Nursing Notes


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Vital Signs/Pain/Pulse Ox: Temp: Location: O, A, R, T Apical Pulse: Rate = BPM Rhythm: Regular Irregular/erratic Thready Bounding Strong Respirations: Rate = Rhythm: Even Regular Irregular Labored Strained Moderate Shallow Deep With stridor / retractions / apnea noted Blood Pressure: / Arm: R / L Patient s Position: Lying / Standing / Reclining / Pain: Scale (1 - 10) Nonverbal cues: Loc: Onset: Duration: Quality: Client states, Neuro: LOC: Alert Oriented X: 1, 2, 3 Oriented to: Person, Place, Time Disoriented to: Person, Place, Time Affect/Mood: Alert, Flat Affect, Tearful, Confused, Pleasant, Glascow Coma Scale: Total Score= Eyes, open 4=Spontaneously, 3=to speech, 2=to pain, 1=n/a Verbal Response: 5=oriented, 4=confused, 3=inappropriate words, 2=incomphnsble sounds, 1=n/a Motor Response: 6= obeys commands, 5=localized pain, 4=flexion w/drawl, 3=abnrml flexion, 2=abnrml extension, 1=flaccid Pupil Size Reaction: PERRLA, unequal, misshapen, unreactive to light, no accommodation Vision: Left = / Right = / , Nearsighted, Farsighted, Astigmatism (L or R) Corrective lenses: Glasses, Contacts, Abnormal findings: Hearing: Normal, Loss (L or R) Degree: , Hearing aid, Pain, Ringing Rushing Communication: Lucid Coherent Incoherent Slurred speech Facial Symmetry: Symmetrical Unsymmetrical (location) Client states, Cardiac: Heart sounds: clearly audible, muffled at A, P, E, T, M Sounds are: with free of murmurs and / or gallops PMI: Location of palpation = Apical Pulse: Rate = BPM Rhythm: Regular Irregular/erratic Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Brachial Pulse: Rate = BPM Rhythm: Regular Irregular/erratic Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Temporal Puls


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