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Nurses Notes Example

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 medications including antibiotics. The nurse assessed the surgical site, administered pain medication when the patient reported pain, and provided health teaching to the family watcher. Vital signs were monitored and found to be stable throughout the shift.

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2K views3 pages

Nurses Notes Example

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 medications including antibiotics. The nurse assessed the surgical site, administered pain medication when the patient reported pain, and provided health teaching to the family watcher. Vital signs were monitored and found to be stable throughout the shift.

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’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.

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