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!