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Nursing note for beginner LPN, my first note..opinions?

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This is my first semester for LPN, I am writing my nursing note, it is based off a physical assessment on another class mate. opinions on how this looks? Be gentle lol:)

08/29/2014 0800, Female, vs. 97.8 F oral, hr 88, bp 138/92, o2 98% room air. weight 150lbs. Alert and oriented x3. speech clear, perria, responds to verbal stimuli, denies pain. grip strength equal, MAE X4, skin pink, warm, dry. elastic turgor. Mucous membrane clear and intact. Negative JVD, trachea midline, respirations clear, unlabored. Lung sounds clear through ausculation. Abdomen soft, nondistended, with bowl sounds in all 4 quadrants. Pink nail beds, capillary refill greater 2 seconds. Peripheral pulse papable in all extremities. Visually impaired, glasses required. Independent with feeding. Independent with bowel, bladder. Urine clear, yellow. Skin intact, negative breakdown. Will continue to monitor------------------------------------------------------------------------------A.Loveless PN Student

sallyrnrrt, ADN, RN

Specializes in critical care, ER,ICU, CVSURG, CCU.

geater than 2sec cap refill is pathology

quality of bowel sounds, hyper, hypo, normal etc

is abdomen tender?

intensity of peph.pulses 2+, 3+, & / or 4+ , are they equal ie right and left

how do you know urine is clear, voiding, or cath in place etc

you covered most of the basics, oh, ? verbal able to make needs known,

"hurry up some of us older nurses need some relief :sneaky:

Thank you so much ive written like 10 notes and keep missing or leaving out things..this is stressful! lol im getting it ill post my revised and maybe it will be better lol

poppycat, ADN, BSN

Specializes in pediatrics; PICU; NICU. Has 43 years experience.

Just keep working on it. It takes lots of practice before you'll be confident that you're addressing everything you need to. Good luck with your schooling!

The visually impaired would go along with the "head" part of the head to toe.

To take this one step further, the BP is elevated a bit--So any follow up note would have to include how you responsed to that ie: MD notified of increased BP, no new orders or manual BP ordered or whatever the order would be. (

Some notes also require "medications reviewed with patient" as part of a medication reconciliation. Additionally, HR 88, regular rythym. (or whatever you heard).

For a first note AWESOME job!! Woo Hoo and keep up the good work.

Thank you so much ive written like 10 notes and keep missing or leaving out things..this is stressful! lol im getting it ill post my revised and maybe it will be better lol

Literally visualize head to toe. That is what I find most helpful. But you are spot on and with your choice of wording!! So excellent and you will get it!

Oh, and also most facilities want the weight in KG, and a cm height....yup, sounds a bit weird for an adult....but it is apparently "the new black" HAHAHAHA!!

sallyrnrrt, ADN, RN

Specializes in critical care, ER,ICU, CVSURG, CCU.

please keep it up, and soon comprehensive "right on" note will flow without thinking, but more just like breathing air in and out ))hugs((

Edited by sallyrnrrt
spelling

BostonFNP, APRN

Specializes in Adult Internal Medicine. Has 10 years experience.

Pertinent positives first then pertinent negatives, just a little catching point I work on with grad students. But a nice assessment note.

Sent from my iPhone.

I went back to my guideline from class, and i went pretty much exactly how they are asking for it and what they want. so does this look better?

08/29/2012 0800. 27 yo. Female. Skin pink, dry, warm. Turgor elastic. Mucous membrane clear, moist. Alert, oriented person, place, time. Pupils PERRLA, size 3mm. Speech clear. MAE X4. Grip strength strong, equal. . Responds appropriate to touch. Responds to verbal stimuli. Respiration 18 strong. symmetrical chest movement, unlabored. All lobes clear through ausculation. O2 room air. Trachea, midline.Capillary refill greater than 3 seconds. Negative JVD. Peripheral pulses papable all extremities. Negative edema. Negative Homans BLE. Bowel sounds present X4 quadrants. Abdomen soft, undistended, regular diet. Independent feeding. Voiding yellow, clear. Emotional reaction calm, coping. 150 lbs. No known allergies. Visually impaired, wears glasses. Denies pain. Vs, 97.8 F oral, hr 88 apical, RR 18 clear, bp 138/92, o2 98% room air. Will continue to monitor---------------------------A.Loveless PN Student

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 11 years experience.

Cap refill should be brisk, less than 3 seconds. Greater than 3 seconds is a positive finding that must be addressed

heartnursing

Specializes in Pediatric Critical Care.

not sure if this is already mentioned but "denies pain" that is subjective... how about rates pain 0/10

amoLucia

Specializes in LTC.

Question - What is MAE X4? I don't know that I've heard of it or else I'm having a brain snap.

This is personal - I usually document as 'no known drug, food or other allergies reported'. I'm thinking of those peanut, strawberry and bee sting type allergies.

sallyrnrrt, ADN, RN

Specializes in critical care, ER,ICU, CVSURG, CCU.

moves all four extremities

edmia, BSN, RN

Specializes in Emergency, ICU. Has 10 years experience.

Good job. Just one thing: you say she's alert and oriented and later on mention she responds to verbal stimulus. I would use the verbal stimulus thing only with a patient who is sleeping, or lethargic, or somehow with a changed mental status to convey that they do respond and didn't need stronger stimulus to wake up. If I say AA&O, then that's it, no need to stimulate them.

And just FYI, Homans sign does not have much diagnostic value according to evidence (many false positives), so it's really not recommended but if that's what your instructor wants you to document, leave it in.

poppycat, ADN, BSN

Specializes in pediatrics; PICU; NICU. Has 43 years experience.

moves all four extremities

Thanks, I was having a senior moment with that, too.

BBRANRN2013, ASN, RN

Has 1 years experience.

Don't write will continue to monitor - will you be there every shift to monitor this patient? This is what I was told! If it's not right feel free to correct me:-)

abbnurse

Has 29 years experience.

Thanks, I was having a senior moment with that, too.

So was I ! I was glad to see that amoLucia asked the question just as I was searching my memory for that one....

kbrn2002, ADN, RN

Specializes in Geriatrics, Dialysis. Has 19 years experience.

If your instructor likes "continue to monitor" go ahead and leave it in. But in real world charting we haven't used the phrase "continue to monitor" for a long time, are you really going to be there to continue to monitor? A better ending note would be "proceed to plan of care" or something along those lines.

As I am sure somebody else must have mentioned, capillary refill greater than 3 seconds would definitely require follow up, are you sure you didn't mean capillary refill less than 2 seconds? Otherwise, not knowing what particulars your instructor likes, it looks pretty good to me.