Tuesday, March 6, 2012

CPNE Documentation: Narrative Notes and documenting with mnemonics

The info and/or pictures below contain copyrighted content from Excelsior College, this information is meant for demonstrative purposes. No replication of this information is permitted. This is part of my post series on Excelsior College's ADN nursing program and the CPNE experience. See all related posts over here. 

I have re-written all of my narrative notes and evaluations as best as I can remember. They may have flowed a bit less smoothly during the weekend, I'd add in a mnemonic that I forgot at the end sometimes and it didn't sound perfect but it hit the important parts. I tended to overdocument a bit rather than just hit the required critical elements. I charted right from my mnemonics on the grid but worded things out of order occasionally so that they sounded better. I'll be honest I didn't write much down on my grids during implementation. I had every intention of doing it in a different colored pen but it became awkward to keep stopping to write things down and take my paper in and out of my pocket 100 times. So I reverted back to waitress days and just remembered everything. I DID write down vitals and I'd write a thing or two here or there after I did about 10 things but I've got a pretty good memory so this worked for me. Wouldn't recommend that to anyone if you're worried about forgetting!

I'll post mnemonics on their own page but I devised mine by taking Sheri Taylor's and comparing them side by side with the critical elements on my EC flashcards. I tweaked them and made a few new ones that worked better for me that hit every single element and reminded me of how to do that particular AOC. (ie. adding in C periph for pva which stands for compare bilat, otherwise I thought I'd forget to document BOTH limbs compared to one another which is a critical element. Just little things like that)


PCS #1

Oxygen management
My Mnemonic: BREATHE sAFER (little S because I didn't use it)
Best position, resp rate/rhythm, ears nares, assess cap refill, triggers to combustion, humidity, eval 02 sats, assess tolerance to activity, finally evaluate & record.
Patient on oxygen at 1L/min via nasal canula, respiratory rate even with slight retractions noted, respiratory rate 18/min, capillary refill less than 3 seconds in both hands, oxygen saturation at 92% on oxygen. No skin irritation noted to ears or nares and patient denies discomfort from oxygen tubing, states that the humidity makes it more tolerable. Patient complains of dyspnea with exertion but states that it is much improved today. Patient positioned upright in bed to facilitate oxygenation, no triggers to combustion noted, oxygen tubing and humidity assessed to be running appropriately as ordered.

Respiratory Assessment
My mnemonic: PI BREATHE
Position upright, instruct to breath normal, breathing abnormalities, resp rate/rhythm, equipment clean, auscultate x4, tell patient breathe slow and deep, hear x4, evaluate & record.
Patient sitting upright in bed on oxygen 1L/min via nasal canula and noted to lean forward at times to breathe easier, respirations are even with slight retractions noted. Abnormal lung sounds in bilateral upper and lower lobes posteriorly. Respiratory rate 18/min.

Mobility
My mnemonic: MOBIL
Mobility status, observe devices, balance abnormalities, implement activity & increase support, log patient response.
Patient ambulatory with no use of assistive devices other than standby x1. Patient does utilize oxygen at 2.5L/min via nasal canula during ambulation.No balance abnormalities noted, steady gait. Encouraged patient to use controlled breathing techniques and to move slowly during activity to improve dyspnea but patient states that he likes to keep a "quick pace". Oxygen saturation dropped to 81% during ambulation but patient denied offers to take rest periods. Patient ambulated the full hallway back to his room with increasing dyspnea towards the end. Patient returned to his bed with difficulty breathing and states that he is surprised that he got that tired walking and agrees to go slower next time. Oxygen saturation returned to 91% after a few minutes and patient resting comfortably in bed.






PCS #2

Respiratory Management
My mnemonic: PBRAE PRRP (said pee bray - purp, I dont know? But it worked lol)
Position upright, Breathing abnormalities, resp rate/rhythm, ausc x4, explain resp activity, provide receptacle, repeat as ordered, reassess lungs, patient response.
Patient positioned to right side, posterior lung sounds clear in bilateral upper and lower lobes, no breathing abnormalities noted, respirations are even and unlabored. Patient completed incentive spirometry x 10 repetitions without complaints of dizziness or dyspnea. No cough or mucous production noted during respiratory hygiene. Posterior lung sounds reassessed and continue to be clear in bilateral upper and lower lobes.

Pain Management
My mnemonic: PAID MGMTTR
Pain level, assess location, intensity sharp/dull, duration, massage, guided imagery, meds, turn, temp hot/cold pack, reassess response.
Patient rates pain level 4 on 0-10 scale but states that it is much better than before. Patient describes pain in the abdomen as constant and aching and worse on the lower right side since surgery. Patient encouraged to use the PCA pump at regular intervals to maintain tolerable pain level. Patient repositioned out of bed to chair and states that it feels "wonderful" and can't believe the difference in pain in just one day. Patient denied offers to give back rub and change linens and stated she was very happy and feeling great. Patient later changed her mind and primary nurse notified of patients request for a new sheet and gown.

Abdominal Assessment
My mnemonic: 4P's LLF RR
Privacy, pain, pee, position, look distention, listen x4, feel tender/rigid, reposition, record.
Patient privacy provided, no complaints of unusual pain, foley cath in place, patient positioned supine as tolerated to about 35 degrees. Abdominal binder removed and slight distention noted. Large midline incision and JP drains to right and left lower abdomen covered in occlusive dressings. Bowel sounds present but hypoactive in all quadrants, moreso in the left upper and lower quadrants. Patient recently changed from npo to clear liquid status. Abdomen palpated to be soft with more rigidity noted on left upper and lower abdomen. Patient denies pain with light palpation. Abdominal binder re-secured.

Drainage
My mnemonic: Drain ACT (Spec OCLC "ock-lock")
Drainage: Assess color and amount, clean skin if assigned, tube replace as found (spec: obtain specimen, correct container, label date time, correct location/lab).
Right JP drain emptied into designated measuring container. 30 mLs of serosanguinous fluid noted with some clots present. Drain reattached to tubing with suction in place as found.

Mobility
MOBIL
Patient is on fall precautions and transfers out of bed to chair with 2 assists. No use of other assistive devices but utilizes oxygen. Some balance abnormalities noted, gait is slow and slightly unsteady. Patient instructed to sit and dangle feet prior to ambulation and to move slowly to improve hypotension. Patient transferred to chair with no signs or complaints of dizziness or hypotension and states that she is feeling much better and stronger today.


PCS #3

Oxygen Management

Patient on oxygen 1.5L/min via nasal canula. Oxygen saturation 92% on oxygen. No humidity running, oxygen tubing and rate running appropriately. No signs of skin irritation to ears or nares and patient denies discomfort. Patient states that oxygen is helping her dyspnea in the hospital. Patient states that she uses oxygen occasionally at home with increased activity. Respiratory effort is even and unlabored, respirations 18/min. No triggers to combustion present and patient states prior knowledge of oxygen flammability. Patient positioned upright out of bed to chair to facilitate adequate oxygenation.


Peripheral Vascular Assessment
My mnemonic: C-PERIPH
Compare bilaterally, pulses, edema, refill cap, inspect sensation eyes closed, pale/pink, hot/cold
Bilateral lower extremities are warm to the touch, pink, with no signs of edema. Strong bilateral dorsal pedal pulses present with capillary refill less than 3 seconds in toes of both feet. Patient is able to move extremities freely and can identify tactile stimulation to both feet with eyes closed.


Mobility
Patient is ambulatory with oxygen to decrease dyspnea. Instructed patient to sit and dangle at bedside and to use controlled breathing techniques during activity to improve dyspnea. Patient transferred out of bed to chair with 1 assist, no balance abnormalities noted, slow and steady gait, no other assistive devices needed and states that she feels much better today. No signs or complaints of dyspnea during or after transfer.

Patient Teaching with fluid management
My mnemonic: LEARN

Learning readiness, evaluate prior knowledge, activity of learning, reassess understanding, need to record.
Patient ready to learn and states that she has some prior knowledge of limiting salt intake to help with CHF but admits that she cheats occasionally. Patient encouraged to continue to watch her salt intake, to elevate legs throughout the day, and to increase fluid intake within dietary orders to help with swelling and symptoms of CHF. Patient states that she will try to keep working on these things at home and says that she finds it easier to keep hydrated during the summer.


Other
Patient assessed to have a relatively low BP reading 109/36. Consulted primary nurse about any orders regarding holding Amlodopine and Lasix with low BP reading. Primary nurse stated that there were no indications to hold the medication and to administer as ordered. Second BP reading taken prior to administration 127/49, both medications administered 0920.





**Evaluations are rationales over here


 

0 comments:

Post a Comment

Related Posts Plugin for WordPress, Blogger...