[angelique777]

I got the book through amazon.com

http://www.amazon.com/gp/product/032...books&v=glance


that should take you right the book at amazon.com

hope it helps

Angela

[angelique777]

[b]NEURO:[/B] Pt recvd AXOX3 (1 2 3 Confused) Speech CLear( nonverbal, slurred etc)Pt has symmetrical strength and sensation with no paresthesia ( ex.or pt has weakness left side etc) . Pt pupils are PERRL, ( or pt has difference in pupil size or has afferent pupil defect etc) and gag reflex intac. Behaviour appropriate to situation. ( or not appropriate etc, calm composed, agitated, If patient has seizures etc)

Cardio: Vital Signs(apical hr, hear rhythm, BP, temp, PO2.pain: pain location type of pain, if radiating non radiating at rest with movement etc describe (0-10)) Are they wnl. as compared to pt baseline. IS Rhythm regular. If edema present ( +1, +2, +3 ....pitting non pitting location extremities , face, hands etc) Calf tenderness, if pt has any palpitations,Absence or presence of JVD. Absence or presence of Chest pain. capillary refil less than 2secs, +PPP equal bilateral


GASTRO: BS sounds + All 4Q.( or not if not what was done) ABdomen soft, nontender, nondistended. (note if bowel sounds active or not )Last BM (date and consistency if regular not regular, if noted any bleeding) Pain or no pain. Palpitations (as in AAA). IF they have N/V/D. Diet , lost of appetitie, weight gain.

GENTI: Voiding patterns (adequate amount, if clear, amber, cloudy, frequency, urgency,, dysuria, hematuria, or nocturia, Bladder distention present or not.

Skin: Skin warm, dry, intact, Color, (if not what the problem what the intervention) (describe size if ulcer present location etc type dressing if any place)

MUSCULOskeletal: Ability to perform ADLS(assistance needed, complete care, self care,) ROM, muscle strength, Steady gait, fall risk etc uses cane , walker, wheelchair etc

psychosocial:communication patterns, mood, effect, coping mechanism (anxious, agitated, violent, calm , composed, note if verbal encouragement provided) intellect Thought processes intact. PT has or does not have family support. Pt lives alone or has help. Pt ability to understand (is there a language barrierm, cognitive problem ( pt is slow to understand, is patient able to understand and comprehend instructions)

Peripheral Site: IV solution, is site intact, dry clean dressing, (iv Left AC #18g heplock infusing NS @ 75cc/hr site intact, no pain, no redness, no swelling pt has no complaint. will continue to monitor) ( should be change Q72hrs so note date inserted) ( same observation for Central lines)

Examples of modification to the above based on your pt problem.
Note for all of the above if any system has a problem note objective data and note intervention and note if improvement observed.

example pt tachycardic rate of 120bpm , PA Smith made aware pt given lopressor 50mg. Note pt heart rate improved hr now 86. or pt heart still tachy pt given bolus lopressor etc)

OR pt SOB PO2 87% room air. Pt placed on 2LNC nebulizer treatment given atrovent. PA smith made aware will continue to monitor. Pt PO2 now 98% with 2lnc will continue to monitor.

Pt anxious about procedure, pt explained what was going to be done . pt allowed to express fears verbal encourgement provided. pt states they understand. note pt less anxious now resting comfortable

PT has midsternal chest pain radiating to the left arm. Pt placed on 2lnc. PA smith made aware. Pt given sublingual nitro 0.4mg with no improvement in pain. pt rates pain =10. Pt given second dose of sublingual nitro.0.4mg......etc, pt noted some improvement. Pt placed on Nitro drip @ 8cc/hr will continue to monitor .VSS BP 120/80. hr= 90 will continue to monitor. PT chest pain relieved......etc.

So the above is modified based on your patient and based on whether the patient had a problem or not and what was done , who did you inform what did you do and how the pt reacted to the treatment.

I still consider myself a novice since not completed a yr yet in nursing so more experience nursing can modify. Not saying this is it for all your patient but it does give you and outline of all the systems and what your looking for as a guide and modifications made based on the condition of your patient.

Good luck

Angela

[candyndel]

Very well seasoned nurses also share your opinions and frustrations about charting, too- so know you are not alone. If it was so easy, there wouldnt be lectures, conferences and books on it, right??
I actually began ED nursing when our charting was done on a plain sheet of paper, too. It was actually much easier!! Switching over to EMRs was difficult!
I cant stress how important 'good' charting is...having known many nurses subpoenaed and having a med/mal attorney for a sister biases me slightly, though...
I think with experience comes knowing what is important and what isnt. And you are def on the right track!!



This is really good advice, and I try to do this, but I just don't have time to document it all. In my ED we don't have EKG techs, we don't have nurse's aides or ED techs the majority of the time. We don't have IV start kits. We often don't have working BP cuffs/monitors. We don't have computerized documentation.

I feel like I just don't have time to document everything I should, so that's why I just do a more fucused assessment. Of course, the sicker the pt. the more I will try to document.

Documentation, to me, is perhaps the hardest part of nursing. There is a constant fear of omission, yet I don't have time for inclusion.[/quote]