Narrative Chart

8/11/2019 Narrative Chart

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NARRATIVE CHARTING

05/31/07...2245...Pt 4 hours postoperative: awakens easily: oriented X3 but

groggy. Incision site in front of L ear extending down and around ear andinto neck-approximately 6" in length - without dressing. No swelling or

bleeding, bluish discoloration below L ear noted, sutures intact. Jackson

Pratt drain in L neck below ear with 20 mL bloody drainage measured.

Drain remains secured in place with suture and anchored to L anterior

chest wall with tape. Pt denied pain but stated she felt nauseated and

promptly vomited 100 mL of clear fluid. Pt attempted to get OOB to

ambulate to bathroom with assistance but felt dizzy upon standing.

Assisted to lie down in bed. Voided 200 mL clear, yellow urine in bedpan.

Pt encouraged to deep-breathe and cough QH and turn frequently in bed.

Antiembolism pads applied to both lower extremeties. Explanations given

re: these preventive measures. Pt verbalized understanding.---------------

Joe Schmoe, RN

05/31/07...2255...Pt continues to feel nauseated. Compazine 10mg I.M.

given in R gluteus maximus.----------------------------------------------Joe

Schmoe, RN

05/31/07...2335...Pt states she is no longer nauseated, remains pain free.

No further vomiting. Pt demonstrated taking deep breaths and coughingeffectively.------------------------------------------------------------------Joe

Schmoe, RN

Example for NG insertion. 16 F NGT placed with ease through the

right nares using clean technique after prep with cetacaine spray

and xylocaine jelly for pt comfort. Placement checked perauscultation and return of gastric contents. 100 ml yellow liquid

gastric contents returned immediately. NG connected to LIWS per

order. Pt tolerated the procedure well and vital signs remain

within normal limits.


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Prior to documenting the placement procedure, of course you would also need to

document what the patient looked like ie: why they needed intubated, then any

medications that were given to relax or sedate the patient. Don't forget the soft

restraint documentation if you are using those. Most places require separate papersfor soft restraints or safety devices.

For an ET I will usually chart this: 8.5 ET tube placed successfully after two

attempts per respiratory or MD (whichever). Placement initially checked by

positive breath sounds bi-lat and positive end tidal Co2. Stat x-ray ordered

to confirm placement. Tube placed 22 at the lip and tube secured. Pt's SpO2

now 98% and pt's color is pink, patient is warm and dry.

Then you would chart either the patient is being bagged per RT or pt placed

on a vent and be sure to document the vent settings. If there is anythingsuctioned from the lungs you would need to document the consistancy, the

color and the amount.

Narrative Nursing Notes:10/13/2010. 1735. Chief complaint: SOB. Age 28,Orient x3. HR 70 BPM (pacemaker), Respiration 20,BP: 100/60 mmHg, O2:95%. Dimished breath sounds, crackles in lower right lung. T 37.0 C. PT

inserted, 600 mL of urine, dark yellow,clear, no odor. Unable to walkwithout assistance. Unable to move from chair to bed withoutassistance.Breathing with nasal canunli. O2is humidified. PT states nopain, 0 on pain scale, but 4-5 when pressureulcer is bothering him.Pressure ulcer on sacral area. Did not assess. PEARLA. Can respond tocommands.Hearing loss in left year. Motor responses are +2. No facialdrooping noticed. Skin tugor: dehydrated,cool to touch. Notable edema onlower extremities, Pitting on lower leg. Pedal purse difficult to feel

07:30 Alert, awake, orientated to person place and time. Follows commands. Skin

warm and dry. Respirations


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unlabored @18. Apical Pulse = 82, regular. Bowel Sounds absent. Hand grasps equal.

@ 4L via nasal cannula. IV

D5/1/2NS infusing @100 to R forearm via pump. Site clean and dry with no swelling or

redness. Abdominal dressing

dry and intact. Foley draining clear amber urine. Compression boots in place. TEDS in

place. Bed in low position,

call bell in reach, siderails CNS

Documenting diet.

The amount of fluid in CCs is recorded in the I&O sheet. In the narrative note document

the type of diet, percentage

consumed, and any pertinent information :

08:00 Took 100% of low sodium, soft diet. Had difficulty swallowing chopped meat._M.

Nurse, BCNS

Documentation of complete physical assessment.

Complete your assessment before 9 a.m. and before giving any medications or

treatments. It may not all be

actually completed at the same time, but document it in one paragraph making sure that

any abnormal or

critical findings are documented and reported immediately.

Ask the patient specifically when he had last BM. In addition to stating of stating no

complaints of

constipation diarrhea or flatus, describe your patients specific status.

0830 Awake, alert, oriented to person, place & time. Skin warm and dry. Turgor recoil

brisk. Face symmetrical.

PERRLA. EOM intact. Follow spoken commands. Mucous membranes pink & moist.Swallows without difficulty. Neck supple, trachea midline, carotids equal, no lymph

nodes palpated. JVD (-) @ 45. Respirations even and

unlabored, rate 16. Breath sounds clear bilaterally & A&P. Apical Pulse=72, regular.

Abdomen soft, non-tender, bowel


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sounds present in all 4 quadrants. No complaints of constipation, diarrhea, flatus.

States last BM yesterday evening.

Urine amber, no complaints of burning. MAE without difficulty. Peripheral pulses 2+.

Homans sign (-). Capillary

refill brisk. Bed in low position, call light within reach.

SR

BCNS

Documentation of hygiene care:

Most institutions have a check-off list of nursing interventions for hygiene, such as back

care, pedicure, Foley care,

mouth care. However, they should be included in a narrative note. Also indicate how

much of the care the patient

did independently and any pertinent observations.

09:30 Complete bath care given with mouth care, peri-care, Foley care, back care.__M.

Nurse, BCNS

Documenting ambulation:

Describe gait, strength, amount of assistance needed, how tolerated.

09:30 OOB to chair with the assistance of two staff members. Gait steady, but slow.Ambulated in hallway 5 minutes.

C/O feeling tired., assisted back to

bed________________________________M. Nurse, BCNS

Documenting a problem such as pain:

State the problem, what was done to solve it, and record result.

10:15 States sharp pain points to LLQ of abdomen, 8 on a scale of 1-10. States gets a

little better when lying on leftside. Respirations 20. Demerol 75 mg IM R ventral gluteal site by M. RealNurse, RN.

Side rails

position, call light in reach. M. Nurse, BCNS

and the result (or evaluation of whether your intervention was successful):


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11:00 States pain 3 on scale of 1-10. Watching TV.__________________M. Nurse,

BCNS

Documenting a physician visit, a test, therapy, treatment, specimen:

10:30 Dr. Jones in to see patient._________________________________M.

Nurse, BCNS

10:40 To x-ray via w/c for chest x-ray_____________________________M.

Nurse, BCNS

11:45. Sputum Specimen to lab.__________________________________M.

Nurse, BCNS

12:00 Abdominal dressing change. 8" midline, vertical abdominal incision well-

approximated. Staples intact. No

redness, swelling or drainage noted. Dry sterile dressing applied._________M. Nurse,

BCNS

FINAL ENTRY:

Verify status of your patient and include safety check

12:15 States pain almost gone, now a 1 on 1-10 scale. Husband visiting. Watching TV.

Side rail

reach, bed in low position.___________________________________M. Nurse,

BCNS

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Narrative Chart