Im a bit confused at the moment (well, more so than usual) :spin: . 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!!!
Jan 20, '07
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
Regular Rhythm, Rate 60-100/min, Bp Stable
No Peripheral Edema
No Dizziness, Chest Pain Or Pressure
Regular Rate 10-20/ Min
Breath Sounds Clear And Unlabored
No Sputum Or Sputum Clear, White, Or Pale Yellow
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
Taking Average Of 75% Diet Over Last 3 Days.
Tolerating Food And Fluid.
No Difficulity Chewing Or Swallowing Or Mouth Pain
Urine Clear To Yellow.
No Signs Current Infect.,drainage, Trauma, Bleeding, Retention.
No Redness, Swelling Or Deformity
Normal Rom Of Extremities
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)
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
Able To Manage Adl's Without Difficulty, Or Has Adequate Support System In Place
Able To Return To Previous Living Situation.
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,
Social Services (update)
Dititian Referral And Nutrition Score
Last edit by MARIAN202 on Jan 20, '07