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KEL2BanRN

KEL2BanRN

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KEL2BanRN's Latest Activity

  1. KEL2BanRN

    Critique my documentation?

    Yes, thank you!! :)
  2. KEL2BanRN

    Critique my documentation?

    Could you be more specific on the abbreviations? So far I've used all of those before and my CI has said it was fine. In fact he's the one who has told me to use most of them. I did do head to toe, and I stick in abnormal things where they happened, kwim? The reason the coccyx dressing was at the end is because she's in LTC and I helped her to the restroom where I helped her undress and did her bath, etc, that's when I assessed her coccyx dressing. It was one of the last things I did before helping her dress and getting her settled. I don't think I'll ever get this stuff right. LOL
  3. KEL2BanRN

    Critique my documentation?

    LOL Thanks. I guess what they're doing with us right now is getting us used to doing full head to toe assessments and learning how to document. I'm really lost on how to document, and I wonder just how everyone automatically knows how to do it...? I have no idea how to word things.
  4. KEL2BanRN

    Critique my documentation?

    Hm, My CI is the one who told me to use UE for the upper extremities. Is there a list somewhere of abbreviations we can't use? As for the PU dressing, I am not to remove it - it was just put on that morning and I'm just supposed to assess the dressing at this point.
  5. KEL2BanRN

    Critique my documentation?

    This is my second day of charting. We're at a nursing home and have same resident each week for now. This is for practice, we will be charting in the actual chart next week. How does this look/sound? 11/09/07 0710 Supine in recliner, resting /c eyes closed. Aroused easily, A&O x 3. T 97.9, P 78, R 20, BP 122/65. PERRL 3mm. AV fistula L upper arm bruit present, thrill bounding. Resps shallow, even, unlabored. Skin on face and chest pink, warm, dry & intact. Chest symmetrical. Lung sounds clear A&P bilaterally. Pulse Ox 98% on room air. Abdomen soft, round, non-tender on light palpation. Bowel sounds present x4. LBM 11/8/07, large, soft, brown. Ap pulse 78, irregular. States "An aide bumped me on my pacemaker yesterday and it really hurts. It hasn't felt right since then." C/O pain 3/10 over pacemaker site. Reported to charge nurse. UEx2 pale, warm, dry. Radial pulses thready. L hand shows 1+ pitting edema. Denies paresthesia and pain, no paralysis noted in UE. Hand grasp = bilaterally. Ankles purple, cracked, peeling from ankles approximately 20 cm up and around the circumference of both legs. Tibial and pedal pulses non-palpable bilaterally. LE show 2+ pitting edema bilaterally. Cap refill 0900 Up in w/c. Feeding self independently. Denies needs. Call light in reach.-------J Doe SN 1100 Participating in activity in dining hall. Denies needs. Report off to charge nurse. J Doe SN
  6. KEL2BanRN

    charting.... critique?

    Yeah I realized just AFTER I posted that I forgot to put "call light in reach" with my entries!! DOH!! LOL
  7. KEL2BanRN

    how do you study?

    There's a sticky on the other forum called "STUDY strategies"... I think it's on the Nursing Student Assistance Forum. HTH.
  8. KEL2BanRN

    Nursing Documentation

    AHA! Finally someone else who has/understands my dilemma. I'm going thru this exact same thing right now. I know *what* to chart, I just don't know HOW and no one teaches us. You just fumble through. Like the other poster said - for something as legally important as charting, I'm shocked there isn't more training in this area.
  9. KEL2BanRN

    Call me crazy... but..

    ::THUD:: You just described me to a T. My friend in NS is just like me, so we stick together, LOL. People joke that we're both "anal", and that we do so well (as if that's a bad thing). I can't help it, this is just my personality and I don't try to fight it anymore. I'm uber-organized and I like having all my ducks in a row when I dive into something. And I do "dive" into it! The one time I've seen others "take advantage" of my ways was during a collaborative effort test - people joked ahead of time that they were all going to crowd around my friend and I since they "knew we'd have all the answers". That was annoying. That was in anatomy. I didn't think we'd ever see another collaborative test, but I found out that our last nursing test of the quarter is collab, and people have already started saying those things to me. Having said that, I DO love to help others. I've already helped a couple students study who were not doing well on the critical thinking tests. But I only help if I have time to give. I'm a really giving person. I think you'll make a great RN!
  10. KEL2BanRN

    charting.... critique?

    Thank you, that is very helpful! I need examples, and no books I see really have very many.
  11. KEL2BanRN

    charting.... critique?

    Daytonite, thank you! Yes, I explained it in a previous post. (about the inability to void)
  12. KEL2BanRN

    doc'ing bruit and thrill

    Well, I ended up changing my mind - I ordered one called "Chart Smart". LOL
  13. KEL2BanRN

    doc'ing bruit and thrill

    Thanks :)
  14. KEL2BanRN

    doc'ing bruit and thrill

  15. KEL2BanRN

    charting.... critique?

    The reason there was no intervention is because my resident is on dialysis 3x week and she really never is able to "go" but once in a while she gets the urge so we help her onto the toilet. I figured I should doc that. She was not in pain, and yes this is normal for her. The 1140 report to LPN is just the end of my doc'ing for the day and my report off. They didn't need to be informed about the toileting. But thanks!
  16. KEL2BanRN

    doc'ing bruit and thrill

    i know all of that, but thanks... i was looking for how to word it in my charting. i got it now, though. :)