[AdelaideChic]

Hi!
Im a bit confused at the moment (well, more so than usual) . Whenever i go to write my nursing notes, i freeze and forget everything . I usually remember, but i want to cut down on the nervousness and the length of time it takes me to write notes.

Can anyone help me out with nursing notes based on the body systems ie: CNS, CVS, Renal, GIT, Metabolic, Skin integ, Social....
I have the list of the systems, but where i used to work had a double sided A4 sheet which listed each thing that went under each heading. Ive been searching the net for ages and cant find anything like it.

Can someone PLEASE direct me to a link, or something to help me out?

Thanks stacks in advance for anyone so kind to help!!!

[Katnip]

I just made up my own cheat sheets to help me remember the details. Just List the systems from head down, then add things to prompt you like meds, dressing changes, etc.

[AdelaideChic]

Thanks cyberkat, ive sorta been jotting things down as I go, but i might try to compile it now!

Any other hints or advice?

Im considering asking someone from my old workplace to try and photocopy that sheet for me, but people werent too happy when i left (I left cos i graduated my RN and i didnt accept the program that my previous workplace offered me, i went somewhere bigger, i dont think they were too happy...)

Thanks

[drpsrn]

When I was a new nurse on a trauma acute care floor, I found it was much easier if I charted the second I stepped out of the room. It only took a few minutes and I could remember right then. I could easily move on to my next patient and didn't have to recall everything about 5-6 patients after I had seen all of them. This also made my charting throughout the day easier and quicker. Good luck.

[cardiodiot]

Easiest way for me:
HEENT: head, eyes, ears, nose, throat
Chest: cardiac & resp
GI: yep
Extremities: you can include trunk, ie pressure sores, etc

For ROV purposes:
HEENT: HA, dizziness, syncope, presyncope, fatigue, weakness, cough, nosebleeds
Chest: CP, SOB, DOE, PND, orthopnea
GI: n/v/d
Extrem: neuro, edema, & depends upon how detailed you wanna be.

hope it helps.

[AfloydRN]

Start w/ the head and work your way down. Every system is covered.

[GatorRN]

I've always found it easier since I'm doing a head to toe assessment, to chart from head to toe. By doin so all systems are covered. Such as:

Vitals
LOC/A&O
Eyes/PERRLA
Skin/dressings
Lungs
ABD
Pulses
MAE or not
any IV's, O2, Ng....etc
Foley/drains
Teds/SCD
Safety....Bed low, rails up X2 etc...

Hope this helps...this way has just always been easier to remember for me, rather then breaking down systems.

________________________________

Go Gators!! 1/8/7 ~ 41-14
National Champions!!

[MARIAN202]

neurological Assessment
Alert And Oriented To Person, Time
Behavior Appropriate To Situation And Memory Intact
Extremities With Symmetry Of Strength
No Numbness Or Parathesis; Face Symmetricial
Vebalization Clear And Understandable

cardiovascular Assessment
Regular Rhythm, Rate 60-100/min, Bp Stable
No Peripheral Edema
No Dizziness, Chest Pain Or Pressure

respiratory
Regular Rate 10-20/ Min
Breath Sounds Clear And Unlabored
No Sputum Or Sputum Clear, White, Or Pale Yellow

gastrointestinal
Abdominal, Soft, Non-distended With Bowel Sounds
Bm's Within The Last 3 Days Prior
Light To Dark Brown, Formed Stool
No Emesis Or Diarrhea

nutrition
Taking Average Of 75% Diet Over Last 3 Days.
Tolerating Food And Fluid.
No Difficulity Chewing Or Swallowing Or Mouth Pain

genitourinary
Urine Clear To Yellow.
No Signs Current Infect.,drainage, Trauma, Bleeding, Retention.

musculoskeletal/mobility
No Redness, Swelling Or Deformity
Normal Rom Of Extremities

integumentary
Skin Color Within Patient's Normal, Afebrile.
Skin Dry And Intact With No Rashes, Lesions Or Ecchymosis.

intravenous Assement (all Sites)
Site Without Signs Or Symptoms Of Redness, Swelling, Or Pain
Dressing Dry Intact
Cath Is Intact When Discontinued

pain Management Assessment
Pain Free (obtain Order If Needed)

surgical Site
Incision Edges Approximated If Visible
No Evidence Of Inflammation Or Purlent Drainage
Sutures, Staples, Steri Strips, Dressing Dry & Intact if Applicable

knowledge And Education Assessment
Demonstrates Readiness And Willing, Capability And Resource To Learn About Condition And Self Care
Understands Diagnosis And Treatment Plan
States Understanding Of Verbal Or Written Instructions

discharge Planning
Able To Manage Adl's Without Difficulty, Or Has Adequate Support System In Place
Able To Return To Previous Living Situation.

psychosocial Asessment
Appropriate Behavior For Condition And Age Range
Cooperative With No Signs Of Distress, Or Depression, Manageable Anxiety

tubes/equipment (if Present)
Ct To Water Seal 20 Cm Suction Drains Serosanguious Fluid, No Air Leak.
Ng In Place Draining Greenish-brown Fluid, Irrigates Well If Ordered.
Foley Cath Drains Clear Yellow Urine.
Hemavac/jp In Place, Compressed, Draining Serosanguious

If Referrals Made, Order In Computer And Record On Top Rand,
Computer Ord:
Social Services
Social Services (update)
Dititian Referral And Nutrition Score