use this format:
Orientation: person, place, time, and event. Are they awake, alert, and oriented?
Skin: Check turgor, edema od dependent areas, temp, moisture/dryness, capillary refill, color, lesions, hair distribution, campare R to L sides.
Head/Neck: note size, shape, symmetry of facial features; PERRLA; color of sclera/conjunctiva; palpate maxillary/frontal sinuses for tenderness; mucous membranes (moist, pink, intact); visualize pharynx and tonsils if indicated; tongue midline; palpate lymph nodes; check for JCD; apparatus (NG tubes, O2 mask, tracheostomy, etc)
Extremities: ROM bilaterally; strength of upper and lower extremities; pulses; sensation; Homan's sign; check for JVD; apparatus (IV's, restraints; dressings; drains)
Chest: Auscultate breath and heart sounds; note retractions or use of accessory muscles; note chest symmetry; palpate for masses; breat exam if indicated; apparatus (telemetry; chest tubes; CVP lines; dressings; drains)
Abdomen: note scars; herniations; bowel sounds in all 4 quadrants; palpate for massess and tenderness; is abdomen firm/sodft; CVA tenderness; apparatus (G tube; ostomy; dressings; drains)
Perineum: note drainage; hemorrhoids; apparatus (catheter)
Equipment: note all monitors and record readings (IV pumps and amt of fluid infused, solution, and rate of infusion; EKG readings; feeding pumps; etx)
Drains/Dressings: note site of dressing and amt of drainage; on catheters note amt of drainage and color of urine Doctor Visits: note who the doctor is, time of visit, what he/she did
Procedures: note all procedures performed and what time (catheters, NG tubtes, trach care, dressing changes, etc)
Safety: bed locked and in low position; HOB side rails x 2; call bell within reach)
Patient Complaints: document all complaints/statements in their words using quotations
then write: hope this example helps you ... my teachers also say i can tell you the amount of hairs on their head. hee hee... i have ALWAYS gotten an A for my head-to-toe and narr notes. i love to do them. let me know if you like?
:spin: :spin: :spin:
Received report from J RN to J RN at 0700. Side rails up x4, call light within reach, bed in low position and locked. HOB elevated to 30 degrees. Name/id, PCN allergy band on right lower arm with easy view. Admit to ER on 02/07/2006 due to SOB with dz of CHF. Lethargic LOC, A&Ox3 responsive to speech and does follow commands. R 3mm, L 3mm. PERRLA moist, pink, intact mucus membranes. Lips moist with Vaseline per md orders. No mouth order. Has majority of teeth, no loose teeth, no dentures. Swallowing and gag reflex intact. Does not have any hearing loss, thus no hearing aids. Does hear whispers bilaterally. Attempts to speak. GCS of 15 out of 15. Comfortably resting facial pain scale indicated no pain due to no grimacing, no guarding behaviors, or verbal reports indicating pain. Morphine 2-5 mg IV Q4H or PRN per MD orders if needed for pain. Hand grips are equal bilaterally but weak. No tremors or seizures. Lorazepam 1 ml Q2H PRN per MD orders for sedation. Levothyroxine 125 mg po per md orders for history of hypothyroidism. TSH lab value is 6 mU/l for a normal level of 6-10. Tracheal position is mid-line. No JVD. Cough is nonproductive. Moderate amount of thick yellow secretions noted upon suctioning. Oral endotracheal tube intact 7 mm with 22 to teeth on right side. Ventilation set is HFV 500, FIO2 40%, R 10, PEEP 7, PS vent 8. ABGs reveals no imbalances at this time. No indications of labored breathing with use of accessory and abdominal muscles. Rales and crackles auscultated bilaterally. No complaints of SOB. Lasix 60mg IV BID per MD orders. No presence of subcutaneous emphysema bilaterally. Apical HR of 112 b/min. irregular with no presence of pulse deficit. Atrial flutter-fibrillation noted on ECG monitoring system at bed side. All leads for telemetry are in correct placement, with no signs of redness or irritation. BP was 117/45 by non-invasive cuff located on right upper arm, with a pulse pressure of 72. CVP monitoring via central line of 8 (6-10). Normal S1/S2 heart sounds upon auscultation at apex. Normal S1/S2 heart sounds upon auscultation at base. No murmurs or rubs auscultated throughout bilaterally. Multiple P wave is present and upright <0.12 before QRS complex, PR interval is <0.230 and QRS is narrow with 0.4-0.8 sec. with interruption of atrial flutter with some runs of atrial fibrillation. Pheripheral pulses are 2+ in upper and lower extremities. Capillary refill is <3sec. Nail beds are 180 degrees with no clubbing. No edema on upper or lower extremities. ASA 81 mg PO per tube per MD orders QD. Atropine 10ml IV PRN for Bradycardia per MD orders. Dig 250 mg PO per tube Q24H, on dose #4 with no current labs available for dig level. Hypoactive bowel sounds in all four quadrants. Abdomen is non-tender, soft obese thus non-distended. NG tube placed on 02/07/2006 in right nare for eternal nutrition set at a rate of 30 ml/hr of renal cal. Residual was 10ml. Not eating or drinking per PO. Esomeprazole 40mg IV over 3min. For peptic ulcer dz and prevention of irritation to ulcer. Foley catheter inserted on 02/07/06 is intact and clean. Urine is not concentrated and is clear and yellow with an output of 40ml for this hour. Bladder is non-distended. Last BM was 02/07/06. No observation of flatulence. No bruises. No pressure ulcer/s formation. Muscle strength scale is 5 out of 5 thus can push against resistance. ROM is limited and weak. Needs assistance with all ADLs. Extremities are cool to touch, trunk is warm to touch. Auxiliary temperature is 100.6 covered with acetaminophen 325 mg Q6H PO per tube per MD orders. WBC are elevated 19.3 (5-10) receiving vancomycim 1gm in 200ml at 100ml/hr Q24H and Zosyn 50ml at 100ml/hr Q24H per MD orders. BG drawn 7, 11, 4, 9. With 0700 BG at 180. Covered humulin regular insulin infusing at 1ml/hr per MD orders. Will re-reevaluate BG at 0930 to determine a need for increase/decrease insulin infusion rate. Dextrose 50ml IV PRN per MD orders for hypoglycemia. Triple lumen central line placed on 02/08/2006 in left SC with reg. insulin at 1 cc/hr with 68 ml remaining in the bag, heprin 18U 500ml at 32ml/hr HELD x2 days due to increase APTT of >300. Labs revealed PT of 25.7, INR of 2.2. INT placed on 02/07/2006 size 20 in left hand no redness or verbal reports of pain or any other signs of infection, dry and intact. Responds to teaching on CHF signs and symptoms, such as daily weights, feeling of SOB. Responds to teaching of diuretics (lasix) to reduce pulmonary edema. Bed-side monitor alert levels are as follows: HR hi-135 lo-65, NIBP sys hi-155 lo-95 dia hi-100 lo-50, O2 stat hi-100 lo-92. Volume for alarms are at 90%. Side rails up x4, call light within reach, bed locked in low position, HOB elevated to 30 degrees, Resting comfortably. door open with easy view.
VS are as follows: HR 100, RR 15, BP vie non-invasive cuff 117/45, temp 100F, O2 98%, CVP 10. Atrial flutter and some runs of atrial fibrillation observed at bed side monitor. Output via foley is 75ml non-concentrated, yellow, clear urine for a total of 175 starting at 0600. Comfortably resting facial pain scale indicated no pain due to no grimacing, no guarding behaviors, or verbal reports indicating pain. Side rails up x4, call light within reach, bed locked in low position, HOB elevated to 30 degrees, Resting comfortably. door open with easy view.