Scribd
Upload
11K views3 pages

Nurses Notes Sample

The nurse documented the care provided to a postoperative patient over a morning shift. Key details include: the patient was admitted post-abdominal surgery, receiving IV fluids and medication for pain. Bleeding was noted from the surgical site in the morning. The wound was cleaned and dressed. Later the patient's pain was alleviated and they were resting comfortably. The nurse completed assessments, administered ordered treatments, and provided health teaching to the patient's watcher.

Uploaded by

leo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
11K views3 pages

Nurses Notes Sample

The nurse documented the care provided to a postoperative patient over a morning shift. Key details include: the patient was admitted post-abdominal surgery, receiving IV fluids and medication for pain. Bleeding was noted from the surgical site in the morning. The wound was cleaned and dressed. Later the patient's pain was alleviated and they were resting comfortably. The nurse completed assessments, administered ordered treatments, and provided health teaching to the patient's watcher.

Uploaded by

leo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Patient Care Log - Day 1 Morning Shift: Logs patient activities and observations during the morning shift such as patient condition, medical intakes, and evaluations.
  • Patient Care Log - Day 1 Afternoon Shift: Records medication administration and patient response, alongside continuous care activities during the afternoon shift.

Patient’s Name: _____________________________ Ward:_________ Room & Bed No.

:__________________ Chart

No:

Date/Time Shift.Time Entry

1/18/21 7-3 7:00 am Received patient asleep lying on the bed.

With dressing on the right lower abdomen dry and intact.

With an IVF of D5LR 1L running @ 80cc/hr due 12 nn.

Intake level 700 cc infusing well over left basilic vein.

With foley catheter French 12 attached to Uro bag.

Still available 1 unit RBC blood type 0+ at laboratory as standby only.

Still for repeat CBC, electrolytes, magnesium. Tomorrow AM encoded.

With follow up chest X-ray result.

IVF to follow D5LR 1L at 60 cc/hr.

Maintain on NPO.

7:30 Bed linens well tucked. Side rails checked and locked.
8:00 am Vital signs checked and recorded: Temperature 38.8 ̊C, BP 140/90. NOD aware

Intake and output taken

Pain in the area of surgery verbalized by the patient, bleeding noted.

Facial grimacing, muscle guarding, moaning noted.

8:10 Wound cleaned, dressing changed.

Uro bag changed, drained yellow colored urine, 500 cc.

8:30 TSB rendered.

Bed elevated to semi fowler’s for comfort.

9:00 Vital signs checked: T 36.4, BP 120/80

Health teaching rendered to watcher, such as:


 Maintain on NPO
9:30
 Encourage deep breathing exercises
 Avoid touching abdomen.

10:00 Patient’s pain alleviated, no facial grimacing, muscle guarding, moaning noted.

10:30 Chest X-ray results received, NOD aware, Dr. Lim aware.

11:00 Seen and examined by Dr. Lim, with orders made.


11:20 Given cefuroxime 250 mg via IV infusion, as ordered

11:50 Checked for allergic response, none noted.

Vital signs taken,


12:00
Intake and Output taken.

12:20 IVF changed, D5LR 1L at 60 cc/hr started. With good backflow.

12:45 IVF site checked, no extravasation noted.

1:30 Assessed RLQ, site of operation, no unusualities noted.

2:15 Patient is resting comfortably in bed with no unusualities noted.

2:30 Left on bed with watcher at bedside.

You might also like