Accident and Emergency Nurse-Vorlage
Emergency Progress Note
Eine professionelle Accident and Emergency Nurse-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a quick and comprehensive way to document patient care in the Emergency Department? This Emergency Progress Note template is designed for Accident and Emergency Nurses to efficiently record patient presentations, treatments, and outcomes. It covers essential areas like presenting issues, progress, physical examinations, investigations, and the plan of care. This template ensures all critical information is captured, helping you create detailed and accurate medical records. With Heidi, this template can be quickly populated from your patient encounter, saving you valuable time and improving documentation accuracy.
Vorlagenvorschau
Introduction:
10-year-old female from school, brought in by ambulance, accompanied by mother.
Issues List:
- Acute asthma exacerbation.
- Administered salbutamol nebulisers and oxygen, patient responding well.
Progress:
- Patient's respiratory rate has decreased from 40 breaths per minute to 28 breaths per minute. Oxygen saturation improved from 88% to 96% on 2L of oxygen via nasal cannula.
- Discussed asthma management plan with mother, including inhaler technique and signs of worsening symptoms.
Physical Examination:
- Vital Signs: BP 110/70, HR 110, RR 28, Temp 37.1, SpO2 96% on 2L O2. CEWT score 0.
- CEWT Score: 0
- General: Alert and responsive, mild respiratory distress.
- Airway: Patent, receiving 2L oxygen via nasal cannula.
- Breathing: Mild wheezing bilaterally.
- Cardiovascular: Regular rhythm, good perfusion.
- Disability: GCS 15, BGL 5.2, no neurological deficits.
- ENT: No obvious signs of infection.
- Abdo: Soft, non-tender.
- MSK: No deformities.
- Neuro: Alert and oriented.
Investigations:
- Pathology: Peak flow reading 250L/min.
- Imaging: Chest X-ray clear.
- Other: ECG normal.
Assessment/Impression:
- Acute asthma exacerbation.
- The patient is experiencing an acute exacerbation of asthma, requiring immediate intervention.
- Pneumonia.
Plan/Treatment:
- Immediate Management: Salbutamol nebulisers, oxygen, and intravenous fluids administered.
- Investigations: Repeat peak flow in 30 minutes.
- Referrals: Discussed with on-call paediatrician.
- Discharge & Follow-Up: Discharge home with salbutamol inhaler and spacer, and a course of oral prednisolone. Review with GP in 2 days.
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