Admission Nurses Notes Sample

ATTENTION BScN 5 NURSING STUDENTS
Dear Nursing Students,
As you are all aware your Level I Examinations are scheduled to begin from the week of 20th October
2014. The roster has been posted on the Notice Board. I personally discussed the format of the
examination with you prior to the start of the semester. Yet I understand that some of you are confused
and are asking the Clinical Instructors what to do. If you were at the meeting and were paying attention
you would not be having a problem now.
Nevertheless to reiterate what was discussed at the meeting, Level I examination requires you to admit
a client to the Ward. This includes filling out the data base form and performing a Health Assessment
based on two (2) systems relevant to your client. The Health Assessment will be written separately from
the Nurses notes. You will also be required to formulate ONE (1) Nursing Diagnosis for your client.
When taking vital signs, please check the pulse manually. You need to assess the character of the pulse.
The machine would not give you this information. Also be prepared to take a manual BP if asked.
Placement of the cuff is important whether it is being done manually or not. Also proper placement of
the thermometer and the client’s arms when checking pulse and respiration is required.
Communication also plays an important part of your examination. You must communicate with your
client, significant others and all levels of STAFF. You must orient your client and relatives to the Ward
environment and ward policies. You must take vital signs, test urine and weigh patient if possible. You
will also be required to perform glucose monitoring for the client as per ward protocol.
Documentation is very important. You will be required to document everything you have done for the
client in chronological sequence. Please note the correct times for your documentation. I have included
a sample for your perusal. Please note that there are variations. However, you must note:
1. The time and date of admission

2. Where the client came from e.g. A&E, home, Clinic, another ward or hospital
3. How did the client arrive on the ward i.e. on a trolley, wheelchair, walking, being held in
mother’s arms, whether mother was ambulant or sitting in a wheelchair.
4. The reason for admission
5. Past medical and surgical history
6. Brief system assessment
7. Whether doctor’s orders were carried out
8. The condition of your client at the end of the admission process
Please note that you must fill out ALL paper work- i.e. Care plan, temperature chart, medicine chart,
intake output chart and any other that is relevant to your client.
I am forwarding you a sample of the Admission notes. If you still have questions please feel free to
contact me.
Mrs. C Bascombe- Mc Cave
Nursing Advisor BScN 5

ADMISSION NURSES NOTES SAMPLE
DATE/TIME NOTES
27/09/14 Patient was admitted at 2pm via A&E on a trolley accompanied by his daughter. He has a
history of abdominal pain by 2hours and vomiting by one episode.
2:30pm Patient was admitted at 2pm from home with an admission order for repair of inguinal
hernia mane. Is fully ambulant and was accompanied by his wife
Patient was admitted via OPC in a wheelchair, with an admission order for stabilization of
elevated BP.
2pm Patient was admitted via A&E complaining of abdominal pain by 2 hours and vomiting dark
green fluid by one episode. He arrived on a trolley and was accompanied by his wife and
daughter. Past medical history-nil. Past Surgical History-Appendectomy two weeks ago.
CNS: Is alert and oriented to person, place and time. C/O intermittent abdominal pain and
guarding abdomen. Was given Pethidine 75mgs and Gravol 50 mgs IM @ 1pm in A&E.
RESP: Is breathing room air spontaneously. Respirations quiet and regular. CVS: Peripheral
pulses/ Radial pulses palpable, of good volume and rhythm. Nail beds pink, good capillary
refill. IV therapy in progress @2L/24 hrs-Normal Saline alt with 5%Dextrose/Water.
Normal Saline -800 mls in progress at present on Rt arm. GI: Has had one episode of
vomiting. Status NPO at present. Bowel movements normal. Last BM this am. Abdominal
pain in right upper quadrant-rated 7 on pain scale. GU: Is voiding urine at will. (Is
incontinent /Is experiencing pain on micturition. Is unable to void. /Urinary catheter insitu
on free drainage-200mls amber coloured urine in bag.)MS: Is fully ambulant.(Is
immobile/Is walking with difficulty).SKIN: Warm to the touch. Is dry and intact. IV access
insitu on dorsal aspect of Rt hand. Healed abdominal scar in Rt lower abdominal quadrant.
Vital signs- BP 130/70 mmHg, P-72 bpm, R 28 bpm, T 37.5 o C .Urinalsis NAD. RBS 88mg/dl
via Accuchek. Patient and relatives oriented to Ward and ward policies. Valuables given to
wife/Valuables given to Nurse in Charge for safe keeping. Patient left lying in bed in lateral
position, relatives at bedside. Is awaiting to be seen by the doctor.----------C.Bobb BScN5---
2:45pm Patient was seen by Dr. Mader . PLAN: (1). Keep NPO-same being done. (2). IV therapy
2l/24hours- N/S alt D5W- N/S in progress.( 3). Administer Pethidine 100mgs and Gravol
50mgs IM q8h. (4). Blood investigations— Blood was taken for CBC and U&E. ( 5). Vital
signs bd.----------------C.Bobb BScN 5-------------------------------------------------------------------------
NURSING DIAGNOSIS
Alteration in comfort (pain)related to surgical adhesions as evidenced by patient complaining of

abdominal pain and guarding the abdomen.

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What are the requirements for the Level I examination?

What details must be documented in the admission notes?

ATTENTION BScN 5 NURSING STUDENTS

Dear Nursing Students,

1. The time and date of admission

Mrs. C Bascombe- Mc Cave

Nursing Advisor BScN 5

Alteration in comfort (pain)related to surgical adhesions as evidenced by patient complaining of

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