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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 Withdrawn, agitated, irritable, crying, combative, pupils unequal.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