Glory Johnstone Progress Notes - LLG p.9

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

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Glory Johnstone Progress Notes - LLG p.9

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