Student Resources: Sequential Narrative Notes
EXAMPLE: Pt with tracheostomy on the rehab unit.
0700 – Received pt in bed, resting quietly with eyes closed. Easily aroused to alert and fully oriented state with voice. Client indicates by shaking head that presently he has no needs and no pain or distress. Respirations even, unlabored via tracheostomy. Pt is receiving humidified oxygen @ 28%, 6 liters, via trach collar. SaO2 97% on continuous pulse oximetry. Trach site is midline and patent, and trach collar is secure to site. Breath sounds are course, with diminished air flow @ bases anteriorly and posteriorly. Suction, ambu bag, and oxygen set-up are at bedside. Pt HOB is mid Fowler’s. Instructed to call for any needs; pt verbalized understanding (by nodding head). Call bell within reach, SR up X 3, bed low position with wheels locked. Will continue to monitor closely.
0730 – FSBS 280 per glucometer # 4. 6 units Novolog insulin administered subcutaneously under supervision of instructor @ left upper outer arm. Pt tolerated well. SaO2 98%.
0820 – Eating 1800 calorie ADA breakfast (no fluid restrictions) without any signs or symptoms of aspiration. Feeding self; indicates he needs no assistance. Scheduled medications administered without difficulty. SaO2 96%.
0900 – Pt given Percocet 5/325 mg oral dose per request, in anticipation of scheduled occupational and physical therapy. SaO2 97%.
0915 – OT in room with patient. Pt indicates that he is tolerating therapy well. SaO2 98%.
1000 – Pt denies pain. Rates pain 0/10. Physical therapy at bedside. Pt taken off unit via wheelchair with portable O2.
1100 – Back to room; indicates he tolerated physical therapy well. Denies pain. Hooked back up to humidified oxygen 28% 6 liters, SaO2 98-99%. Tracheostomy care performed under supervision of instructor. Inner cannula changed out. Site without erythema or discharge. Skin intact. Patient tolerated well. Pt denies need for suctioning at present time. Only small amount of thick yellow mucous noted, which patient adequately coughs up.
1130 – FSBS 205 per glucometer # 4. 4 units Novolog insulin administered subcutaneously @ right upper outer arm, under supervision of instructor. Pt tolerated well. Denies any needs. SaO2 98%.
1200 – Sitting up in chair. Eating lunch in no acute distress. No changes noted from earlier assessment. Trach remains midline, patent, and intact. Humidified oxygen 28% 6 liters via trach collar, continuous pulse oximetry. SaO2 96%. Call bell within reach. Reported off to primary nurse.
About VickyRN Guide
VickyRN has '16' year(s) of experience and specializes in 'Gerontological, cardiac, med-surg, peds'. From 'Under the shadow of His wings...'; Joined Mar '01; Posts: 12,051; Likes: 6,448.Oct 4, '09 by VickyRN GuideQuote from orangepinkYou're very welcomethis is good stuff! thanks!Oct 9, '09 by nevertooold:o)I am midway through my first semester. I've found that my Fundamentals of Success book really helps prepare me for exams. But! I've tried to find other NCLEX type practice exam books, but often times they aren't organized by unit, and there are too many ?s that are above my level of understanding right now. Has anyone found a good practice book that they can't live without now????
Thanks in advance!Oct 10, '09 by caliotter3Quote from nevertooold:o)Check out the NCLEX discussion forum. This question addressed often there.I am midway through my first semester. I've found that my Fundamentals of Success book really helps prepare me for exams. But! I've tried to find other NCLEX type practice exam books, but often times they aren't organized by unit, and there are too many ?s that are above my level of understanding right now. Has anyone found a good practice book that they can't live without now????
Thanks in advance!
Must Read Topics