charting.... critique? last care plan, I must pass.

  1. This is my last care plan I have to do. I've had a few good ones but mostly NI. This is my last chance to prove myself. I've bought tons of books and studied and read all weekend on charting! I've read countless posts on this site and hope to gosh it has helped me. I would really appreciate critique on this last one.



    7:05 Standard & contact precautions maintained. Lying in bed in supine position, resting with eyes closed, mouth open. R-15, equal and unlabored. IV patent & intact on right inner forearm. Free from redness, edema and drainage. Infusing 40cc/hr of 1000ml D-5-W. O2 2liters by nasula cannula. Foley draining by gravity. Urine reddish brown. Both feet in foot pillow under bed cradle. Large left toe with dry dressing, no fluid or drainage present. Bed alarm on, side rails up x2. Remains in bed with eyes closed. Reported urine color to nurse. -----------------s. butler svn


    8:30 In bed, supine position, eyes open. Son and daughter-in-law present. No acute distress noted at this time. NPO due to EGD 11.12.2007. VS t -96.6, p 102, r18, bp 123/65. Pulse oximetry 100%. Orientated x2, disorientated to time. Responds to verbal loud stimuli, hearing aid x2. Incomprehensible speech. Head atraumatic, free of infection and normocephalic. Flat affect - Bell's Palsy. Eyes symmetrical, sclera white, pupils irregular and sluggish. Possible cataract surgery. Conjunctiva moist. Drainage bilaterally. Nasal patent bilaterally. 02 at 2 litters by nasal cannula. Buccal mucosa dry, oral mucosa pink and dry. Upper and lower dentures present. Lips dry. Ears symmetrical, dried drainage present. Carotid weak bilaterally. No bruits or thrills present on neck. Full Rom in neck. Breath sounds clear to auscultation. No cough present "She only coughs to clear her throat" states daughter-in-law. R-18 even and unlabored. Apical 65, rhythm equal, s1 and s2 noted but irregular. Skin warm to touch, thin, hyper pigmentation present. Multiple bruises bilaterally on inner and outer forearm and upper arm in various stages of healing. 3 cm bruise noted at old iv site on left hand covered with cotton ball and transparent tape. Iv site patent on right inner forearm, site free of redness/edema/warmth. Dressed with transparent tape. Iv infusing 40cc/ml of 1000 ml d-5-w. Complains of no pain in area. Capillary refill on nail beds <3. Radial pulse weak and bilaterally. Nodule present under skin 1X1 cm , denies pain upon palpation. "She usually flinches when we touch it, even when she's asleep" states daughter-in-law. Weak in both upper extremities, assistance rom. Hypoactive bowel sounds in all 4 quadrants of abdomen. No complaints upon light palpation. Right quads and LUQ soft, LLQ hard. Bowel movements "just runs all day long, constantly goes, we usually can tell she's going when she makes some grunts and that face she's making now" - states daughter-in-law. Grimacing face, no odor present, Runny light brown bm on chux. At risk for skin breakdown r/t limited mobility and incontinence. Incontinent caterher voiding, urine reddish brown color at 100 ml. No cloudiness or clumps present. Lower extremities several bruising bilaterally at various stages of healing. Knees swollen bilaterally, denies pain at touch. Varicose veins present. Dorsalis and tibialis pulses non-palable. Feet cold to touch. Both feet in foot pillows under bed cradle. Weak ROMand strength in both lower extremities. Cap refills >3. Toenails splintered and thick. 2X2 dressing on Greater Large Left toe, no drainage present. Small necrotic tissue present on second left toe <1cm. NPO for EGD today. Normal diet pureed foods. Instructed family to call for any needs or assistance.Rails up X2, bed alarm on, bed in low position. Reported findings to nurse. ---------------sb svn


    9:15 Standard and contact precautions taken. Assisted can in changing chux. Loose light brown stools. Skin bruising and moist skin on sacral area, >10X10 cm. No skin breakdown at this time. Peri care provided. Moisture Barrier Cream applied to sacral and buttock area. Explained reason for sacral area and rational of cream protecting skin and repelling moisture. Instructed family to use call bell for needs or assistance especially when BM has occurred. Explained keeping her dry will help to prevent skin breakdown from runny stools. Verbalized understanding. Bed rails up X2, bed in low position, bed alarm on.---------sb svn


    9:30 resting, eyes closed. Family stated "comfortable". Iv site patent, no signs of distress. Will continue to monitor closely----------------------------------------------------------------------------------sb svn


    10:42 eyes closed in bed. Family reading. Nurse infused piggyback piperail 2.25g @ 75ml/hr. Awoke to stimulus. C/o "dry mouth". Explained she cannot have anything to drink because of procedure scheduled today. Insistent on "dry mouth" Explained again she can't have anything to drink but I can return with mouth swaps to help relieve the dryness. Son voiced concern on what time they will be coming to get her for the procedure, "11 hours is a long time to go without water or food, she must be miserable". Told son i would relay the message to the nurse to call doctor and find out time. 02 at 2liters, pulse oximetry 98%. Reported to nurse--------------------------------------------------------------------sb svn


    11:05 back to room with oral care pack. Pt eyes closed, r even and unlabored. Instructed family how to use swabs and tube of lip care upon her awakening. Explained not to allow her to swallow. ------sb svn


    12:15 pt in bed resting, eyes closed, family present. "Didn't like the swabs, but better than nothing. Still complains of dry mouth." Instructed family to swab again in 30 min to help relieve dryness. Reported now news of doctor call back. ----------------------------------------------------------------sb svn


    12:26 call be rang, "she need to be changed" states daughter-in-law. Called for can. Standard and contact precautions maintained. Brown runny BM. No odor. No consistency. Changed chux. Peri Care provided. Moisture barrier applied to sacral and buttock area. Pt's words incomprehensible. Family states shes "mumbling." Bed rails up X2, bed in low position. Iv site patent, site free of complications. -----------------------------------------------------------------------------sb svn


    1:20 Nurse in room assisting change to stretcher for EGD. Family "relieved" to finally get her to procedure. Reported off to nurse. ----------------------------------------------------------sb svn
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  2. 5 Comments

  3. by   fizzgigger
    so would this nanda be:

    bowel incontinence r/t infectious disease?
  4. by   ukstudent
    This is not a care plan. These are nurses notes. You need to keep it objective, take the stuff about the family out.
  5. by   fizzgigger
    Quote from ukstudent
    This is not a care plan. These are nurses notes. You need to keep it objective, take the stuff about the family out.
    .

    It's apart of my whole care plan. Sorry i did not make it clear. Since the patient is unable to speak with me since I do not know spanish my teacher told me to use the family's quotes.
  6. by   Daytonite
    i'm putting my changes in red for you. . .


    7:05 standard & contact precautions maintained. lying in bed in supine position, resting with eyes closed, mouth open. r-15, equal and unlabored. iv patent & intact on right inner forearm. free from redness, edema and drainage. infusing 40cc/hr of 1000ml d-5-w. o2 2liters by nasula cannula. foley draining by gravity. urine reddish brown. both feet in foot pillow under bed cradle. large left toe with dry dressing, no fluid or drainage present. bed alarm on, side rails up x2. remains in bed with eyes closed. reported urine color to nurse. -----------------s. butler svn
    7:05 contact precautions maintained. supine in bed with eyes closed, breathing through open mouth. respirations 15, regular and unlabored. continuous o2 at 2 liters per nasal cannula. iv of 1000cc d5w infusing at 40cc/hour with no redness or swelling at or above insertion site right inner forearm. foley catheter patent and draining reddish brown urine and reported to charge nurse. bed cradle in place at foot of bed with linens off patient's feet and lower legs. dressing to left great toe dry and intact with no drainage noted. side rails up x 2. bed alarm in place and activated.

    8:30 in bed, supine position, eyes open. son and daughter-in-law present. no acute distress noted at this time. npo due to egd 11.12.2007. vs t -96.6, p 102, r18, bp 123/65. pulse oximetry 100%. orientated x2, disorientated to time. responds to verbal loud stimuli, hearing aid x2. incomprehensible speech. head atraumatic, free of infection and normocephalic. flat affect – bell's palsy. eyes symmetrical, sclera white, pupils irregular and sluggish. possible cataract surgery. conjunctiva moist. drainage bilaterally. nasal patent bilaterally. 02 at 2 litters by nasal cannula. buccal mucosa dry, oral mucosa pink and dry. upper and lower dentures present. lips dry. ears symmetrical, dried drainage present. carotid weak bilaterally. no bruits or thrills present on neck. full rom in neck. breath sounds clear to auscultation. no cough present “she only coughs to clear her throat” states daughter-in-law. r-18 even and unlabored. apical 65, rhythm equal, s1 and s2 noted but irregular. skin warm to touch, thin, hyper pigmentation present. multiple bruises bilaterally on inner and outer forearm and upper arm in various stages of healing. 3 cm bruise noted at old iv site on left hand covered with cotton ball and transparent tape. iv site patent on right inner forearm, site free of redness/edema/warmth. dressed with transparent tape. iv infusing 40cc/ml of 1000 ml d-5-w. complains of no pain in area. capillary refill on nail beds <3. radial pulse weak and bilaterally. nodule present under skin 1x1 cm , denies pain upon palpation. “she usually flinches when we touch it, even when she's asleep” states daughter-in-law. weak in both upper extremities, assistance rom. hypoactive bowel sounds in all 4 quadrants of abdomen. no complaints upon light palpation. right quads and luq soft, llq hard. bowel movements “just runs all day long, constantly goes, we usually can tell she's going when she makes some grunts and that face she's making now” - states daughter-in-law. grimacing face, no odor present, runny light brown bm on chux. at risk for skin breakdown r/t limited mobility and incontinence. incontinent caterher voiding, urine reddish brown color at 100 ml. no cloudiness or clumps present. lower extremities several bruising bilaterally at various stages of healing. knees swollen bilaterally, denies pain at touch. varicose veins present. dorsalis and tibialis pulses non-palable. feet cold to touch. both feet in foot pillows under bed cradle. weak romand strength in both lower extremities. cap refills >3. toenails splintered and thick. 2x2 dressing on greater large left toe, no drainage present. small necrotic tissue present on second left toe <1cm. npo for egd today. normal diet pureed foods. instructed family to call for any needs or assistance.rails up x2, bed alarm on, bed in low position. reported findings to nurse. ---------------sb svn
    8:30 remains supine in bed. son and daughter-in-law visiting. b/p 123/65, t 96.6, p 102, r 18,pulse ox 100%. oriented to person and place but not time. skin warm and dry. hyper pigmentation present. multiple bruises bilaterally on inner and outer forearm and upper arm in various stages of healing. 3 cm bruise noted at old iv site on back of left hand covered with cotton ball and transparent tape. head normocephalic and without trauma. eyes symmetrical. sclera white. pupils irregular and react sluggishly. conjunctive moist with _________ drainage noted bilaterally [describe the drainage from the eye]. nasal passages clear bilaterally. continuous o2 at 2l per minute by nasal cannula. hearing aids in place bilaterally. oral mucosa pink and dry. lips dry. upper and lower dentures in place. npo for egd. speech is incomprehensible. responds to verbal loud stimuli by ________. flat affect. ears symmetrical with dried drainage noted both outer ear canals. able to palpate a weak carotid pulse bilaterally. no carotid bruit appreciated. has full rom of neck. lung sounds clear to auscultation. respirations even and unlabored. no cough noted, but daughter-in-law stated, "she coughs to clear her throat." heart rate irregular. weak in both upper extremities. radial pulse weak bilaterally. capillary refill >3 seconds in fingers. abdomen rounded and hard in llq with hypoactive bowel sounds in all 4 quadrants. no tenderness to palpation. daughter-in-law reports the patient has bowel movements that, "just run all day long, constantly goes, we usually can tell she's going when she makes some grunts and that face she's making now." grimacing. incontinent liquid brown bm noted on chux. foley catheter intact with 100cc draining clear reddish-brown urine in drainage bag. several bruises noted in both lower extremities in various stages of healing. knees swollen bilaterally. no pain to palpation. varicose veins noted in both lower legs below the knees. unable to palpate bilateral dorsalis pedis or tibialis pulses. feet cold to touch and elevated on pillows. bed cradle in place. limited rom and strength bilateral lower extremities. cap refill >3 seconds. toenails splintered and thick. 2x2 dressing on left great toe dry and intact with no drainage noted. 1 cm diameter dry necrotic area noted on second toe of left foot. iv of 1000cc d5w infusing at 40cc/hour with no redness, swelling or pain at or above insertion site right inner forearm. clear dressing intact. instructed family to call for any needs or assistance. side rails up x2. bed alarm in place and activated. bed in low position. reported findings to nurse.

    9:15 standard and contact precautions taken. assisted can in changing chux. loose light brown stools. skin bruising and moist skin on sacral area, >10x10 cm. no skin breakdown at this time. peri care provided. moisture barrier cream applied to sacral and buttock area. explained reason for sacral area and rational of cream protecting skin and repelling moisture. instructed family to use call bell for needs or assistance especially when bm has occurred. explained keeping her dry will help to prevent skin breakdown from runny stools. verbalized understanding. bed rails up x2, bed in low position, bed alarm on.---------sb svn
    9:15 contact precautions maintained. incontinent of liquid light brown stool. assisted cna in cleaning patient. 10cm diameter bruised, but intact skin area noted on sacrum. moisture barrier cream applied to sacrum and buttocks. explained reason for sacral care to family. instructed family to use call bell for needs or assistance especially when bm has occurred. explained keeping her dry will help to prevent skin breakdown from the liquid stools. verbalized understanding. bed rails up x2. bed in low position. bed alarm on.

    9:30 resting, eyes closed. family stated “comfortable”. iv site patent, no signs of distress. will continue to monitor closely----------------------------------------------------------------------------------sb svn
    9:30 resting with eyes close. no signs of distress. iv patent. continuing to monitor closely.

    10:42 eyes closed in bed. family reading. nurse infused piggyback piperail 2.25g @ 75ml/hr. awoke to stimulus. c/o “dry mouth”. explained she cannot have anything to drink because of procedure scheduled today. insistent on “dry mouth” explained again she can't have anything to drink but i can return with mouth swaps to help relieve the dryness. son voiced concern on what time they will be coming to get her for the procedure, “11 hours is a long time to go without water or food, she must be miserable”. told son i would relay the message to the nurse to call doctor and find out time. 02 at 2liters, pulse oximetry 98%. reported to nurse--------------------------------------------------------------------sb svn
    10:42 resting with eyes closed. continuous o2 at 2l per nasal cannula. pulse ox 98%. piggyback of pipracil 2.25g infusing at 75ml/hour. awoke to stimulus. c/o dry mouth and insisting on something to drink. explained to patient why she is npo and mouth swabs offered. family concerned that "11 hours is a long time to go without water or food, she must be miserable". reported this to patient's nurse.

    11:05 back to room with oral care pack. pt eyes closed, r even and unlabored. instructed family how to use swabs and tube of lip care upon her awakening. explained not to allow her to swallow. ------sb svn
    11:05 back from ???. resting with eyes closed. respirations regular and unlabored. family instructed on how to use swabs and tube of lip care from oral care pack when she awakes. explained importance to family of keeping patient npo.

    12:15 pt in bed resting, eyes closed, family present. “didn't like the swabs, but better than nothing. still complains of dry mouth.” instructed family to swab again in 30 min to help relieve dryness. reported now news of doctor call back. ----------------------------------------------------------------sb svn
    12:15 resting in bed with eyes closed. family remains at bedside and report that patient "didn't like the swabs, but better than nothing. still complains of dry mouth." instructed family to swab again in 30 minutes to help relieve dryness. reported that the doctor has not called back yet.

    12:26 call be rang, “she need to be changed” states daughter-in-law. called for can. standard and contact precautions maintained. brown runny bm. no odor. no consistency. changed chux. peri care provided. moisture barrier applied to sacral and buttock area. pt's words incomprehensible. family states shes “mumbling.” bed rails up x2, bed in low position. iv site patent, site free of complications. -----------------------------------------------------------------------------sb svn
    12:26 incontinent of liquid brown bm. peri care done. moisture barrier applied to sacrum and buttock area. iv remains patent. side rails up x 2. bed in low position.

    1:20 nurse in room assisting change to stretcher for egd. family “relieved” to finally get her to procedure. reported off to nurse. ----------------------------------------------------------sb svn
    1:20 to egd via stretcher by nursing staff. reported off to nurse.
  7. by   kukukajoo
    something that helped me write better notes was that whenever there was a problem, we had to address it and note what we did to help the situation. I think there is a plce where you note stool on chux but not pericare done. I would note this is for preventative measures. Also you note that O2 is in place- is this NC or mask, if so which type.

    Other than that looks good. I am sooo glad we chart by exception!!!!

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