000000000000001000000000000000020010200511630000000000000000000000000000000000000000000200102005116312001020051263320010200511631200102005126332001020051277BLAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005127700000000000000000000000000000000000000000000000200102005127700010000000000000000000000000000000000000000000000000010000000000000000200102005127700000000000000000000000000000000000000000002001020051278BMAA12812864255255255000000000000000002550001Arial1400501018421504000000000200102005127800000000000000000000000000000000000000000000000200102005127800010000000000000000000000000000000000000000000000000010000000000000000200102005127800000000000000000000000000000000000000000002001020051264GOAL TIME:BMAB21220820000010100000000000001105251020000Arial80000018421504000000000200102005126400000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005126400000000000000000000000000000002000000000000011011100000000000000000000000000000000200102005126400000000000000000000000000000000000000000000000200102005126400000100000000100000000001000000000000000000000000000010000000000000000200102005126400000000000000000000000000000000000000000002001020051341Specify Date:IA==BMAC025525500000100100000000001105251020000Arial8000001842150400000000020010200513410000000000000000000000000000000000000000000000020010200513410120000000000000000000010000000000000000000000000000001000000000000000020010200513410000000000000000000000000000000000000000000200102005134112001020051264320010200513411200102005126432001020051191One weekBMAD02552550000010010000000000110525102000000000018421504000000000200102005119100000000000000000000000000000000000000000000000200102005119100000000000000000000000100000000000000000000000000000000000000000000000200102005119112001020051264320010200511911200102005126432001020051192Two weeksBMAE02552550000010010000000000110525102000000000018421504000000000200102005119200000000000000000000000000000000000000000000000200102005119200000000000000000000000100000000000000000000000000000000000000000000000200102005119212001020051264320010200511921200102005126432001020051193Three weeksBMAF02552550000010010000000000110525102000000000018421504000000000200102005119300000000000000000000000000000000000000000000000200102005119300000000000000000000000100000000000000000000000000000000000000000000000200102005119312001020051264320010200511931200102005126432001020051194One monthBMAG02552550000010010000000000110525102000000000018421504000000000200102005119400000000000000000000000000000000000000000000000200102005119400000000000000000000000100000000000000000000000000000000000000000000000200102005119412001020051264320010200511941200102005126432001020051195Two monthsBMAH02552550000010010000000000110525102000000000018421504000000000200102005119500000000000000000000000000000000000000000000000200102005119500000000000000000000000100000000000000000000000000000000000000000000000200102005119512001020051264320010200511951200102005126432001020051196Three 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20010Nursing Care Plans3617721901Arial1010

119TCP (Skin Integrity)/Ulcer0000000000110000138060000001191200102005124611192200102005111119320010200512511119420010200511381119520010200511391119620010200517211197200102005115311198200102005152111992001020051641119102001020051251119112001020051252111912200102005175111913200102005155111914200102005178111915200102005111711191620010200517911191720010200518111191820010200512601119192001020051411192020010200512631119212001020051163111922200102005116811192320010200512641119242001020051192113806TCP (Skin Integrity)/Ulcer2201380611138061110100138061112001020051246-1-1-1-1