Review on Vital Sign

Review on Vital Signs & MIO Respiratory Rate

Vital signs: The number of breaths per minute that a patient makes.
The rate is usually measured when a person is at rest
These are measurements of the body’s most basic and simply involves counting the number of breaths for
functions. one minute. Counting the number of times the chest
 BP rises.
 Temperature  Eupnea
 Pulse  Bradypnea
 Respiratory Rate  Tachypnea
Blood Pressure:  Apnea

 Defined as the amount of pressure exerted on MIO

the walls of the arteries as the blood moves  Intake- Refers to all the liquids that go into the
through them. It is measured in millimeters of patient’s body, including IVF’s.
mercury (mmHg). Both the systolic and diastolic
 Output- refers to all liquids that the patient
pressures are measured and these figures are
excretes or eliminates like, urine and vomit.
usually represented with the systolic pressure
first followed by the diastolic pressure. Example:
 Systolic pressure- is the blood pressure that is
Patient Rosie, a 9 yo girl with complaints of loose
exerted when the heart beats and forces blood
around the body. watery stool. At 8:00 her IV fluid level is at 1 liter. She
had consumed 100 ml of milk with her breakfast. At
 Diastolic pressure- is the measure of blood
10:45 she had an episode of loose watery stool of about
pressure when the heart is resting between
200 cc, she was made to drink 200 ml of ORS right after.
beats.
She was able to urinate to approximately 175 ml at 11
Temperature am. During lunch time she was able to drink 1 glass of
water. At 3 pm she was able to urinate again to an
Defined as the measure of heat inside the body: the approximately 280 ml of urine. Before the shift ends her
balance between heat produced and heat lost. IVF level is at 600 ml. What is her Intake and output for
 Pyrexia the 8 hour shift.
 Hyperpyrexia
 Febrile
 Afebrile

Pulse

Is the vibration of each wave of blood going through the

arteries as the heart beats . The pulse rate is usually
equal to heart rate but maybe lower if there is an
obstruction of the artery or if the heart rhythm is weak
or irregular.

 Tachycardia
 Bradychardia
Guidelines in Charting
1. Be sure to know the agency policies and procedures
about documentation.
 Follow health care facility guidelines for
admission and discharge
2. Do check the name on the chart before making an
entry.
 Write the name and identification number of
the client on each page.
3. Always read the note written by the other health
team professionals before you write your own, and
further comments on their comments on their findings
to maintain continuity of care.
4. Spell correctly, if unsure of spelling, check dictionary.
5. Chart accurately and only after procedures have been
done. Do not delay documentation until the end of the
shift.
6. Chart the time with each entry:
a. Chart in present or past tense, depending on
the situation.
b. Chart all procedures done for the client, the
result & the client’s response.
c. Chart your observation objectively, describing
behaviors. Use objective measurable terms such
as time, severity, location, duration, amount,
size, frequency, relationship to each
occurrences.
d. Document subjective data, not your subjective
interpretation of events.
e. Do not use quotes whenever appropriate to relate to
what the client actually said. Use the word “states” and
put quotation marks around any statement made by the
client or family member. Be sure to indicate who made
the statement.
f. Do not chart “no complaints” or no “c/o”. If a client
had “no complaints”, he/she would not be in the
hospital. Avoid vague words like “normal”, “good” or
“adequate”, “seems to be”, or “appears to be”.
g. Do report and document failure of client to follow
regimens and to take medications or receive treatments
and the rationale given by the client.
h. Chart safety measures taken: for example, bed on
low position, side rails up, restraints applied, visual
safety checks, rounds done, or with a family member in
attendance, etc.
i. Chart all occasion when a client leaves the unit:
the time left & returned. Destination and mode
of transportation.
j. Chart all specimens obtained, any abnormal
characteristics of the specimens, and where and when
the specimen was sent.
k. Always document in the client’s progress notes when
you observe:
∙ A change in his condition, or the development
of a new problem.
∙ Lack of change in condition that will need
further evaluation or referral.
∙ Response to treatment or medication.
∙ Response to teaching.
7. Do mean what you say, and say what you mean.
8. Do not skip lines or write between lines, Draw a line
through any blank spaces.
9. Do not chart for someone else. Do not sign for
anyone else’s entry.
10. Do not erase. To correct wrong entry, draw a line
through it (the error must be readable); write word
“error” or “mistaken entry” and your initial above it.
11. Do make addendums as necessary.
12. Protect the confidentiality of all documented
information.
13. Do not make entries suggesting an error or unsafe
practice.
14. Do not write opinions or biased statements.
15. Record the client’s jewelry in terms of metal’s color
or the stone’s color such as, “one clear white stone in a
wide yellow band”.
16. Document all visits and consultations (including
telephone conversations) by the doctor and other
caregivers.
17. Do not name another patient.
18. If you question a doctor’s order, document your
question and how it was answered. Note your questions
and how you acted; document the discussion, the date
& time.
19. Do name anyone who becomes involved in the
client’s care, including managers, primary care
providers.
NURSES NOTES
It is a written facts regarding patient & the care
provided based on assessment data as well as the
patient’s response to interventions given by the nurse
or midwife.
• Purpose:
1. To communicate the facts concerning a patient
from one nurse to another.
2. To make an accurate record of events/
observation concerning a patient.
3. To provide information for the physician &
other members of the health team.
4. To make a record of medication, treatment, diet
given & the reaction of the patient to this care.
TYPES OF CHARTING ( Nurse’ Notes)
1. Narrative Charting
∙ It provides information in the form of
statements that describe events surrounding
patient care. It is unstructured, providing
flexibility in determining how information is
recorded. It follows a sequence of events.
Maybe time consuming and makes retrieval of
information and tracking of progress &
outcomes difficult.
Narrative Charting
∙ Example:
02/ 09/ 2021 9:00 am
Complains of abdominal pain, status post
appendectomy, day #1; rated 5 on the pain scale
( 0=no pain, 1-4=tolerable pain, 5= moderate pain,
10 worst pain) with facial grimace noted upon
movement like walking, alleviated by lying on bed.
Request for pain medication. Instructed to perform
deep breathing exercises ten times, turned to
unaffected side when lying, support the affected
side upon walking. Provided with reading materials
and turned on television for viewing. Ponstan 500
mgs 1 tablet by mouth given for pain, as
prescribed.__ nurse’s signature
APIE Charting
∙ The process begins with the admission
assessment that is usually completed on a
separate form, and the initiation of problem list.
Documentation of client care is focused on
interventions and evaluation related to the
problem listed.
∙ Process
A. Assessment
• P- problem identification
I. interventions
• E- evaluation
APIE Charting
• 02/ 09/2021 10:00 am
• Problem # 1 Pain related to surgical incision on
the abdomen
A. Complains of pain to the abdomen, status post
appendectomy day #2; rated 5 on the pain scale
( 0=no pain, 1-4=tolerable pain, 5= moderate
 pain, 10 worst pain) with facial grimace noted
upon movement like walking, alleviated by lying
on bed. Request for pain medication.
• I -Instructed to perform deep breathing
exercises ten times, turned to unaffected side
when lying, support the affected side upon
walking. Provided with reading materials and
turned on television for viewing. Ponstan 500
mgs 1 tablet by mouth given for pain, as
prescribed.___nurse’s signature
• 10:30 am
c foley catheter to gravity drain
S: “Nagabara ang sip-on sa ilong ko, nabudlayan ko
magginhawa tungod dira” as verbalized by the patient
O: Nasal secretions seen upon inspection
A: Ineffective airway clearance related to retained
mucus secretions
P: To clear nasal passages to promote better breathing
I: Instructed patient to slowly blow nose on a wet wash
cloth

• E- States pain level at 2 basing on the 0-10 pain Prepared a hot water on a dipper and made patient
rating scale. No facial grimace. Ambulated 10 in inhale the vapor
hallway accompanied by one person._nurse’s
Instructed to increase oral fluid intake to clear up
signature
secretions
SOAPIE Charting
E: “Daw naghalong na pagginhawa ko” as verbalized
∙ It is used to record progress with problem –
4 Endorsed.
focused charting. The progress notes include
narrative notes as well as flow sheets, and they
are used by all members of the health team.
They are specifically related to a problem list Focus(DAR) Charting
and are numbered and titled accordingly.
∙ It addresses the client problems or needs and
∙ Process includes a column that summarizes the focus of
entry. It does not necessarily require the use of
• S- subjective data a nursing diagnosis.
• O- objective data Process:
D- data
• A- assessment
A- action
• P- plan R- response

• I-interventions

• E-evaluation

SOAPIE Charting

• October 19, 2020 8 Received patient awake,

dangling on bed c O2 at
2 lpm via nasal cannula

c IVF of PNSS 1L x 80 cc/h, patent, infusing well

RULES AND GUIDELINES IN CHARTING
 NURSING PROCESS
 NURSING CARE PLAN
 NURSES NOTES
• CHARTING IS A PERMANENT RECORD OF THE
PATIENT’S DATA, VITAL SIGNS & PROGRESS; IN
THE FORM OF GRAPHS AND CHART.
• NURSING CHARTING
• CHARTING IN NURSING PROVIDES A
DOCUMENTED MEDICAL RECORD OF SERVICES
PROVIDED DURING A PATIENT'S CARE,
INCLUDING PROCEDURES PERFORMED,
MEDICATIONS ADMINISTERED, DIAGNOSTIC
TEST RESULTS AND INTERACTIONS BETWEEN
THE PATIENT AND HEALTHCARE
PROFESSIONALS.
• DIFFERENT TYPES OF CHARTING IN NURSING
• THERE ARE MANY DIFFERENT METHODS OF
DOCUMENTATION INCLUDING BUT NOT
LIMITED TO: NARRATIVE CHARTING, SOURCE-
ORIENTED CHARTING, PROBLEM-ORIENTED
CHARTING (SOAP/SOAPIE),
• PROBLEM-INTERVENTION-EVALUATION
CHARTING (PIE),
• FOCUS CHARTING (DARP-DATA, ACTION,
RESPONSE, PLAN),
• CRITICAL PATHWAYS, AND
• CHARTING BY EXCEPTION.
PURPOSE
• TO MAINTAIN AN ACCURATE RECORD OF THE
PATIENT’S CONDITION.
• THE PATIENT’S CHART IS A LEGAL DOCUMENT &
MUST BE CONSIDERED AS SUCH.
• QUALITIES OF A SATISFACTORY RECORD SHEET
OR CHART ARE:
1. ACCURATE- MUST BE FACTUAL
2. LEGIBLE- READABLE, CAN BE READ
3. NEAT- NO ERASURES, NO WHITE OUT
4. UNIFORM – IT MUST BE WRITTEN IN PRINTED NOT
LONGHAND STYLE
5. COMPLETE- PROPERLY ENDORSED AND SIGNED
RULES IN CHARTING
1. DO ACCURATE, CONCISE & NEAT CHART. WRITE
FACTUAL OBSERVATION & STATEMENT; OMIT
NON-ESSENTIAL & FAMILIAR TECHNICAL
TERMS.
2. USE STANDARD INK.
a. BLACK INK FOR:
1.CHARTING FROM: 7:00 AM TO 6:59 PM
2. CHART NUMBERS & PATIENT’S NAME IN ALL
HEADINGS
3. ALL INFORMATION INCLUDING HISTORY ON
ADMISSION SHEET.
4. TEMPERATURE
6. NOTATIONS ON GRAPHIC SHEET:
A. “ON ADMISSION” TERM
B. WEIGHT C) TRANSFER OF PATIENT TO NEW BED OR
ROOM
7. RECORDING THE SPONGE TEMPERATURE ON
NURSE’S NOTES RECORD
8. BLOOD PRESSURE WHEN CHECKED B.I. D. OR Q.I.D.
NOTATION ON MEDICAL SURGICAL SHEET.
B. RED INK FOR:
1. CHARTING FROM 7:00 PM – 6:59 AM
2. MEDICATION & THE TERM “DISCONTINUED” ON
MEDICATION SHEET,
3. DAYS OF HOSPITALIZATION; PULSE; & OUTPUT ON
GRAPHIC SHEET
C. PENCIL FOR:
1. PATIENT’S ACCOMMODATION BED OR ROOM
NUMBER ( AT THE LEFT HAND CORNER OF THE
TREATMENT & ADMISSION SHEET.
WHEN THE PATIENT IS TRANSFERRED, DO NOT ERASE
BUT INSTEAD PLACE A NEW NUMBER IN SPACE BEFORE
THE NAME.
4. ADMITTING NURSE / CLERK ARE RESPONSIBLE FOR
COMPLETING ADMISSION DATA AS WELL AS FOR THE
VITAL SIGNS ON ADMISSION.
5. REQUIRE ALL ADMISSION NOTES ON ALL NEW
ADMISSION WHICH INCLUDE:
A. DATE &EXACT TIME OF ADMISSION
B. MODE OF ADMISSION (AMBULATORY, PER
WHEELCHAIR OR STRETCHER, ARMBORNE)
C. STATE OF CONSCIOUSNESS; CEPHALO-CAUDAL &
SKIN ASSESSMENT (FOR DECUBITUS ULCER),
D. INCLUDE THE CHIEF COMPLAINTS, NEVER THE
DIAGNOSIS,
E. ALWAYS INCLUDE THE NAME OF THE PHYSICIAN
NOTIFIED
6. PRINT RECORD IN PLAIN, LEGIBLE, SMALL
CHARACTERS. PROPER SPACING OF WORDS SHOULD BE
OBSERVED & SHOULD NOT BE CROWDED. RECORD N
OBSERVATION THAT COULD BE READ AT A GLANCE;
START EACH NEW STATEMENT IN THE REMARK
COLUMN WITH A CAPITAL LETTER.
7. DO NOT USE UNAUTHORIZED ABBREVIATIONS.
8. MAKE UNIFORM SIZE DOTS IN TEMPERATURE &
PULSE RATE COLUMN TO INDICATE RESULT TAKEN.
CONNECT THE DOTS WITH STRAIGHT LINE (USE RULER).
9. TO RECORD THE FREQUENCY (NUMBER OF TIMES) OF
THE :
A. VOIDED IN “U” (URINATE) COLUMN
B. DEFECATED LOOSE STOOL IS PLACED IN “S”(STOOL)
COLUMN
*ALL OF THESE ARE FOUND IN THE GRAPHIC SHEET.
• TO RECORD THE AMOUNT (VOLUME) VOIDED
AND OR DEFECATED TO A LOOSE STOOL, IN
RECORDING THE IS WRITTEN INTAKE &
OUTPUT SHEET.
• * NURSES FOR EACH SHIFT ARE RESPONSIBLE IN
RECORDING THE RESULT. NIGHT SHIFT NURSES
TOTAL (ADD) ALL THE RESULTS FOR THE WHOLE
24 HOURS.
• 10. RECORD DIETS IN THE CHART & STATE
WHETHER PATIENTS ARE WELL OR NOT.
• 11. POST THE LABORATORY AND X-RAY RESULTS
ON THE LABORATORY SHEET.
• 12. WHEN ERROR IN CHARTING/ GRAPHING IS
COMMITTED “DO NOT ERASE” OR CRASH OUT
BUT REPORT TO YOUR INSTRUCTOR THE ERROR
& PROPER ADVICE WILL BE GIVEN.
HOSPITAL FORMS
ORDER OF SHEETS
Upon Admission
1. Physicians’ Order Sheet
2. Graphic Sheet
3. Daily Medication Sheet
4. Flowsheets
5. Nurses’ Notes
6. Progress Notes
7. Laboratory Results
8. History and Physical Exam Sheet
9. Other Forms 10. Admission Sheets
11. Checklist for Admission
12. Client Summary Slip
Upon Discharge special instructions like those that need to be
monitored every hour or every 2 hours.
1. Admission Sheets • Intake and output sheet
2. Checklist for Admission • IV fluid sheet
• Blood transfusion sheet
3. Physicians’ Order Sheet • Glucose Monitoring sheet
• Medical Surgical Worksheet
4. Graphic Sheet
• Neurovital signs
5. Daily Medication Sheet
NURSES NOTES
6. Flowsheets
• This is where nurses document their
7. Nurses’ Notes assessment, diagnosis, planning, things done
during the shift and evaluation.
8. Progress Notes • In IDH, the charting style used is SOAPIE

9. Laboratory Results PROGRESS NOTES

10. History and Physical Exam Sheet This is where residents and medical clerks document
the progress of the client. Things done to the patient
11. Other Forms
while in the ward like results of skin tests and Cardio
12. Client Summary Slip pulmonary status are written here.

13. Client’s Summary Slip OTHER FORMS

14. Kardex These include:

15. Going Home Instruction • Anesthesia Record Sheet

• Report of Operation
• OR Nurses Record
• Consent for Operation
PHYSICIANS’ ORDER SHEET
• Pre-post op checklist
Contains the written orders of Physicians including, • Recovery room record
residents and consultants.
ADMISSION SHEETS
GRAPHIC SHEET
These include:
This contains the plotted version of the patient’s vital
• Discharge summary (waiver of liability)
signs which reflects the progression or regression of the
patients status. • Authorization

DAILY MEDICATION SHEET • Consent of Admission

This reflects the medication given to the client. It • Certificate of responsibility

contains separate sheets for Standing medication sheet,
PRN Medication sheet and Inhalation therapy sheets. • Admission and Discharge record

FLOWSHEETS

 These comprises of monitoring sheets aside

from those in the graphic sheet, those with
KARDEX Flaggings

• Kardex (plural Kardexes) (medicine) A medical-patient
information system which uses forms preprinted on
durable card stock; loosely, any similar system for
paper-based record-keeping. The device used to hold
the cards of such a system.
These are small color coded cards, usually the
size of 2” x 3”. They contain updated
information about what is currently being done
or are to be done with the patient. These cards
help nurses endorse the situation of their
patient faster without looking into the chart. As
the procedure, IV bottle or special order is
done, they are being crushed out from the
flaggings in order for the information to remain
updated.

Colors of Flagging Used in IDH

Yellow flaggings- These contain the list of IV fluids that

are running on the patient. Bottle number, rate, kind
and when it was started and when it is due is found
there.

Pink Flaggings: These contain special orders for the

patient like TPR and MIO monitoring, CBG monitoring or
special precautions like seizure precautions, fall hazard
and other orders specified by the physician.

Blue flaggings- These contain the list of laboratories

ordered for the patient.

Green Flaggings- These contain the operation to be

done on the patient including diagnostic procedures,
schedules and materials needed.

Medication Cards:

These are small , color coded cards, usually the

size of 1” x 2”. They contain the name of the
patient, doctor and room number, the name of
the medication including brand and generic
name, stock dose, desired dose and timing.

Kardex They are color coded according to the routes

Kardex (plural Kardexes) (medicine) A medical-
patient information system which uses forms
preprinted on durable card stock; loosely, any
similar system for paper-based record-keeping.
The device used to hold the cards of such a
system.
the medication are to be given.
White Medication Card- for Oral Medications
Yellow Medication Card- for IV Medications
Pink Medication Card- for other routes of
medications like topical, ophthalmic, otic etc.