Sample Nurses Notes Cu

SAMPLE NURSES NOTES

DATE/TIME 3PM

FOCUS

3:20pm

5pm 5:05pm

6pm 6:20pm 6:40pm DAT/soft/general liquids/npo/OF 1800kcal

10pm

NURSE’S NOTES  Received awake(comatose) on bed with intravenous fluid of (note the name of IVF) #(of the bottle) at 500 cc level regulated at ___gtts/min  With O2 inhalation at ___LPM via (nasal cannula, face mask, rebreathing mask…)  With endotracheal tube attached to mechanical ventilator/Manual bag resuscitator attached to O2 supply at 10LPM  Continuous manual resuscitation done  With chest thoracostomy tube at left mid-axillary line attached to water-sealed-bottle draining to bloody drainage at ____level  Fluctuation noted  With Foley bag catheter attached to urobag draining to a yellowish urine at ____level  Vital signs taken and recorded with BP:__mmHg, HR:__bpm, RR__cpm, temp:___C, O2 saturation___%  Above intravenous fluid (name of IVF, number bottle) consumed and followed up with (name of IVF, #) and regulated at __gtts/min  Bipedal edema noted  Productive cough noted expectorating to a yellowish sputum  Crackles noted upon auscultation of the chest  Encourage deep breathing and coughing exercise  Encourage increase fluid intake  Chest physiotherapy done  Placed in semi-fowler’s position  Suctioning of secretions at oral and endotracheal at 30 sec interval done  Body weakness noted at upper and lower extremities  Passive and active range of motion exercise done at both lower and upper extremities  Turned to sides every 2 hours  Body temperature rechecked- febrile Temp:40degrees Celsius$  Tepid sponge bath done  Body temperature rechecked Temp: 37.6 degrees Celsius  Blood transfusion started with one unit PRBC blood type ___ Rh(+/-) with serial number_______and segment number_______ at 450cc level regulated at 10 gtts/min for the first 15minutes  Vital signs rechecked  Above blood transfusion regulated at 20 gtts/min  Seen and examine by Dr.____________with new orders----carried out  Brought to x-ray/ ultrasound pre stretcher accompanied by_____  Brought back to ward and ushered to bed comfortably  Ate and consumed share with fair appetite  Fed through NGT with aspiration precaution  Served and consumed half of share with poor appetite  Maintained and instructed  Due meds given  Above blood transfusion consumed, mainline resumed and regulated at KVO rate  Still for CBC, serum K, Na determination---requested  For urinalysis—specimen bottle given with instructions  Intake and output monitored and recorded  Observed for any unusualities  Encouraged to verbalize discomfort  Health teachings imparted with emphasis on: • compliance of medication regimen • avoidance of dark colored foods • importance of nutritious food rich in vitamins and minerals such as fruits and vegetables (note: find out what causes the disease….) Endorsed sleeping on bed with latest vital signs BP:__mmHg, HR:__bpm, RR: ___cpm, Temp:____C