Author: Frank Gomez

Patient arrived to unit via stretcher at 12:19. Transferred from stretcher to bed with assist x1. Patient on O₂ 2 L/min via nasal cannula on arrival; alert and oriented x4. Vital signs obtained: BP 108/65, HR 79, T 98.6, RR 24, SpO₂ 85% on 2 L NC. Patient repositioned in bed; head of bed elevated…

Patient observed awake, alert, and confused. Non-violent soft wrist restraints in place with safety precautions in effect. Bilateral upper extremities observed with intact circulation and skin integrity [or describe specific finding]. Restraint order verified in chart [if done]. IV fluids running via patent IV site [location]. [Provider notified at ___ / no provider notification required].…

Patient experienced an episode of emotional distress while RN was temporarily out of the room attending to other patients. Upon RN return approximately 10–15 minutes later, patient was observed screaming loudly and repeatedly calling out for help. RN remained at bedside. Plan of care was re-explained. PRN clonidine was offered; medication indication, rationale, and potential…

At 1930, assumed care after receiving report from offgoing nurse. Patient observed in bed, awake, alert, and oriented ×4. Telemetry displayed sinus rhythm. Patient reported head pain rated 6/10 and declined offered ordered analgesics. Patient oriented to room and use of call light. Assumed care of new patient after receiving report from offgoing nurse. Patient…

Report received from offgoing nurse regarding patient plan of care. Patient observed in bed, asleep, with family present at bedside. Respirations observed even and unlabored. No use of accessory muscles noted. Patient denies pain when asked. Lines / Drains: Foley catheter in place, draining yellow urine. Safety: Bed in lowest position with wheels locked. Call…

Received patient during handoff. Patient noted to be in non-behavioral soft restraints to bilateral upper extremities (right and left wrists). Indication: risk of harm to self related to pulling at lines/tubes. Active restraint order verified in EMR and current. Skin to restrained extremities intact with no redness, breakdown, or swelling noted at this time. Patient…