Assessments & IV meds

[malaga00]

Hello! I'm in my second semester of nursing school & we're in the middle of our assessment class & our Peds clinicals. Does anyone know of any good websites or is willing to share from experience how you chart normal findings for each system in a physical assessment? We have guides that tell us all the things we are supposed to be assessing, but nothing that says how we are supposed to chart what is normal (i.e. how to say it in medical terms other than 'wnl').

My other question - are there any good resources out there on IV medications? We have been giving IV meds for three days now in clinicals and I am still very confused because each nurse I work with does it differently. Any advice or know of any resources I can look up?

Thanks in advance for your help!!

Anna

[MsippiSN]

Hi. I'm in my 3rd semester of nursing school and the teachers gave us examples of how to chart the "normal" things. Here's an example...

Rec'd awake and alert, oriented x3. No c/o pain at this time. PERRLA. Skin warm and dry. Good skin turgor. NaCl at 75cc/hr/infusion pump in right hand with no signs of redness, edema, or drainage noted. Capillary refill

Hope this helps!

[foreverhope]

Do you need info on the IV meds themselves? Is it the skills you are asking about? We have to have an IV med book at clinicals. I also have a nursing procedures book. Your Nursing (Fundamentals) text should explain the procedures.

[andi2634]

There are lots of threads on assessment if you do a search you'll find tons of great info- this is how I chart. We have a flow sheet that we can check of most of our assessment such as lung sounds, IV's, chest tubes, bowel sounds, cap refill, etc, and technically we could just write as a note assessment done as charted and write any exceptions, but for my first assessment of the shift I usually write a note like this: Complete assessment done as charted, see flowsheet. Pt. A & O x3, answers questions appropriately, MAE. Denies any c/o of pain or SOB. Lungs CTA bilat, O2 sats 98%. Monitor showing sinus rhythm. Abd soft, non distended, pt denies tenderness, +BS x4. NG to left nare placement checked with air bolus, to low wall sxn. #22 Hep lock to left hand, flushes well, good blood return. Foley draining clear yellow urine. All periph pulses palp. Monitor alarms on, call bell within reach.

If there are IV fluids or drips the rates will be on the flowsheet. I always check the drips and rates against the orders at the beginning of my shift and redo the calculations to be sure that they are infusing at the rate that's ordered. We all make errors and if the nurse before calculated something wrong and you don't check it the patient could be getting the wrong dose of the med. I'll usually write NS and Dopamine infusing per order without difficulty, see flowsheet for rates.

For IV med administration- check your hospital policy- there should be specific policies for flushing peripheral IV's and central lines, also for how long IV's can stay in, meds, and dressing changes. You will see nurses doing a lot of things their own way- they may not be wrong- but it may not be the exact way your instructor has shown you. There are IV therapy textbooks- they should be able to help you learn the steps for giving meds through IV's. If you see someone doing something different than you learned ask- you could learn a great tip technique.