Nurses Notes

[jox1962]

write a nurses documented note to put in a chart. An 85 year old male was brought to the ER his RR= 38 BP=200/110 HR= 110. He ambulates, came from home, he has slurred speech, difficulty in holding cup, his skin is intact, has mild synosis lips. his EKG and labs were taken. He is on aspirin, digoxin,metroprolol and his daughter is waiting in the hallway.

Pt. c/o having hard time breathing. Vitals obtained were as follows. RR, labored at 38/min, BP, 200/110, HR, 110. Pt. was alert oriented to place and time, follows command and able to ambulate. Skin color pale, skin wam and intact. Face looks okay with mild synopsis lips. Pt has dentures. EKG was given and values was abnormal. Pt. has difficulty communicating and signs of edema on left eye. Breath sounds auscultated, crackles and wheezes on both lobes. Abdomen soft, non- tenders, bowel sounds in all 4 quadrants. No complain of diarrhea and constipation. Pt. states last bowel movement last evening. Pt. is on Rx aspirin, digoxin, and metropolol. Last took medication last night at hs. Pt has a history of CHF. Pt. will be kept overnight and monitored for CHF. Daughter notified. Nurse Jox

[notmanydaysoff]

what's the question?

I have some comments on how the notes are written, but I'll wait for a reply.

[jox1962]

This is the question

write a nurses documented note to put in a chart. An 85 year old male was brought to the ER his RR= 38 BP=200/110 HR= 110. He ambulates, came from home, he has slurred speech, difficulty in holding cup, his skin is intact, has mild synosis lips. his EKG and labs were taken. He is on aspirin, digoxin,metroprolol and his daughter is waiting in the hallway.

[rn/writer, RN]

We can't do your homework for you. That wouldn't be fair to you, your classmates or your future patients.

Why don't you write a note that you think is appropriate and we can then offer suggestions and comments.

[notmanydaysoff]

if the 2nd paragraph in the original post (OP) is your nurse's note, then I have a few comments.

some tips that run thru my head everytime I write:

I was taught, and it makes perfect sense, that if we note an abnormal finding, then we need to include an intervention.

write for a jury.

it takes a while to gain charting skills. when first learning, I looked at many notes and copied phrases (in my trusty little notebook) that I thought were exceptionally well written. I also had a check-off list of observations that I needed to include (IV lines, FC, dressings/drainage, oxygen, AV shunts, skin condition, etc.). I referred to them on a regular basis. my notes were as complete as they could be.

assess from head to toe. group like systems/problems/issues

notes need to be more concise: Vitals obtained were as follows. RR, labored at 38/min, BP, 200/110, HR, 110.

VS BP, T, P, R, O2, pain. Labored breathing. Dr/charge nurse/etc. notified.

drop repeated use of words, ex. Pt. states last bowel movement last evening. Last took medication last night at hs.

No subjective comments like "Face looks okay" where does it say that in the OP?

Combine related issues in same sentence. "Pt. has difficulty communicating and signs of edema on left eye"

you mentioned that EKG and labs were drawn but there is no mention of that in the OP. what was abnormal?

good luck. I have 5, count 'em, FIVE more weeks of school left.

and yes, I am counting!