need help with narrative charting

[uramanda1]

this is my first narrative charting and im not sure how to start it i finished it but have no idea if im missing anything or if i have to much,

(0700/ 6-3-10)

Pt is resting in bed, HIB elevated, call light in reach. Mr Edward Watts is a 68 year old caucasian male who weight 60kg. I received him from the er at 0700 he is admitted with abdominal pain. Fatigue and black stool. Pt is on O2 at room air with nose cannula

Awake and alert resting in bed. Orientated and able to communicate. Oriented person, place, time and purpose coming to hospital. Babinski test is normal. Weak hand and leg strength, has osteoarthritis in hands, takes asprin for pain 4-5 a day,Pt came up from ER with IV on left arm. Iv site shows signs of erythema and warm to touch, Iv solution is NS running at 500ml/hr

Scalp is free of dandruff, lesions, lumps and parasites.

Eyes are symmetric, free of exudate and redness. Equal pupil dilation. Sclera of eye is white. Pt complains of dryness in eyes while reading or watching tv for long periods of time.

Nose is free of debris no signs of dryness or drainage, pt states he does not have any sinus problems.

Lips and mucous membrane: mucous membrane is moist no sores, lips show signs of dryness. Teeth are clean. Gums show no signs of redness, free of sores. Mouth odor is normal no signs of fruity or musty odor. Pt is able to speak and swallow with no pain.

Ears are symmetric. Ear canal are free of debris, pt is able to follow commands,

Perform ROM exercise on neck, shoulder and arms. Able to perform without pain.

Heart sounds are 110/min. Chest is clear no rash or laceration. Has had no heart problems in the past.

Capillary refill is at 3 seconds, pedal pulses is easily palpable, no edema detected,

Lung sounds are normal no wheezing or crackles. Pt has no pain when he exhales or inhales.

Pt is on room air, nasal cannulas, O2 saturation level is 98%

Bowl sounds are at 45, hyperactive, loud, gurgling sounds are present abdominal distention is present, pt complains of pain during palpation. Has no past history of abdominal surgry, has GB no problems with liver in the past. Last BM was two days ago, does not use laxatives

Has foley, placed in ER, clear yellow urine, 120ml in bag. No signs of skin break down on member or thighs, able to go on his own, no burning sensation when he urinates, has not seen blood in urnie,

No sign of skin break down on peri area, buttocks and coccyx show no sign of redness or skin break down

No signs of edema on feet, or legs, able to preform ROM with little pain, able to stand and walk on own, no skin break down on feet or legs

Vitals are 135/65, pulse is 110, respirations are 29 temp is 99.3