nursing student needs help

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I did a rotation in CCU and forgot to do a nursing note, can someone please give me an initial nursing note for someone who came from the cath lab. He was transferred via litter he didn't have any complications. Thanks

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Specializes in Education, FP, LNC, Forensics, ED, OB.

hello, kushball21 and welcome to allnurses.com

i moved your thread to the nursing assistance forum for a better response.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

You either haven't posed your question correctly, or you are asking us to, in effect, falsify a record for you. I am assuming you would want to use this piece of charting to place in this patient's chart. You can only chart what you observed and what you did. I would love to help you, but I can't read your mind and I won't make up a charting entry that you are likely to use.

That aside, I'm going to assume that you want some guidance on what are the important things you should chart. You want to address the condition of the dressing over the puncture site that was made by the doctors when they did the catheterization, what measures were in place to make sure the wound wasn't bleeding and an assessment of the extremity involved distal to the puncture site.

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Specializes in Critical Care.

I think that the student wants to put something in the paperwork for the insturctor. At least I hope this is true.

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I have to do a paper on this rotation and I didn't know that I had to write a nurses note. I would never falsify a record.

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