Normal narrative bank — stable / at-baseline
Each shows what was assessed, the objective finding, the baseline comparison, functional or safety relevance, skilled judgment, and reinforcement — edit to the actual visit.
N1 Stable COPD at baseline | Skilled respiratory assessment completed. Respiratory rate 18 and unlabored; lungs with chronic diminished sounds at the bases bilaterally, unchanged from baseline, no new wheezes or crackles; SpO2 94% on room air at the patient's baseline; no accessory-muscle use; speaks in full sentences. Denies increased cough, sputum change, or worsening dyspnea, and reports activity tolerance at baseline. Inhaler and spacer technique observed and correct. Findings stable from prior visit. RN-level assessment was required to distinguish baseline chronic findings from early exacerbation and to evaluate the response to the bronchodilator and inhaled-corticosteroid regimen. Action-plan thresholds and inhaler technique reinforced; continued skilled monitoring indicated. |
|---|---|
N2 Stable on home oxygen at target | Skilled respiratory assessment completed. Respiratory rate 16 and unlabored; lungs clear to diminished without new adventitious sounds; SpO2 93% on the ordered 2 L per nasal cannula, at target; cannula placement correct and oxygen tubing intact. No accessory-muscle use; speaks in full sentences; denies new dyspnea, cough, or sputum change. Findings stable. RN-level assessment was required to confirm adequate oxygenation on the ordered flow and to evaluate for signs of hypoxemia or hypercapnia. Oxygen safety, flow accuracy, and symptoms requiring a call reinforced; continued skilled monitoring indicated. |
N3 Controlled asthma, asymptomatic | Skilled respiratory assessment completed. Respiratory rate 16 and unlabored; lungs clear to auscultation in all fields, no wheezes; SpO2 98% on room air; no accessory-muscle use; speaks in full sentences. Patient denies cough, wheeze, nocturnal symptoms, or rescue-inhaler use beyond the controller regimen, and reports activity without limitation. Findings at baseline. RN-level assessment was required to detect early airflow limitation and to evaluate adherence to and technique with the controller regimen. Rescue-versus-controller use, trigger avoidance, and action-plan thresholds reinforced; teach-back accurate. Continued skilled monitoring indicated. |
N4 Post-pneumonia recovery, improving | Skilled respiratory assessment completed at the post-illness visit. Respiratory rate 18 and unlabored; scattered fine crackles at the right base, improved from coarse crackles at the prior visit; SpO2 95% on room air, up from 91%; no accessory-muscle use; speaks in full sentences. Cough now minimally productive with clear sputum; patient reports improved exertional tolerance and is afebrile. Findings reflect ongoing recovery. RN-level assessment was required to confirm continued resolution and to evaluate completion of and response to the antibiotic course. Hydration, completing the antibiotic, and symptoms requiring a call reinforced; continued skilled monitoring indicated. |
N5 CPAP-adherent OSA, stable | Skilled respiratory assessment completed. Respiratory rate 14 and unlabored; lungs clear; SpO2 96% on room air; no accessory-muscle use; speaks in full sentences. Patient reports consistent nightly CPAP use with the prescribed settings, improved daytime alertness, and no morning headache; mask fit and skin integrity intact. Findings stable. RN-level assessment was required to evaluate device adherence and effectiveness and to screen for untreated sleep-disordered breathing affecting cardiopulmonary status. Mask care, adherence, and follow-up reinforced; continued skilled monitoring indicated. |
N6 Interval monitoring — stable on inhaled regimen | Skilled respiratory assessment completed at the scheduled interval visit. Respiratory rate 16 and unlabored; lungs clear to auscultation in all fields; SpO2 96% on room air; no accessory-muscle use; speaks in full sentences. Patient denies cough, sputum, dyspnea, or change in activity tolerance and reports tolerating the inhaled regimen without adverse effects. Findings stable and consistent with baseline. RN-level assessment was required to detect any interval change in pulmonary status and to evaluate the effect and adverse effects of the inhaled regimen given the pulmonary diagnosis. Symptoms requiring prompt reporting reviewed; continued skilled monitoring indicated. |