Nursing Documentation - Body Systems

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Hi!

Im a bit confused at the moment (well, more so than usual) . Whenever i go to write my nursing notes, i freeze and forget everything:uhoh3: . I usually remember, but i want to cut down on the nervousness and the length of time it takes me to write notes.

Can anyone help me out with nursing notes based on the body systems ie: CNS, CVS, Renal, GIT, Metabolic, Skin integ, Social....

I have the list of the systems, but where i used to work had a double sided A4 sheet which listed each thing that went under each heading. Ive been searching the net for ages and cant find anything like it.

Can someone PLEASE direct me to a link, or something to help me out?

Thanks stacks in advance for anyone so kind to help!!!

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I just made up my own cheat sheets to help me remember the details. Just List the systems from head down, then add things to prompt you like meds, dressing changes, etc.

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Thanks cyberkat, ive sorta been jotting things down as I go, but i might try to compile it now!

Any other hints or advice?

Im considering asking someone from my old workplace to try and photocopy that sheet for me, but people werent too happy when i left (I left cos i graduated my RN and i didnt accept the program that my previous workplace offered me, i went somewhere bigger, i dont think they were too happy...)

Thanks

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When I was a new nurse on a trauma acute care floor, I found it was much easier if I charted the second I stepped out of the room. It only took a few minutes and I could remember right then. I could easily move on to my next patient and didn't have to recall everything about 5-6 patients after I had seen all of them. This also made my charting throughout the day easier and quicker. Good luck.

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Easiest way for me:

HEENT: head, eyes, ears, nose, throat

Chest: cardiac & resp

GI: yep

Extremities: you can include trunk, ie pressure sores, etc

For ROV purposes:

HEENT: HA, dizziness, syncope, presyncope, fatigue, weakness, cough, nosebleeds

Chest: CP, SOB, DOE, PND, orthopnea

GI: n/v/d

Extrem: neuro, edema, & depends upon how detailed you wanna be.

hope it helps.

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Specializes in ER/ ICU.

Start w/ the head and work your way down. Every system is covered.

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i've always found it easier since i'm doing a head to toe assessment, to chart from head to toe. by doin so all systems are covered. such as:

vitals

loc/a&o

eyes/perrla

skin/dressings

lungs

abd

pulses

mae or not

any iv's, o2, ng....etc

foley/drains

teds/scd

safety....bed low, rails up x2 etc...

hope this helps...this way has just always been easier to remember for me, rather then breaking down systems.

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neurological Assessment

Alert And Oriented To Person, Time

Behavior Appropriate To Situation And Memory Intact

Extremities With Symmetry Of Strength

No Numbness Or Parathesis; Face Symmetricial

Vebalization Clear And Understandable

cardiovascular Assessment

Regular Rhythm, Rate 60-100/min, Bp Stable

No Peripheral Edema

No Dizziness, Chest Pain Or Pressure

respiratory

Regular Rate 10-20/ Min

Breath Sounds Clear And Unlabored

No Sputum Or Sputum Clear, White, Or Pale Yellow

gastrointestinal

Abdominal, Soft, Non-distended With Bowel Sounds

Bm's Within The Last 3 Days Prior

Light To Dark Brown, Formed Stool

No Emesis Or Diarrhea

nutrition

Taking Average Of 75% Diet Over Last 3 Days.

Tolerating Food And Fluid.

No Difficulity Chewing Or Swallowing Or Mouth Pain

genitourinary

Urine Clear To Yellow.

No Signs Current Infect.,drainage, Trauma, Bleeding, Retention.

musculoskeletal/mobility

No Redness, Swelling Or Deformity

Normal Rom Of Extremities

integumentary

Skin Color Within Patient's Normal, Afebrile.

Skin Dry And Intact With No Rashes, Lesions Or Ecchymosis.

intravenous Assement (all Sites)

Site Without Signs Or Symptoms Of Redness, Swelling, Or Pain

Dressing Dry Intact

Cath Is Intact When Discontinued

pain Management Assessment

Pain Free (obtain Order If Needed)

surgical Site

Incision Edges Approximated If Visible

No Evidence Of Inflammation Or Purlent Drainage

Sutures, Staples, Steri Strips, Dressing Dry & Intact if Applicable

knowledge And Education Assessment

Demonstrates Readiness And Willing, Capability And Resource To Learn About Condition And Self Care

Understands Diagnosis And Treatment Plan

States Understanding Of Verbal Or Written Instructions

discharge Planning

Able To Manage Adl's Without Difficulty, Or Has Adequate Support System In Place

Able To Return To Previous Living Situation.

psychosocial Asessment

Appropriate Behavior For Condition And Age Range

Cooperative With No Signs Of Distress, Or Depression, Manageable Anxiety

tubes/equipment (if Present)

Ct To Water Seal 20 Cm Suction Drains Serosanguious Fluid, No Air Leak.

Ng In Place Draining Greenish-brown Fluid, Irrigates Well If Ordered.

Foley Cath Drains Clear Yellow Urine.

Hemavac/jp In Place, Compressed, Draining Serosanguious

If Referrals Made, Order In Computer And Record On Top Rand,

Computer Ord:

Social Services

Social Services (update)

Dititian Referral And Nutrition Score

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