Nursing notes

Sample Nurses Notes

                                     

CHIEF OF COMPLAINTS: BODY MALAISE & RIGHT SIDE BODY WEAKNESS

Date & time                                                                 Nurses notes

12/14/2011  Received pt. lying on bed; awake

8:00AM
  Responsive & coherent upon interaction

  c IVF no. 3 D5%NM 1L @ 25 gtts/min inserted@ right metacarpal vein

  c piggy back 500 cc @ 15cc/hr

  O2 nasal cannula @ 15 L/min

  V/S taken as follows:

  T- 37.5 P- 88 bpm R- 28 BP- 130/70mmhg

9:30 AM   Diet served ate just enough

  Morning care done

  Pt. escorted to radiology unit for x-ray

9:50 AM   X-ray done

  Pt. place on bed c side rails up

  Meds given

10:25 AM   Pt. assisted to ROM

11:00 AM   Seen & examined by Dr. dacudaw c orders carried out

12:00 PM   Diet served; ate in small amount

1:00 PM   Pt. brought to hospitals garden and assisted for ROM

2:30 PM   Hematoma noted on Lateral part of gluteal muscle

  Beddings are changed

3:00 PM   Health teachings given to significant others such as:

1.       Assist pt. in ROM as always

2.       Take medications on time as prescribed

3.       Always ask pt. for current date, time and place

4.       Turn pt. side  to side every hour to

 3:30 PM   IVF consumed 300cc

  Due meds given

  V/S taken and recorded

  I & O measured

  Needs attended

4:00 PM   Endorsed to NOD for continuity of  care

                                                                 Noguerra.,SN-II / Sinco.,RPh,RM,RN,MN /

Salinas.,RN

                                                                                      

                                                                                     SAMPLE CHARTING

CHIEF OF COMPLAINTS: DYSPNEA, VOMITING

Date & time                                                                 Nurses notes

12/15/2011  Received pt. lying on bed; awake

4:00 PM
  Responsive & coherent upon interaction

  c IVF no. 2 D5%NaCl 1L @ 60 mcgtts/min inserted @ left cephalic vein

  02 via face mask @ 60 L/min

  Weak looking

  V/S taken as follows:

  T- 36.3 P- 92 bpm R- 18 cpm BP- 120/80mmhg

  PE Performed

  Lung sounds assessed c wheezing and crackles heard

5:00 PM   Vomitus collected in large amount 150cc

  Wheeled pt. to laboratory for dx test

  Vomitus collected in large amount 190cc

6:00 PM   Diet served ate just enough

  Meds given
 7:00 PM   Seen & examined by dr. sy c orders carried out

  Bed care done

8:00 PM   O2 replaced via nasal cannula @ 75 L/min

9:00 PM   Vomitus collected in small amount 49cc

  Health teaching given such as:

1.       Taught pt. the proper  hand washing

2.       Encouraged pt.  not to eat street foods

3.       Encouraged pt. to increased fluid intake

4.       Taught pt. the importance of utensils sterilization

10:00 PM   Vomiting not noted

11:00 PM   Due meds given

  V/S taken and recorded

  I & O measured

  IVF consumed 320cc

11:50 PM   Needs attended

12:00 PM    Endorsed to NOD for continuity of care

                                                                                       Noguerra.,SN-II /
Rom.,RN,MN / Ang.,RN

                                                                         BUTUAN DOCTORS COLLEGE   

                                                                            J.C Aquino Avenue, Butuan City

                                                                                     SAMPLE CHARTING

CHIEF OF COMPLAINTS: Epigastric Pain

Date & time                                                                 Nurses notes

12/16/2011  Received pt. lying on bed: awake

8:00 AM
  Responsive & coherent upon interaction

  c IVF no. 1 PNSS 1L @ 25 gtts/min inserted @ left basilic vein

  weak & pale looking

  V/S taken as follows:

  T- 35.5 P- 78 bpm R- 20 cpm BP- 130/60

9:00 AM   Epigastric pain felt pt. stated pain scaled 9/10

   Diet served ate just enough

  Meds given

  Morning care done

10:00 AM   Seen & examined by Dr. layese c orders carried out 

11:00 AM   Health teachings given such as:

1.       Refrain from eating imported goods which manufacturer and expiration date is not
indicated.

2.       Encourage pt. to eat well balance diet.

3.       Taught pt. the importance of early consultation to physician if unnecessary pain is

felt.

11:30 AM   Diet served pt. did not ate

12:00 PM   Meds given

1:30 PM   Epigastric pain felt by pt. @ scale of 8/10

2:30 PM   Pt. brought to laboratory for S/E

3:00 PM   Place pt. on bed

3:50 PM   V/S taken and recorded

  IVF consumed 600cc

  I &  O measured

  Needs attended

4:00 PM   Endorsed to NOD for continuity of care.

                                                                            Noguerra.,SN-II / Aromin.,RN,MN /

Escasio.,RN

                                  

                                                                                     SAMPLE CHARTING

CHIEF OF COMPLAINTS: FEVER

Date & time                                                                 Nurses notes

12/   Received pt. lying on bed: awake

17/2011
4:00 PM   Responsive & coherent upon interaction

5:00 PM   c IVF no. 1 D5%NaCl 1L @ 60mcgtts/min inserted @ left metacarpal vein.

  Weak &  Pale looking

   V/S taken as follows:

T- 38.9 P- 89 bpm R- 26 BP- 130/90 mmhg

  PE DONE

6:00 PM   TSB DONE

  Meds given

  Diet served ate in small amount

6:50 PM   Pt. brought to laboratory for CBC

7:10 PM   Seen & examine by Dr. Gonzalez c orders carried out.

8:00 PM   Elevated temperature monitored

  TSB DONE

  STAT meds given for fever

9:00 PM   Convulsion observed notified the attending physician.

9:30 PM   Temp. flow  down to 37.8

  Vomitus  collected in large amount 100 cc

10:13 PM   Pts. IVF replaced c D5%NM 1L @ 40gtts/min inserted @ right cephalic vein

  Health teaching given such as:

1.       Consult physician when fever is more than 1 wk.

2.       Clean surroundings to eliminate mosquitoes.

3.       Increased fluid intake.

11:00 PM   Temp. down to 37.2

  Pt. ate in small amount but more on liquids.

11:30 PM   No fever had been reported and noted.

  V/S taken and recorded accurately

  Due meds given

  I & O measured & recorded accurately.

  Needs attended.

12:00 PM   Endorsed to NOD for continuity of care.

                                                                                       Noguerra.,SN-II /
Besa.,RN,MN / Sue.,RN

                                                                         
                                                                                     SAMPLE CHARTING

CHIEF OF COMPLAINTS: Fracture pain @ TIBIALIS

Date & time                                                                 Nurses notes

12/18/2011  Received pt. on O.R Arrival area

8:00 AM
  s IVF attached

  responsive & coherent  upon interaction

  weak & pale looking

9:00 AM   surgeon ordered for IVF

  c IVF no. 1 D5%NaCl 1L @ 30 gtts/min inserted @ left cephalic vein

  c O2 via nasal cannula @ 20 lpm

10:00 AM   start of incision

  Pt. breathing pattern is diminished

  Increased O2 saturation  was  ordered @ 60 lpm

11:00 AM   Bone alignment

  Pt. shows signs of distress during the operation.

1:00 PM   Closing area of incision.

1:30 PM   Pt. brought to recovery room for 2 hours monitoring.

3:30 PM   Pt. brought to his unit

  Health teachings given to significant others such as:

1.       Never leave pt. s assistants specially @ home

2.       Elevate extremities if pain occurs

3.       Assist pt. in performing ADL specially grooming

4.       Put side rails to pts. Bed for safety

  V/S rechecked & recorded

  IVF consumed 240 cc

  Needs attended

4:00 PM   Endorse to NOD  for continuity of care

                                                               Noguerra.,SN-II  / Suguitan.,RN,MN / Delos

santos.,RN