Published
Did you really just call GrnTea dude? Really? SHE was only trying to help (she IS a nursing instructor, if anyone can help it is GrnTea).
I'm assuming its a paper you need to fill out with the assessment data you collected on your patient. List it in a head to toe (body system) way. Neuro, head/neck, Cardiac, Respiratory, GI, GU, musculo-skeletal, skin/nails, any IVs tubes etc.
NEURO: Neuro-orientaiton, hand grasps, LOC, PERRLA, etc.
HEAD/NECK: head, eyes, ears, nose, mouth, mucous membrains moist/dry?
RESP: breath sounds, o2 sat, on o2, normal breathing, cough present, sputum, respiration rate?
CARDIAC: cap refill, heart beat (reg/irreg), + pulses (pedal, radial, carotid etc), heart rate, BP
GI: bowel sounds, pain, distention, last BM
GU: urine color, clarity, any odor, bladder distentin pain etc
MS: balance, gait, strength, muscle mass
IV/tubes" any presence of IV's (peripheral or central), tubes (foley, rectal,) drains (JP, etc)
SKIN/NAILS: bruises, dressings, open areas, temp, pallor
Just put all the info you collected on your patient in to the appropriate section.
Hey now, no one can help you if you jump down everyone's throat when they try. We need a little more info on this data sheet to be able to help you. Like a pp said, it's most likely an assessment sheet and you fill it out with patient info. You should have gotten the info from the patient, chart, and your own nursing assessment/things you did that day.
Were you assigned to make your own? Or are you just curious what's on it?
Esme posts some excellent brain sheets if they're for your own personal use. I'm sure she'll be along soon enough :)
If you're needed full patient info I'd include all the suggestions about head to toe assessment data as well as a med sheet where you can write drugs, dose, usual dose (to double check for errors in orders) and why the pt is taking the drug.
asma6
22 Posts
I have No clue how we make one.
I dont know how to fell this data sheet thingy up! Help!!!!