Help with my nursing note !!

[NhonLai]

03-25-14 13:30 Alert and oriented x4. Dried skin with scaly patches. Had tremorous both hands. Warm compress was applied to tremorous hands as requested for comfort. Ambulated with PT showing signs of weakness and slow movement. BP 84/54 @ 15:00. RN notified. Held antihypertensive medication for SBP

please help

[JustBeachyNurse, LPN]

What skin was scaly? Facial, trunk?

[BettyS456]

If you withheld meds for SBP

SBP = 84? Did RN or doctor instruct you to go ahead and give them? If so, document that. This is a red flag that could be legally exploited by a lawyer if pt's records/treatment ever were in question.

[OCNRN63, RN]

​It was 128/84.

[BettyS456]

My apologies! I misread and answered incorrectly.

[jadelpn, LPN, EMT-B]

I obviously made up a lot of this, however, when you assess for a shift, it is always a good idea to do your own complete assessment, to document thorougly--especially if it is a paper documentation as opposed to a computer documentation:

1500: Received report from off-going RN. Patient sitting in chair, NAD noted. A&Ox4, (communication--does parkinsons affect speech? Swallowing?) Vitals:________________. Charge RN notified of patient's blood pressure. Patient reclined in chair, will continue to monitor. MD notified of BP, and per MD order, BP medication held due to SBP >90.

Patient continues with tremors noted in BL hands. Needs partial assist in eating. Patient requests hot packs for his hands for comfort. Provided with same. (and you should get an order for this as a complete aside--how long on/off how many times a day--)

Lungs CTA, + bowel sounds all 4 quads, last BM _______. Quanity sufficient clear yellow urine, output 900 ml, patient is continent. Skin condition is dry and scaly. Daily skin care regime initiated, per plan of care. +pp in lower extremeties. Patient has no complaint of pain or discomfort at this time, will monitor.

Patient is currently walking with a walker and states that he is "tired after PT". Observed to have slow movements and appeared weak. (if you saw this yourself).

Patient requests to remain in recliner. Call bell in reach. Reminded to call for assistance and not to ambulate independently, verbalizes understanding of same. Will continue to monitor.----------------

I am sure that there could be more to it, but it is a written head to toe, touches on interventions to assessment findings, function of the patient, safety issues, pain.

[LVN_it1995, BSN, RN]

making it!

M entation (Oriented)

A irway

K ardiovascular

IN tegumentary

G astrointestinal

I nvasive procedures/Xrays Labs, Vital Signs

T ubings

[I♥Scrubs, LPN]

I really like that!

making it!

M entation (Oriented)

A irway

K ardiovascular

IN tegumentary

G astrointestinal

I nvasive procedures/Xrays Labs, Vital Signs

T ubings