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    Nurses Charting

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    demethra
    The patient is a 78-year-old female who was recently hospitalized for exacerbation of COPD. She has multiple comorbidities including COPD, CAD, HTN, anemia, and diabetes. The nurse assessed the patient and noted her vital signs were within normal limits, she has diminished lung sounds bilaterally, a small skin tear on her forearm, and edema in her legs; the plan is to provide education on COPD management, medications, safety, and ways to decrease edema while monitoring her wound.

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    Nurses Charting

    Uploaded by

    demethra
    566 views2 pages
    The patient is a 78-year-old female who was recently hospitalized for exacerbation of COPD. She has multiple comorbidities including COPD, CAD, HTN, anemia, and diabetes. The nurse assessed the patient and noted her vital signs were within normal limits, she has diminished lung sounds bilaterally, a small skin tear on her forearm, and edema in her legs; the plan is to provide education on COPD management, medications, safety, and ways to decrease edema while monitoring her wound.

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    nurses charting

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    The patient is a 78-year-old female who was recently hospitalized for exacerbation of COPD. She has multiple comorbidities including COPD, CAD, HTN, anemia, and diabetes. The nurse assessed the patient and noted her vital signs were within normal limits, she has diminished lung sounds bilaterally, a small skin tear on her forearm, and edema in her legs; the plan is to provide education on COPD management, medications, safety, and ways to decrease edema while monitoring her wound.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    566 views2 pages

    Nurses Charting

    Uploaded by

    demethra
    The patient is a 78-year-old female who was recently hospitalized for exacerbation of COPD. She has multiple comorbidities including COPD, CAD, HTN, anemia, and diabetes. The nurse assessed the patient and noted her vital signs were within normal limits, she has diminished lung sounds bilaterally, a small skin tear on her forearm, and edema in her legs; the plan is to provide education on COPD management, medications, safety, and ways to decrease edema while monitoring her wound.

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    SAMPLE DAR CHARTING Date/Time Focus Nurse's Notes 31/5/2010 pre-operative care F >Received

    asleep lying on bed with ongoing 5thIVF of PLRS iL+1 amp vit.b and vit.C x 16hoursat 150 cc level
    infusing well at the rightcephalic vein. D>With intact and patent CTT at 5th left intercostalspace
    connected to thorabottle draining toyellowish secretion. No signs of respiratorydistress. No compliants
    as of this moment. A>Established rapport. Assessed for signs andsymptoms of respiratory
    distress.Checked presence of dentures,nail polish, and jewelries.Dentures removed and handed
    towatcher.Consent signed for Cholecystectomyattached to chart.Instructed on NPO.Oral caredone.
    Shaving done. Skin prep done andclothing changed to O.R gown.Advised to dodeep breathing
    exercises.Encouraged toverbalize feelings and concerns to upcoming procedure. 1:00 a.m >Above IVF
    consumed and replaced withthe 6thIVF of D5LRS 1L regulated to 28gtts/min. R>Pt. was able to show
    readiness to upcomingoperation.Endorsed with an ongoing 6th IVF ofD5LRS iL x 28 gtts/min at 650 cc
    level andscheduled for cholecystectomy at 8 a.m

    Date/Time Focus Nurse's Notes

    31/5/2010 Focus:mild pain >Received lying on bed with ongoing 1st IVF of PNSS iL+2 amps.vit B and
    vit.C x 16 at 360cclevel infusing well at left metacarpal vein.

    D>With O2 inhalation at 2-4 LPM via nasalcannula.Poor skin nturgor noted. "nasakit ti takebko karkaru
    nu agkutikuti ak" as verbalized. Pain israted as 4/10 and is localized on the anterior chest.Characterized
    as pricking pain.Facial grimaces andguarding behaviors noted when in pain.

    A> Established rapport. Assessed pain level andcharacteristic.Assessed skin turgor. Cutaneous
    stimulation done. Provided quiet and calm environment.Positioned to comfort.
    Encouragedverbalization of feelings. 5:20pm >above IVF consumed and 2nd IVF of PNSS il x16 hours
    replaced.
    B> R>Pt. verbalized that pain is reduced from 4/10to 2/10. 11:00pm >Endorsed with ongoing 2nd IVF
    of PNSS iLx16at 800 cc level Date/Time Focus Nurse's Notes 5/31/2010Focus:elevated body
    >Received awake in a semi-fowler's position 7:00 am temperature with ongoing IVF of D5NSS il x8
    at 950 cclevel infusing well at right cephalic vein arm. D>with intact and patent IFC connected
    tourine bag draining to light yellow urine. >"napudot ti riknak"as verbalized.With bodytemperature
    of 38.2oC per axilla.Withflushed face and skin warm to touch. A>Assessed patency of IFC.Assessed
    for signs of fever.TSB continuouslydone.Offered fluids available at bedside.Removed extra clothings
    and blankets.Opened windows to enhance ventilation. Emphasized importance of increasing
    fluidintake.Encouraged verbalization of feelingsand concerns. 2:30pm >Above IVF consumed and
    removed asordered. R>Temperature lowered from 38.2oC to37oC

    PATIENT IS 78 Y/O FEMALE POST HOSPITALIZATION FOR EXAC OF COPD. INDEPENDENT


    PRIOR TO HOSPITAL PMH: COPD, CAD, HTN, ANEMIA, NIDDM. CURRENTLY, A&OX3,
    VITALS WNL. USES 2L/NC OXYGEN CONTINUOUSLY. DYSPNEA WITH MINIMAL EXERTION.
    LUNGS SOUNDS DIMINISHED BILAT. NEW NEBULIZER AND RX FOR ALBUTEROL. ADMITS
    TO STRESS BLADDER INCONTINENCE. POSITIVE BS X4. SHE HAS A 0.5 X 0.5 X 0.2 CM
    WOUND (SKIN TEAR) ON HER RIGHT ANTERIOR FOREARM. POSSIBLE TAPE BURN.
    WOUND BED IS BRIGHT PINK WITH NO DRAINAGE. BANDAID APPLIED. FBS 110 TODAY
    AND COMPLIANT WITH GLUCOMETER AND 1800 ADA DIET .EDEMA: 2+ PEDAL
    BILATERAL, LEFT INSTEP 28CM, RIGHT INSTEP 26CM. RATES PAIN 2/10 IN BACK DUE TO
    ARTHRITIS. UNSTEADY GAIT, USES WALKER. INDEPENDENT WITH ADL'S EXCEPT
    BATHING. LIVES WITH BROTHER WHO IS MAIN CAREGIVER. PLAN TO TEACH COPD
    DISEASE PROCESS AND MANAGEMENT; TEACH MEDICATIONS, SAFETY, NEBULIZER, HOW
    TO DECREASE EDEMA. MONITOR WOUND.

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