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Hospital, Hospital, Hospital: Nurses Notes

The patient, Covida Mascarra, a 50-year-old female (Hosp #:___) was admitted to Room 323 with abdominal pain related to her present illness. Her nurse's notes document assessments of her pain level, interventions to relieve it including medication and relaxation techniques, and the evaluation that her pain was reduced from an initial 8/10 to a 4/10. Physician orders were received and carried out. Vital signs were monitored regularly and intake/output was tracked.

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2K views2 pages

Hospital, Hospital, Hospital: Nurses Notes

The patient, Covida Mascarra, a 50-year-old female (Hosp #:___) was admitted to Room 323 with abdominal pain related to her present illness. Her nurse's notes document assessments of her pain level, interventions to relieve it including medication and relaxation techniques, and the evaluation that her pain was reduced from an initial 8/10 to a 4/10. Physician orders were received and carried out. Vital signs were monitored regularly and intake/output was tracked.

Uploaded by

jay kusain
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
  • Nurses Notes

Hospital,Hospital, Hospital

NURSES NOTES
Patient’s Name: Covida Mascarra Age: 50 Sex: FEMALE Hosp #:______
Attending Physician: DR. SHAUN MURPHY Room / Ward: 323

DATE TIME NURSING DIAGNOSIS S – subjective


O – objective
P – planning
I – intervention
E - evaluation
9/01/20 7:00 am Received patient lying on bed;
awake; responsive; restless noted;
with ongoing IVF of PNSSS 1L x
KVO infusig well at right
metacarpal vein.
8:00 Abdominal pain related to S- “sakit akong tiyan ma’am mga
present illness condition. 8/10 ang kasakit.” as verbalized by
patient.
O- Tense, restless, and guarding at
lower abdomen is noted.
P- Patient will verbalize relieve of
pain from 8 to 5-4/10.
10:00 am I- VS checked and recorded; VS
monitor every 4 hours thereafter;
Bed side care; Administered pain
reliever as ordered; Assist client to
use relaxation techniques such as,
-Deep breathing techniques,
guided imagery, refocusing
attention, proper positioning.
- Asses level of pain
01:30 pm -Seen and examined by Dr.
Pandemia with orders made and
carried out.
-Nurse on duty administered
Ranitidine 50mg IVTT and
Furosemide 40mg IVTT as ordered.
2:00 pm -Intake and output summed up
and recorded.
3:00pm E- Goal met. Patient verbalized
ease of pain and rated 4/10.
Endorsed to nurse on duty for
continuity of care------------==-SN

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