Sample Nurses Notes Cu

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SAMPLE NURSES NOTES

DATE/TIME FOCUS NURSE’S NOTES


3PM  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
3:20pm  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
5pm  Passive and active range of motion exercise done at both lower
5:05pm 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_______
6pm at 450cc level regulated at 10 gtts/min for the first 15minutes
6:20pm  Vital signs rechecked
6:40pm  Above blood transfusion regulated at 20 gtts/min
DAT/soft/general  Seen and examine by Dr.____________with new orders----carried
liquids/npo/OF out
1800kcal  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
10pm  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

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