- by VickyRN Asst. Admin Sep 27, '09This is an example of a head-to-toe narrative assessment note. I have my first semester nursing students start by writing out a narrative assessment on the clinical floor, before proceeding to any facility assessment flowcharts.
Excellent resources concerning nursing documentation:10/05/2009 0800. 86 y.o. male admitted 10/01/09 for left-sided CVA with right-sided hemiparesis. VS 37.4° C, HR 97, RR 22, BP 140/76. Alert and oriented to person, place, day/ time, and situation; denies any pain or distress. PERRLA. Responds appropriately to verbal stimuli; no slurring of speech. At risk for aspiration related to dysphagia; on thickened dysphagia diet. Feeds self with assistance. Skin acyanotic with loose turgor. Mucous membranes moist and pink. Negative JVD. Respirations even, unlabored. Breath sounds clear to auscultation throughout all lung fields. (If your patient is on O2, make sure you record the O2 rate and delivery system here, along with pulse ox readings). Apical pulse regular rate and rhythm; S1, S2 noted. Abdomen soft & nondistended with bowel sounds active in all 4 quadrants. Pink nailbeds with capillary refill less than 2 seconds in all extremities. Peripheral pulses palpable in all extremities. Moves all extremities. Hand grips unequal: strong on left, weak on right. Right arm has limited mobility due to weakness secondary to CVA. Has a 20 gauge saline lock to left lateral forearm. Site is free from redness or drainage, with Tegaderm dressing intact. (If your patient has an infusing IV, make sure you record the fluid and rate in your assessment). Uses urinal, has occasional episodes of incontinence. Urine clear yellow. No skin breakdown noted. TED hose on bilaterally. Homan’s sign negative bilaterally. Feet cool, dry, intact, with thick toenails bilaterally. Side rails up x 3, bed in low position. Call bell within easy reach of left hand. Instructed to call for any needs or to request assistance before attempting to get up. Verbalized understanding. Will continue to monitor closely. ……………………………….. S.Johnson, Student Nurse
Interactive Exercises on Assessment Charting from freenursetutor
Complete Guide to Documentation
Practice Standard: Nursing Documentation
Documentation PowerPoint from Delmarlearning
Methods of Charting (pp 112-114)
Soap Note Documentation
Ladies & gentlemen of the jury, I present... the nursing documentation
Do's and Don'ts of Documentation
Documentation: Proactive Prevention of Litigation
8 Common Charting Mistakes to Avoid
Abbreviations: A Shortcut to DisasterLast edit by VickyRN on Oct 1, '09 -
APA Style Citation
VickyRN. (Sep 27, '09). Student Resources: Narrative Head-to-Toe Assessment. Retrieved Tuesday, May 22, 2012, from http://allnurses.com/showthread.php?t=427052
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Oct 7, '09 by kristikkcThank you so much for the tips. Even those of us with nursing experience should go over pointers and webpages that help us with out charting.
caliotter3 and VickyRN like this. - Oct 7, '09 by Tina1968I am a first semester nursing student and this is really helpful, thank you!!VickyRN likes this.
- Asst. Admin
Oct 8, '09 by VickyRNQuote from Tina1968Glad this was helpful to you. Best wishes to you in nursing schoolI am a first semester nursing student and this is really helpful, thank you!!
- Oct 8, '09 by DondieI'm a new CNA so I don't know much about assessments, but this part caught my attention. Could you give me a brief explaination of what this represents? How do you check the grip, by having them squeeze your hands?Hand grips unequal: strong on left, weak on right.
I'm just curious. Thanks!
Dondie - Asst. AdminOct 9, '09 by VickyRNQuote from DondieHi Dondie and welcomeI'm a new CNA so I don't know much about assessments, but this part caught my attention. Could you give me a brief explaination of what this represents? How do you check the grip, by having them squeeze your hands?
I'm just curious. Thanks!
Dondie
Yes, you're on the right track You have the client squeeze your hands (both hands at the same time - only allow two fingers from each of your hands to be squeezed, to avoid being "crushed" by a very strong grip) and then let go. The client must be able to both grip and let go. Rate according to strength and equality of left and right.
- Oct 9, '09 by Savvy20RNTwo months ago none of this would have made sense to me. I've learned so much since starting nursing school. -squeals- Thanks so much for this. We just started clinicals so this really helps. XDVickyRN likes this.
- Asst. AdminOct 9, '09 by VickyRNQuote from savvy20Glad this has been helpful to youTwo months ago none of this would have made sense to me. I've learned so much since starting nursing school. -squeals- Thanks so much for this. We just started clinicals so this really helps. XD It is amazing how fast you "grow" once in school.
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Oct 11, '09 by felixfelixThe A on PERRLA means the ability to accommodate. Only people who can follow commands can do so. Otherwise, it is PERRL (for toddlers or confused adults).tewdles likes this. -
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