KEL2BanRN

I didn't want medical advice with the post I just put on here. I know enough to not seek medical advice on a message board. All she wanted to know is if it's possible that the vaccine came out of the needle or what when he got the injection. I've seen WAY more descriptive posts and replies on this board than that one regarding shots. I'm sorry and I won't post again.

Floor nurses have time to surf the 'Net??? I'm actually surprised. LOL I'm still just a student, but from what I see in clinicals, I can't imagine nurses having time to sit at the desk and play online.

My school is on quarters. The ADN program is 7 quarters. We have to take a HESI after 4th quarter. If you don't score high enough, you have to stay after summer quarter for 3 weeks of remediation. Then you take another HESI before graduation, and same deal - I think it's 2 weeks of remediation then if you don't score high enough.

Here's what I just found: Q. Why does the tubing on my stethoscope become stiff and rigid? A. The tubing used in all 3M™ Littmann® Stethoscopes is a PVC (polyvinylchloride) tubing that becomes hard when exposed for long periods of time to the lipids found in human skin. Wearing the stethoscope around the neck may cause stiffening of the tubing over time. If worn around the neck, we recommend trying not to let it come in contact with skin by wearing it under a collar. It is also recommended that the tubing is treated with a vinyl protector such as Armor All® Protector once a month. This will not prevent stiffening, but may slow the process down.

Yes, thank you!! :)

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

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.

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.

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

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

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.

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

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

THANK YOU!!

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!

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

Thank you!

Thanks :) I wondered what to do about the knee pain thing. Basically this is in a nursing home, and my resident mentioned that her arthritis was acting up in that knee. I wasn't sure how to do that... NICU huh? That's my goal someday in the future :)

OK, here I go... I'm putting this out here so y'all can tear me up. This is only my second attempt at documenting, and we don't use any charting books so I am really bad at how to phrase things. Anyone wanna critique me?? (PS - this isn't something we are graded on this quarter; we are doing it for practice) Thanks for any help! Charting for Friday, November 2 11022007 0705 Lying in bed, resting with eyes closed. Difficult to arouse. Apical P 70 & regular, R 24 rapid, shallow & irregular. Skin pink, cool, dry. Turgor good. Anterior lung sounds clear bilat. Ankles purple, dry, flaking, +4 pitting edema bilat. Feet and toes cool bilat. Tibial and pedal pulses not palpable bilat. Cap refill 0730 In bed, eyes closed, snoring. Difficult to awaken. A&O x2, disoriented to time. States wants to sleep longer. Remains in bed /c eyes closed.----------------------------------------------------S Sumith SN 0815 In bed, eyes closed. Awakened /c difficulty. A&O x2, disoriented to time. Assist x2 to W/C. Assist x2 /c transfer to bathroom. Unable to void. Assist x1 to get dressed and return to W/C and transfer back to room. Resting quietly in W/C /c eyes closed, shallow resps.---------- S Smith SN 0900 Sitting in W/C. A&O x3. Fistula L bicep warm, pulsating, dressing clean, dry and intact. Eating breakfast, denies further needs.-------------------------------------------------------------------S Smith SN 0930 Sitting in W/C. Ate 50% of breakfast. Drank 100 mL tea, 100 mL milk. Denies needs at this time.---------------------------------------------------------------------------------------------------------S Smith SN 0945 Sitting in W/C. Lung sounds clear posterior bilat. C/O pain in R knee, 2/10, refuses meds. Denies further needs.-------------------------------------------------------------------------------------S Smith SN 1000 Sitting in W/C. Transfer to PT via W/C with assist x1.---------------------------------S SMith SN 1115 Assist /c transfer to BR. Assist x2 onto toilet. Unable to void at present but states feeling of urgency. Assist x2 to W/C, back to room. Denies needs, remains in W/C.-----------------S Smith SN 1140 Report given to LPN on duty.-----------------------------------------------------------------S Smith SN

I have a resident with a fistula in her upper L arm. I am only on my 3rd day of clinical and need to document the bruit and thrill. What is the appropriate way to chart this? I'm considering buying the book everyone is suggesting, "Charting Made Incredibly Easy." Thanks in advance for any help.

LOL Daytonite! That would be so funny!

LOL Thanks, Daytonite. All I really wondered is if there was a medical term for "purple" like there is for "blue". (cyanotic) But that was interesting!

Thank you. I just wasn't sure if there was a term for purple, like there is for blue (cyanotic). I used purple. :)

I know this might seem like a dumb question, but we're just learning how to document findings. My resident has edematous, dry, and very purple ankles. How do I document that (the color)? I asked my instructor and his answer was "how ever you think is correct". I don't KNOW what is correct nor do I have any clue, since I have no medical background whatsoever. I know what NOT to put (cyanotic, pink, etc). I'm stuck on the purple thing - do I just chart as "purple"?? Thanks to anyone for suggestions. :)

thanks, daytonite! i had my second test on tuesday and i got a 94% on it!! i was so happy!! i think there were only 2-3 a's out of 98 of us, so i did something right this time around. oh and yay, i have a sticky now! lol! there really are some good hints on this thread.