Zusammenfassung der Ressource
Glory Johnstone
Progress Notes - LLG p.9
- End of shift progress note
- ADLs
- Phyio review - 1x assist st t/f,
showered, BO, good oral intake,
pt SOOB until after lunch
- Vital signs
- QADDs 2 = SpO2 91%, O2 2L via NP
- Sit pt up, DB & C exercises
- did it work? Is the cough
productive or
non-productive? Continue
to monitor and report
concerns
- Pain assessment
- PQRSTU
- Consider osteoarthritis
as well as the pt
presenting condition of
aches and pains
- Refer to RN, PRN analgesia -
did it work?, reposition - did
it work?
- Functional Activity Scale
- General Assessment,
psychosocial, & interventions
- Nil concerns
reported, visited
by daughter
- Medications
administered as charted
plus PRN ___ for pain
with good effect
- Alert & orientated
- IDC
- IDC removed at 1000hrs per MO order,
10mL water for injection removed from
IDC, nil concerns voiced during
procedure, trial of void (TOV)
commenced, pt education provided
- Trial of void required. Post
void bladder scan x3 minimal
to no residual.
- BGL
- Situational progress note
- 0800hrs - QADDs = 8 for RR 26, SpO2 91%, O2 2L
via NP, BP 150/92mmHg, HR 111, temp 38.5
degrees C, alert.
- For RR - sit pt up and
encouraged deep
breathing
- MET call initiated
- Events of MET as
per MET
documentation
OR state exactly
what happened
- Pt stabilised at ___hrs QADDs 4
for ____, to continue 30min vital
signs per MO
- Did the patient stabilise? What
time? Did they t/f to a higher
dependency unit like ICU?
What time?
- Temperature
- Blood cultures
- Paracetamol
(antipyretic) to reduce
fever
- Antibiotics (depends on Dr order)
- Consider follow up assessments. Pain etc.