PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN NFDN 1002 Client Chart Over the duration of NFDN 1002 you will practice using these chart forms. The following documents may not be exactly what you will see in a practice setting, but are very similar. Even if utilizing electronic documentation, understanding the principles of documenting with the following documents will help in your practice. Please print to practice at home AND bring to lab with you. These will be required on your Clinical Simulation Shifts. Please note that in practice facilities, chart documents should NEVER be photographed or copied. Student Name ________________ Lab Group _______________ NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Admission and Medical History Past Medical History Heart attack in 2019, Osteoarthritis, Hypertension, Hearing loss left ear, Dementia (early onset), Angina, CAD, Conjunctivitis, GERD, NIDDM, Dementia, Crohn’s disease, UTI Previous Surgeries Hysterectomy 1985 Colostomy creation 2010 Name: Harpreet Kaur Left knee replacement 2014 ID: 23475 Cataract surgery both eyes 2015 DOB 21 April 1945 Biographical Data Gender: Female Relationship Status: Widow, spouse passed 3 years Pronouns : She/Her ago from CVA Children: 3 children, 2 sons and 1 daughter Occupation: Retired Dialysis Nurse. Immigrated to ROOM: NorQuest Rm# SCFL Canada in 1977 from India. Primary Language spoken: Hindi / English Allergies: Latex Primary Diagnosis Dementia, UTI, Conjunctivitis, Failure to Thrive, Broken left hip Hobbies / Recreation Enjoys watching cooking shows on TV and weekly art classes. Enjoys music. Spiritual Considerations Prefers female caregivers Lifestyle Practices Vegetarian/CDA ↓ Sodium Enjoys socializing with other residents and playing Bridge. Reaction: Skin Rash Activities of Daily Living Health Promotion Physician: Dr. M Brown Bathing/Grooming: Stand by assist. Prefers baths to showers. Mobility: Can use a cane for short distances. Uses wheeled walker when mobilizing for >5 minutes, with stand by assist and transfer belt. Independent to toilet/Continent Residence: Has lived in Assisted Living for the last 2 years. Wears Glasses and Hearing aid in left ear. Wears dentures, both top and bottom. Attends facility exercise classes 2x per week. When weather is nice, enjoys going for a walk around the grounds when family comes to visit. GOC: R1 Height: 185 cm Last Weight: 79 kg Current BMI: _26.0 Social Supports Has one son and daughter living close, both married, with 7 grandchildren. One son deceased. 1 brother who lives in Calgary, in a Long Term Care Facility. Childhood Illnesses Chicken pox, Measles, Pertussis Typhoid fever when about 18 years old Appendectomy (uncertain of date) Family History Father died from Stroke (age 75), Mother passed away many years ago from Breast cancer (age 61). Brother has IDDM, managed well. Grandparents – unknown. Emergency Contact Information Karun Singh (Son) (587) 555-1234 (Edmonton) NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Goals of Care Designation (GCD) Order Date (yyyy-Mon-dd) 2020-05-15 Time (hh:mm) 09:35 Goals of Care Designation Order To order a Goals of Care Designation for this patient, check the appropriate Goals of Care Designation below and write your initials on the line below it. (See revers side for detailed definitions) Check ˃ Initials > ☒ R1 __HK____ ☐ R2 ______ ☐ R3 ______ ☐ M1 _______ ☐ M2 ______ ☐ C1 ☐ C2 ______ ______ Check √ here ☐ if the GCD Order is an interim Order awaiting the outcome of a Dispute Resolution Process. Document further details on the ACP/GCD Tracking Record. Specify here if there are specific clarifications to this GCD Order. Document these clarifications on the ACP/GCD Tracking Record as well. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Patient’s location of care where this GCD Order was ordered (Home; or clinic or facility name) Physician’s Office Indicate which of the following apply regarding involvement of the Patient or alternate decision-maker (ADM) ☒ This GCD has been ordered after relevant conversation with the patient. ☐ This GCD has been ordered after relevant conversation with the alternative decision-maker (ADM), or others. (Names of formally appointed or informal ADM’s should be noted on the ACP/GCD Tracking Record) ☐ This is an interim GCD Order prior to conversation with patient of ADM. History/Current Status of GCD Order Indicate one of the following ☒ This is the GCD Order I am aware of for this patient. ☐ This GCD Order is a revision from the most recent prior GCD (See ACP/GCD Record for details of previous GCD Order). ☐ This GCD Order is unchanged from the most recent prior GCD. Name of Physician/Designated Most Responsible Health Practitioner who Discipline has ordered this GCD Family Medicine Dr. R. Brown Signature NFDN 1002 Practice Chart Mrs. Harpreet Kaur Date (yyyy-Mon-dd) 2020-05-15 Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN CAUTION Important Patient Information Allergies and Adverse Reactions Patient Information: Admission Height: ___185__cm Weight: __79__kg (Weight: ☒ Measured ☐ Estimated ☐Pregnant ☐ Lactating ☐ Dialysis List known allergies and adverse reactions below. Update if new allergies and adverse reactions occur. ☐ No known allergy / adverse reaction. Initial: ________ ☐ Unknown (no information available) Initial: ________ Medications: ______________________ ______________________ Reaction ____________________ ____________________ Initial ________ ________ ______________________ ______________________ ____________________ ____________________ ________ ________ ☐ ☐ ☒ Latex Allergy __Skin Rash_________ Initial: _JF__ ☒ Reaction: Foods: Reaction Initial _______________________ ____________________ _________ _______________________ ____________________ _________ _______________________ ____________________ _________ _______________________ ____________________ _________ Other Substances: Reaction Initial ________________________ _____________________ _________ ________________________ _____________________ _________ Date: __15 May, 2020______ Date of 1st Revision: ___________________ Date of 2nd Revision: _______________ Date of 3rd Revision: ___________________ Data Entry* ☐ ☐ Data Entry* ☐ ☐ ☐ Data Entry* ☐ ☐ * Data entered electronically into required database(s). Completed form to be forwarded electronically to Pharmacy and to Food Services immediately upon admission, and upon each revision. Form to be placed inside front cover of patient’s chart. NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Signature / Initial Identification Record NAME (Last, First) (please print) SIGNATURE + Designation INITIAL Frost, Jane J. Frost SPN JF NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 Physician’s Orders PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Allergies: Latex DATE DD/Mon/Yr TIME Now Admit to NorQuest Hospital, Unit SCFL Vital signs every 8 hours, keep O2 > 94%. Notify physician if T>38⁰ Ins and Outs every shift. Push PO fluids if urine output <0.5ml/kg/hr CTEMPS PRN Apply TED Stockings as required Activity with transfer belt, and cane or walker (patient uses both) CDA/Low Sodium Diet, as per dietician Metoprolol 25 mg PO Daily Pantoprazole 20 mg PO daily Gentamicin ointment 1 cm strip to both eyes every 12 hours Potassium Chloride 40mEq PO Daily Betamethasone Valerate 0.1% scant amount to left leg rash three times daily X 7 days Nitroglycerin patch 0.4mg/hour - on at 0800/off at 2000 Enoxaparin 30 mg subcutaneous every 12 hours for 7 days CBC bloodwork every three days while on Enoxaparin Acetylsalicylic Acid 81 mg PO Daily once complete Exoxaparin regimen Ceftriaxone 500 mg IM every 8 hours for 24 hours Then Keflex 500 mg PO every 12 hours x 9 days Metformin 500 mg PO twice daily Complete Blood Glucose Levels before bed If BGL >12 mmol/L, give Lantus 12 units SC at 2200. Notify physician if BGL <4 or >19 HBA1C every 3 months Diphenhydramine 50 mg PO every 6 hours PRN Tylenol 325mg PO Every 6 hours PRN Hydromorphone 1mg SC every 4 hours PRN Lorazepam 1mg SL x1 for agitation and aggression. Notify physician prior to administering. Hypodermoclysis 500 mLs 0.9% NS Normal saline at 50 ml/hour overnight PRN if fluid intake is less than 1000ml during the day Change Ostomy system every 5-7 days or PRN. ----------------------------------------------------- Dr. M Brown NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN MEDICATION ADMINISTRATION RECORD Allergies: Latex SCHEDULED MEDICATIONS Mon, Year_____________ Medication Metoprolol 25 mg PO daily Date→ Time ↓ 0800 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2000 Pantoprazole 20mg PO Daily 0800 Gentamicin Ointment 1cm strip to both eyes every 12 hours Potassium Chloride 40 mEq PO Daily 0800 Betamethasone Valerate 0.1% scant amount left leg rash 3 times a day x7 days 0800 1400 2200 Nitroglycerin patch 0.4 mg/hr 0800 On___ 2000 Off 0800 Enoxaparin 30mg SC every 12 hours Ceftriaxone 500 mg IM every 8 hours x 24 hours 2000 0800 2000 0800 1600 0000 NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN MEDICATION ADMINISTRATION RECORD Allergies: Latex SCHEDULED MEDICATIONS Mon, Year_____________ Medication Date→ 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 Time ↓ Keflex 500mg PO every 12 hours x 9 days (Once Ceftriaxone IM complete) 0800 Metformin 500 mg PO Twice daily 0800 2000 2000 Lantus 12u SC at HS Give if BGL >12mmol/L 2200 Acetylsalicylic Acid 81 mg PO Daily – To start once Enoxaparin regimen complete 0800 Transdermal Patch Site Legend Right shoulder = RS Right Chest front = RCF Right back = RB Right lower chest = RLC Left shoulder = LS Left Chest Front = LCF Left Back = LB Left lower Chest= LLC NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN MEDICATION ADMINISTRATION RECORD Allergies: Latex PRN MEDICATIONS Mon, Year_____________ Medication Date→ Time ↓ 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 23 Diphenhydramine 50mg PO every 6 hours PRN Tylenol 325mg PO every 6 hours PRN Hydromorphone 1mg SC every 4 hours PRN Lorazepam 1mg SL x1 PRN for agitation and aggression. Notify physican prior to administration NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Diabetic Record DATE BLOOD TIME GLUCOSE INSULIN DRUG AND DOSE NFDN 1002 Practice Chart Mrs. Harpreet Kaur NURSE INJECTION SIGNATURE SITE + CO-SIGNATURE Nov 27, 2023 NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 Venous Thromboembolism (VTE) Prophylaxis Adult Patient Care Orders PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Allergies Height Weight Date (yyyy-Mon-dd) Latex 185 cm 79 kg Today’s Date RISK ASSESSMENT (**see risk factors for VTE and bleeding on reverse side) VTE Risk and Recommended Thromboprophylaxis in Hospitalized Patients Level of VTE Risk Factors for VTE Approximate Risk of VTE Suggested Thromboprophylaxis Risk without Prophylaxis Options ▪ Expected length of stay less than 72 hours ▪ Minor Surgery Less than 10% ▪ Early ambulation ☐ Low ▪ Mobile medical patient or age less than 60 without additional risk factors for VTE ▪ One minor and no major risk factors ▪ Most general, gynecology, or ▪ Low molecular weight heparin 10 – 40 % ☒ Moderate urological surgery patients (LMWH) ▪ Immobilized medical patients ▪ One major or two or more minor risk factors 40 – 60% ▪ LMWH ☐ High ▪ Age greater than 75 years ▪ Multiple major risk factors ▪ LMWH ▪ Major trauma ▪ Consider extended prophylaxis ▪ Spinal cord injury ▪ fondaparinux* 40 – 80% ☐ Very high ▪ Major cancer surgery ▪ Xa inhibitor: rivaroxaban ▪ Hip fracture* ▪ apixaban ** to Xa inhibitor ▪ Hip or knee arthroplasty* Bleeding Risk ▪ Mechanical prophylaxis ☐High Bleeding Risk (reevaluate for pharmacological prophylaxis once bleeding risk lessens) MEDICATION MANAGEMENT Consider the alternatives for weight and renal dosing (see table on reverse) and use of weight band dosing with closes prefilled syringes as per formulary. Select Only One of the following 4500 Units subcutaneously daily standard dose for weights 40 – 100 kg ☐ deltaparin inj 30 subcutaneously q12h for major trauma mg ☒ enoxaparin inj Other (specify drug and dosage): ☐ Opt out of VTE prophylaxis. Reason: ADDITIONAL ORDERS Apply For patients with contraindications to anticoagulants and ☐ Sequential compression device Apply recommended for highest risk patients as additional therapy ☐ Graduated compression stockings LABORATORY ORDERS ☐ Serum creatinine today (if not already ordered) ☒ Complete Blood Count (CBC) every 3 days, repeat up to 5 times (HIT screening) for heparin exposed patients with risk of HIT greater than 1% Physician Signature Date (yyyy-Mon-dd) Today’s Date NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Anticoagulant Record INTIAL NURSE ANTICOAGULANT AGENT DATE INR PTT RESULT RESULT TIME 00/Mon/year NFDN 1002 Practice Chart Mrs. Harpreet Kaur COUMADIN DOSAGE LMWH DOSAGE ROUTE Nov 27, 2023 SITE CO-SIGN PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 Patient Label Here ULI: 123456789 DR. R. BROWN Fluid Intake/Output Record (Shift) INTAKE DATE TIME ORAL /TUBE I.V / CLYSIS MINI BAG OTHER OUTPUT BLOOD PROD. TOTAL INPUT URINE EMESIS SUCTION BILE 2300 0700 N 0700 1500 D 1500 2300 E TOTAL 2300 0700 N 0700 1500 D 1500 2300 E TOTAL 2300 0700 N 0700 1500 D 1500 2300 E TOTAL 2300 0700 N 0700 1500 D 1500 2300 E TOTAL 2300 0700 N 0700 1500 D 1500 2300 E TOTAL NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 DRAIN OTHER TOTAL OUTPUT PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Fluid Therapy Form (Intravenous /Hypodermoclysis) Date Type of Cannula Time infusion Gauge (HDC/IV) Infusion Solution Site Site Assess Loca ed tion () Action New Volume of Tubing Rate Reason (use Tubing Solution Labelled infusing for Initials legend attached mL/hr removal () () below) LEGEND ACTION SITE Central/PICC Phlebitis P Peripheral I Interstitial HDC Hypodermoclysis D/C Discontinued SL Saline Lock L Left AC Antecubital O E Existing R Right TH Thigh P A Attached new bag H Hand C Chest C Saline lock A Arm AB D Abdomen U Unsuccessful (x2) B Back Attached/Infusing Note with * = see NCR NFDN 1002 Practice Chart Mrs. Harpreet Kaur TYPE CVC I Initiated ATT REASON FOR REMOVAL Occluded Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN STOOL CHART DATE Legend: TIME Amount: COLOUR CONSISTENCY AMOUNT Small Medium Large If ostomy Fraction of fullness eg. 1/3 full NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 Adult Vital Signs Record Year: PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Month: Day: Time: Respiratory Rate ● -3530 -2520 -1510 -5- -3530 -2520 -1510 -5- SpO₂ % ● If less than 90% Sats on 8-10L or 50% FiO2 = Call Response Team -10095 -9085 -80- -10095 -9085 -80- RA or O₂ LPM: Blood Pressure ˅ ˄ Positions L = Lying Sit = Sit Std = Standing -220210 -200190 -180170 -160150 -140130 -120110 -10090 -8070 -6050 -40- -220210 -200190 -180170 -160150 -140130 -120110 -10090 -8070 -6050 -40- Position Heart Rate ● Locations A = Apical R = Radial -180170 -160150 -140130 -120110 -10090 -8070 -6050 -40- -180170 -160150 -140130 -120110 -10090 -8070 -6050 -40- Location Temperature BM – Bowel Movement Initials NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Glasgow Coma Scale (Adult) Year: Month: Day Time Disability Neurological If acute change in GREY = Clinical Review A=Alert A V= Rouse by voice V P = Rouse by pain P U = Unresponsive U Pupil Size & Reaction 1mm 2mm 3mm 4mm 5mm 6mm V = Consider GCS P or U = Conduct GCS N = Normal F = Fixed S = Sluggish UTA = Unable to Assess Right Eye Size Right EYE Reaction Left EYE Size Left EYE Reaction MOTOR RESPONSE Clinical Review IF↓ Strength = S=Strong M=Moderate W=Weak A=Absent AF=Abnormal Flexion AE=Abnormal Extension SP=Spontaneous WD=Withdrawal Right Arm Left Arm Right Leg Left Leg Eye Score Response 4 Spontaneously 3 To Speech 2 To Pain None 1 Verbal Score Response 5 Oriented x3 4 Confused 3 Inappropriate Words 2 Incomprehensible 1 None Motor Score Response 6 Obeys Commands 5 Localized Pain 4 Flexion Withdrawal 3 Flexion Abnormal 2 Extension 1 None GCS Score Initials NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Patient’s Name: Sensory Perception Ability to respond meaningfully to pressure-related discomfort Moisture Degree to which skin is exposed to moisture Activity Date of Assessment: 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level on consciousness or sedation; OR Limited ability to feel pain over most of body. 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness; OR Has sensory impairment which limits the ability to feel pain or discomfort over ½ of body. 1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 1. Bedfast Confined to bed. 2. Very Moist Skin is often, but not always, moist. Linen must be changed at least once a shift. 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance. 2. Very Limited Makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. 2. Probably inadequate Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement; OR Receives less than optimum amount of liquid diet or tube feeding. 2. Potential Problem Moves feebly or required minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slide down. Degree of physical activity Mobility Ability to change and control body position Nutrition Usual food intake pattern Friction & Shear 1. Very Poor Never eats a complete meal. Rarely eats more than ⅓ of any food offered. Eats 2 services or less of protein (meat or dairy products). Does not take a liquid dietary supplement; OR Is NPO and/or maintained on clear fluids or IV’s for more than 5 days. 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. 2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort of the need to be turned; OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 3 extremities. 3. Occasionally Moist: Skin is occasionally moist, requiring extra linen changes, approximately once a day. 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. 3. Slightly Limited Makes frequent thought slight changes in body or extremity position independently. 4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours. 4. No Limitation Makes major and frequent changes in position without assistance. 3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered; OR Is on a tube feeding or TPN regiment which probably meets most nutritional needs. 3. No Apparent Problem Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. 4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. 4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals. Total Score NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Extremity Neurovascular Assessment Abnormal findings require documentation on the Patient Care Record. Date Time Limb Colour (√) Temperature (√) Pulses A= absent W= weak M= moderate S= strong D= doppler U= unable to assess Capillary refill (√) Edema (√) Sensation N= normal D= decreased A= absent Motor S= strong M= moderate W= weak A= absent Pain on passive stretch ( √ ) Arm Leg Arm Leg Arm Leg Arm Leg Arm Leg Arm Leg Arm Leg Arm Leg Arm Leg R R R R R R R R R L L L L L L Pink / Natural Red White / Pale Mottled / Blue Warm Hot Cool Cold Brachial Radial Ulnar Femoral Popliteal Posterior tibialis Dorsalis pedis < 2 seconds > 2 seconds Absent Present Radial (thumb web space) Median (index finger pad) Ulnar (little finger pad) Peroneal (great toe web space) Tibial (sole of foot) Hyper- extension of thumb and fifth finger Opposition of thumb and fifth finger Abduction of fingers Foot dorsiflexion Foot plantar flexion Wiggle toes Absent Present Nurse’s Initials Abnormal findings require documentation on the Patient Care Record. NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nov 27, 2023 L L L PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Nursing Care Record (bring this with you to each lab skills practice session) Date Time NFDN 1002 Practice Chart Mrs. Harpreet Kaur Notes Nov 27, 2023 PT ID: 23475 NAME: Kaur, Harpreet SEX: F DOB: 21 April 1945 ULI: 123456789 DR. R. BROWN Date Time NFDN 1002 Practice Chart Mrs. Harpreet Kaur Nurse’s Notes Nov 27, 2023
