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

NURSES 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-fowlers 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 urinalysisspecimen 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