question about charting

[lmh81]

Can someone give me an example on ways to chart the following:Skin tents in 2 seconds. Heart rate is irregular and rapid at 105 BPM. Fingers and toes all Blanche in 2 seconds. Radial and dorsalis pedis pulses are regular. Receiving oxygen at 2L/min by nasal cannula.

[JustBeachyNurse, LPN]

Blanch is often referred to as capillary refill and "skin tents" as skin turgid. However you cannot have regular distal pulses if heart/pulse rate is irregular. 105 is considered tachycardia by definition (assuming this is NOT a pediatric patient which in that case it could be bradycardia in a newborn or young infant). What about respiratory assessment other than O2?

HR 105, irregular. Skin turgor WNL, cap. refill

[Jazziepants]

List vitals: tpr bp o2 and pain. Skin turgor less than 3 seconds. Heart sounds irregular and rapid. Capillary refill less than 3 seconds. Pedal pulses present and strong bilaterally.

[lmh81]

Thank you! We get assignments with different situations and we have to chart it. That's exactly how the assignment described it and I was unsure of those particular things. Obviously that is my first one and I really have no idea how to do it yet so thank you!

[psu_213, BSN, RN]

When assessing pulses: document how they "feel": normal, weak/thready, bounding, etc. This is another case where a "plus" scale is used: "0 = absent, 1+ = diminished (weak/thready), 2+ = normal, 3+ = full, firm. There is a bit of subjectivity with this, however it gives those who reads your charting a good idea of what you felt.