Download Narrative charting resource sheet

Narrative charting resource sheet – Use this to help with wording & what to look for. Graded charting should be on course form.
PALM BEACH STATE COLLEGE- PRACTICAL NURSING PROGRAM. PRN0005 – PRN0021
Systems Data
Expected normal findings.
Specify - do not use normal word.
Reported to ___
Vital Signs
Pain (6th VS)
Mentation
behavior
General
appearance
Integumentary
MusculoSkeletal
CardioVascular
Abnormal –select appropriate wording only
Denies pain.
(A & O X 3). Alert, oriented to time, place &
person; Follows commands & answers
appropriately. Speech clear. Maintains eye
contact. Pupils equal & reactive to light
(PERLA # mm)
Neat, relaxed, no signs of distress.
Physique well developed.
Skin pink, warm, dry & intact with elastic
turgor. No lesions noted
Mucus membranes moist, intact & pink.
Bony prominences free of redness
Strong & equal handgrasp bil. Full ROM all
joints. Denies stiffness / pain with
movement. No gross muscle weakness.
Absence of joint pain, tenderness or
swelling. Erect posture. Steady gait.
Includes vital signs compared to baseline.
Regular, full apical pulse,
With regular rhythm. S1, S2. BP within pts.
baseline. Palpable peripheral pulses + 2 bil
X 4 limbs. OR Bil peripheral pulses +2 LE &
LU. Capillary refill <3 sec X 4 limbs. Pink
moist, mucus membranes & conjunctiva. No
neck vein distention observed. No edema
noted.
IV site (location) free of erythema, swelling
or tenderness
Location, type, duration.
What makes it better / worse?
A&O X 1 or 2 (specify disoriented to which). Drowsy, lethargic,
confused, sedated, unconscious. Withdrawn, agitated, irritable, crying,
combative, pupils unequal. Does not make eye contact. Volunteers no
information. Lack of /or inappropriate response to questions. Garbled
or slurred speech. HOH.
Unshaven, Hygiene unkempt.
Visible signs of distress (SOB, crying, grimacing, moaning). Facial
expression___. Abnormal positioning (slumped, leaning, hunched
over___, knees drawn). Obese, emaciated.
Skin color ashen, cyanotic, or jaundiced. Change in skin pigmentation,
texture, or tenting. Skin hot or cool or moist. Skin eruptions, rashes,
lesions, wounds (location). Unusual hair growth or loss. Nails, thick
yellow, broken, or brittle. Per report wounds -location. Covered with
dressing-not assessed.
Handgrasp (unequal / weak or absent). Muscle weakness or atrophy
(location). Deformity, joint stiffness or pain. Posture (hunched, leaning,
kyphosis, scoliosis, lordosis). Paralysis (where).
Amputations, dislocations, fractures, casts, traction assistive devices,
elevation or immobilization of extremity or body part.
Changes in apical pulse (irregular, weak, thready, bounding). Jugular
vein distention. BP bounding or difficult to auscultate.
Asymmetry, weak or absent peripheral pulses. Edema pitting or
non-pitting (location & grade). Pt. c/o dizzy, faint, chest pain,
palpitations, leg pain. Capillary refill >3 seconds (location). Color
changes (pallor, cyanosis, rubor, flushed, ashen, ecchymosis).
Varicose veins (location). IV site (location) reddened, edema, or
tender /pain – reported to__. Ortho BP readings if ordered (lying,
sitting, standing). Apical/ radial pulse deficit
AE or SCD AK or BK. Ace wrap.
RESOURCE ONLY –Not to be submitted as charting for clinical grade.
Note: List is not all inclusive. It is intended to provide a quick reference for a new student
Time _____T ______ P______
R______
BP __________________O2 sat____
Time ______T______ P______
R______
BP ______ O2 sat
DIET order:
ACTIVITY order:
Rev 08/2012 CMP
Narrative charting resource sheet – Use this to help with wording & what to look for. Graded charting should be on course form.
PALM BEACH STATE COLLEGE- PRACTICAL NURSING PROGRAM. PRN0005 – PRN0021
Note: List is not all inclusive. It is =.
SystemData Normal
RESP
GI
URINARY
Abnormal (Specify Location)
Respiratory rate even, regular & easy.
Depth within acceptable parameters. Lungs
sounds clear all lobes.
No adventitious lung sounds.
Absence of spontaneous cough.
Absence of cough.
O2 saturation >93%
Resp rate-& type. Dyspnea, bradypnea, tachypnea, SOB. (Position if
Resp abnormal). Lung sounds: rhonchi, crackles, wheezes
auscultated (specify lobe). Cough dry, hacking, productive (specify
sputum color, consistency & amount). (If O2 sats <93%. - re-check &
report to whom). Position (leaning over table or semi/high Fowler’s),
splints chest with arm or pillow. Abnormal chest contour (barrel).
Indrawing intercostal spaces, substernal or suprasternal. Sneezing
Nasal discharge. O2 @__ liters /min via NC, simple mask, nonrebreather mask, re-breather mask, Venturi mask). Taught incentive
spirometer X 10 Q2H. Volume ____ ml.
Specimens if obtained.
Lips dry & smooth. Mucus membranes
moist, pink & smooth.
Teeth white & shiny.
Gums pink, moist & firm.
Tongue medium red or pink, moist & smooth.
Abdomen concave or convex, soft, nontender to palpation. No distention noted.
Bowel sounds active X 4 quads. Denies
N/V/D or constipation. Last BM ___
Lips dry, cracked, tender. Lesions on oral mucosa.
Mouth dry inflamed, ulcerated, pale, white patches, deep tongue
furrows. Teeth discolored, broken, dentures, partial plate,
edentulous.
Gums inflamed, receding, tender, bleeding. Poor oral hygiene.
Abdomen - concave, convex, asymmetric, protruberant, firm,
distended, tender or painful.
Bowel sounds hypoactive or hyperactive in __quadrant (location).
N/V/D, constipation. Last BM __. Flatulence.
Ostomy-location-type. Specimens if obtained.
Continent. Bladder non-palpable.
Urine clear, pale, yellow to amber in color, no
sediment.
Voids without difficult. Denies dysuria. .
Palpable bladder (superpubic.). Last void ___. HNV since ___
Incontinence. C/o dysuria, frequency, dribbling.
Urine cloudy, foul odor, color (tea colored, orange, concentrated) with
sediment.
Catheter type (external, indwelling or suprapubic) connected to
__BSD or leg bag.
RESOURCE ONLY –Not to be submitted as charting for clinical grade.
Note: List is not all inclusive. It is intended to provide a quick reference for a new student
Rev 08/2012 CMP