Question

Using the assessment data provided in the box below, write a narrative nurses’ note describing your encounter with the patient.

PERRLA	Laying in bed	Pulse 86, left radial, even
Bowel sounds present in all 4 quadrants	Call light within reach	Capillary refill <3 seconds on all fingers/toes
Male	Trachea midline	86 years old
Temperature 99.1° F tympanic	Reports bowel movement yesterday, brown, formed	Drowsy, awakens to verbal stimuli
Refused to ambulate	“bad” breath	#20 IV in left forearm, instilling 0.9% normal saline at 125 mL/hour
Wears reading glasses	Reports decreased appetite for last week	Hair gray
Alert and oriented to person and place	Lips dry, cracked	Upper/lower right extremities weak, grasp weak
Reports that his favorite food is ice cream	Conjunctiva pink	Speech clear
Respirations 18, regular rhythm, even, unlabored	Midline abdominal incision, ABD in place, clean/dry/intact	Side rails up x2
Dry cough, non-productive	Reports that he loves baseball, favorite team is the Reds	Chest expansion equal
Mouth without sores	Follows commands	States that his daughter lives in Maine
Rhonchi heard in all lung fields	Dorsalis pedis, posterior tibialis pulses +1	Push/pull weaker on right side
Facial expressions appropriate	Urine in urinal, clear, dark yellow, no odor	Sclera white
No lumps, bumps, lesions noted	Dentures, full set, top and bottom	Jackson-Pratt drain to abdominal incision, 30 mL thin serosanguinous drainage, no odor
S1, S2 present, murmur present	Caucasian	Blood pressure 128/86 left arm, lying down
Pain 3/10 center of head, ache, for 30 minutes, constant, does not want treatment, worse with lights on	2+ pitting edema in legs	Reports use of walker
Skin pale, dry, no sores noted	Tongue pink, midline	Pulse oximetry 97% on room air

Answer 1

Nursing notes is the process of describing the condition of patient and explaining the physicians.

Nursing narrative notes should be descriptive a d understanding.

Perrla, a 86 yr old, male patient of cascasian is alert and oriented to person and place, wears reading glasses.

States that daughter lives in maine. The patient love baseball game and ice-cream

Reports decreased appetite for last weak lips dry cracked, push or pull weaker on right side and also reports the use of walker and refuse to ambulate, even, unlabored dry cough non productive.

Has the TEMP- 99.1° F, Respirations 18, regular rhythm, pulse - 86 left radial even Capillary refill <3 seconds on all fingers/toes, Bp - 128/86,

Has Bowelsounds present in all 4 quadrants, hairs-grey, conjunctiva - pink, tongue-pink, tracheal midline reports bowel movement brown., yesterday, formed bad breath

Upper/lower right extremities weak, grasp weak, speech clear, chest expansion equal, Dorsalis pedis, posterior tibialis pulses +1, urine os urinal clear dark, yellow no odor, Dentures, full set, top and bottom

Mouth without sores, Rhonchi heard in all lung fields, Facial expressions appropriate, No lumps, bumps, lesions notedS1, S2 present, murmur present, Pain 3/10 center of head, ache, for 30 minutes, constant, does not want treatment,2+ pitting edema in legs

worse with lights on, skin pale, dry, no sores noted. Jackson-Pratt drain to abdominal incision, 30 mL thin serosanguinous drainage, no odor

Now lying on the bed call light with on reach., #20 IV in left forearm, instilling 0.9% normal saline at 125 mL/hour, Midline abdominal incision, ABD in place, clean/dry/intact, Side rails up x2.