M. McKinley Clients Initials: WP
Date: 04/30/2021
Clinical Week: 4
Nursing Narrative Clinical Week 4
04/30/2021, 0630, received patient from K. Yako, RN. 0645, received report hand off from
Skylar, b, RN. 0700, patient expressed no pain and brief was dry. 0715, began head to toe
assessment. 75-year-old, male, admitted for dementia and Parkinson’s disease. Patient has one
medical allergy to penicillin’s. Patient has no environmental or food allergies. Patient is a full
code. Patient is a fall risk. Patient is an aspiration risk. Patient is a max person assist for transfers.
Patient is alert and oriented x0. Glasgow score of 9. Morse Fall Scale score of 35. Patient lying
supine in bed, patient opens eyes to verbal command. Verbal responses are incomprehensible
words. Motor response, flexes and withdraws. Head is normocephalic; no lump, bumps, or
infestations noted. Facial features are symmetric; no droop noted. Skin is clean, dry, intact.
PERRLA. Conjunctiva is pink. Pupil size is 4 mm bilaterally. Nares are intact; no lesions or
breakdown noted. External ear is clean and intact; no excessive cerumen noted. Oral mucous
membranes are pink and moist. Dentition is partially intact. Gums are in poor condition; bleeding
and breakdown noted on lower gums. Foul odor noted. Soft palate rises. Uvula midline. Tongue
midline. Lips are pink and dry. Patient has full range of motion in neck. No JVD noted. Lymph
nodes are non-palpable. No crepitus noted. Carotid pulses are 2+ bilaterally and are regular in
rate and rhythm. Skin turgor is brisk. No wounds or breakdown noted. Radial and ulnar pulses
are 2+ bilaterally. Patient has full range of motion in RUE. Patient has limited range of motion in
RLE and both left side extremities. No edema noted in all 4 extremities. Normal S1 and S2 heart
sounds. Apical pulse is regular in rate and rhythm. Apical heart rate is 68. Capillary refill is less
than 3 seconds. Patient is on room air. Respirations are regular in rate and rhythm, dyspnea on
exertion. Skin is clean, intact, and diaphoretic. Spinous process is midline. Sacrum is intact.
Patient had grip is strong bilaterally. Foot push is absent bilaterally. Patient abdomen is soft,
rounded, and non-tender. No masses or distention noted. Bowel sounds are hypoactive in all 4
quadrants; listened for full 5 minutes in each quadrant. Patient genital and perineum is clean and
intact; no bleeding, discharge, lesions, breakdown or odor noted. Patient is incontinent of urine
and bowels; patient wears a brief. Patient reports no pain in calves. Posterior tibial and dorsalis
pedis pulses are 2+. Feet are clean, dry and intact. Patient capillary refill in lower extremities is
less than 3 seconds. Patient express no pain at end of head-to-toe assessment. 0745, obtained
patient vitals. Vitals were stable. 0800, patient breakfast arrives. Assisted patient with tray set up
and feeding. Patient ate 100% of breakfast meal. 0830, provided complete oral care for patient.
0900, checked patients brief for soiling and turned patient to left side. 0930, refilled patients
water pitcher. 1000, performed passive range of motion with patient as tolerated. 1030, changed
patient’s brief; 1 urine count and 1 stool count. 1100, turned patient onto back and allowed
patient to sleep. 1200, changed patients brief; 1 urine count. Provided complete bath and linen
change for patient. 1345, changed patient brief; 1 urine count. Turned patient to right side. 1400,
refill patients water pitcher. Turned patient to back. 1445, said thank you and goodbye to patient
and nursing staff. Reported off to Skylar, B, RN. 1500, reported to K. Yako, RN in facility chapel
for post-conference meeting and evaluation.
This study source was downloaded by 100000790220931 from CourseHero.com on 04-10-2022 23:20:47 GMT -05:00
https://www.coursehero.com/file/99444961/ClinicalWeek4NursingNarrativedocx/
Powered by TCPDF (www.tcpdf.org)