Glory Johnstone Progress Notes - LLG p.9

Glory Johnstone Progress Notes - LLG p.9

1. 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

2. 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.