Head To Toe Narrative Charting 191n9

Jun 30, '07 by VickyRN Here is a head-to-toe narrative charting template that I developed for my first semester RN students last semester: 2/12/2007 0800. 86 y.o. male itted 2/1/07 for left CVA. VS 37.4 C, HR 97, RR 22, BP 140/76. Alert and oriented x 4; denies any pain or distress. PERRLA. Responds appropriately to verbal stimuli; no slurring of speech. At risk for aspiration related to dysphagia; on thickened dysphagia diet. Feeds self with assistance. Skin acyanotic with loose turgor. Mucous membranes moist and pink. Negative JVD. Respirations even, unlabored. Breath sounds clear to auscultation throughout all lung fields. (If your patient is on O2, make sure you record the O2 rate and delivery system here, along with pulse ox readings). Apical pulse regular rate and rhythm; S1, S2 noted. Abdomen soft & nondistended with bowel sounds active in all 4 quadrants. Pink nailbeds with capillary refill less than 2 seconds in all extremities. Peripheral pulses palpable in all extremities. Moves all extremities. Hand grips unequal: strong on right, weak on left. Left arm has limited mobility due to weakness secondary to CVA. Has a 20 gauge saline lock to right forearm. Site is free from redness or drainage, with Tegaderm dressing intact. (If your patient has an infusing IV, make sure you record the fluid and rate in your assessment). Uses urinal, has occasional episodes of incontinence. Urine clear yellow. No skin breakdown noted. TED hose on bilaterally. Homan’s sign negative bilaterally. Feet cool, dry, intact, with thick toenails bilaterally. Side rails up x 3, bed in low position. Call bell within easy reach of right hand. Instructed to call for any needs or to request assistance before attempting to get up. Verbalized understanding. Side rails up X 3. Will continue to monitor closely………………………… S.Johnson, SN, *****