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Nursing notes

Posted
jox1962 jox1962 (New) New

Hi folks I need help with my nursing notes. This is the scenario

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.

This is what I wrote

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