Nursing notes

[Sunshine60]

Hello, I was wondering if anyone could help me with a nurses note?! I am almost finished with my PN program, and have never written a nursing note. Today we were randomly assigned a scenerio and I am not sure how to write it. It must be narrative. I will include the scenerio if anyone is willing to help me! If so, please respond on here, private message me, or email me! [email protected]

Scenerio:

Mrs. Smith has presented to your hospital unit via ambulance. As the LPN assigned, you had been notified by your Rn and Charge nurse that you would be getting this patient. You have not received report from the long term care facility in which she resides, prior to her arrival. In addition to the EMR computerized documentation check list style assessment, a detailed narrative nursing note is necessary in this situation. Using the following information and any additional observations you can think of to formulate a narrative note which includes all necessary elements which you believe must be covered. You are assisted by 2 EMS personnel to transfer Mrs. Smith to her bed. You immediately observe that: Mrs. Smith is lethargic, has a Foley catheter that is draining a small amount of dark yellow urine and is unable to follow verbal commands. Upon turning Mrs. Smith you also visualize that she has a 4x4 bandage to her coccyx which has a quarter sized area of dried brown drainage. No family has accompanied this patient and the RN with whom you are working has just begun her lunch break off of the unit. VS obtained by a nursing assistant that is working with you are as follows: T 37.9, P 96, R 24, and BP 130/78.

THIS IS NOT A REAL PATIENT. IT IS JUST A SCENERIO CREATED BY MY TEACHER.

Please Help!

Thank you,

Sunshine!

[JustBeachyNurse, LPN]

What do you have so far? What do you know to be the critical elements of an initial nursing assessment/narrative? What information is missing? What further investigations are needed ( I.e.what have you not observed/assessed yet? )Happy to help but I/we need to know what you have so far to guide you.

[JustBeachyNurse, LPN]

Moving thread to nursing student assistance to elicit further response

[PunkBenRN]

The important points to highlight (I'm not going to write this for you, but this should help):

STAY OBJECTIVE!

-It does at times happen that you don't recieve a report, or you recieve a report that is poor and Pt arrives in trouble :icon_roll. You need to document who you recieved report from, or in this case, that you did not recieve report on arrival. You can put in any follow up as well (It always looks good when you call who is transferring and ask for report; maybe the fax machine got jammed?)

-Document that they arrived accompanied by EMS. I don't know why, but hospitals can be sticklers on who is with them on arrival.

-Document exactly what you see. It helps when you get a routine on documenting all the systems, but in this case where you have a limited amount of information, document what you do know. Do not speculate, just say what you see. Dark urine (Scant amt), Lethargy/Responsiveness, and be sure to mention that she arrived with the foley in place.

-As far as the wound, you need to be as specific as you can. Color, odor, amt of drainage. Site of wound. Dressing that is in place on arrival. Size and depth of wound. Also, note that the wound was present on arrival - missing this piece of information, the hospital is responsible for all payment of treatment of that wound (if you can't prove the Pt had prior to hospitalization).

Thats it, really. Hope that helps.