SAMPLE NURSE’S NOTES

Date / Time Focus D Data Action Response Signature

A
R
January 28, 2018 7AM Receiving Assessment Awake in a semi-fowler’s position with ongoing IVF # 3 of PNSS 1L @ 100 cc/o @ 950 cc
Level infusing well @ right cephalic vein_____________________________________SMG
8 Increased body D – With intact and patent IFC, connected to urine bag draining to light yellow urine, with body
temperature Temperature of 38.2oC per axilla, with flushed face and skin warm to touch__________SMG
810 A- Assessed patency of IFC, assessed for signs of fever, TSB continuously done, offered fluids
Available @ bedside, removed extra clothing & blankets, opened windows to enhance ventila-
tion, emphasized importance of increasing fluid intake, encouraged verbalization of feelings
and concerns__________________________________________________________SMG
1015 R – temperature lowered from 38.2oC to 37 oC________________________________ SMG
230 Above IVF consumed & removed as ordered________________________________SMG
Endorsing Assessment Endorsed without IVF, BP – 110/70 mmHg, HR-60 bpm, RR- 18cpm, Temp- 37oC_SGersava
3
January 28, 2018 3pm Receiving Assessment Lying on bed with ongoing 1st IVF of PNSS 1L + 2 amps Vit B and Vit. C
@ 120cc/o @ 360 cc level infusing well at left metacarpal vein, with BP of
120/80, HR-70pbm, RR-20cpm & temp of 37.4oC___________________SMG
4 Mild pain D – with 02 inhalation via nasal cannula, poor skin turgor noted, “masakit and
dibdib ko” as verbalized pain scale of 4/10, localized on the anterior chest,
characterized as pricking pain, facial grimace and guiding behaviors noted
when in pain_______________________________________________SMG
410 A – Established rapport, assessed pain level and characteristic, assessed skin
turgor, cutaneous stimulation done, provided with a quiet and calm environment
positioned to comfort, encouraged verbalization of feelings___________SMG
10
5 R – verbalized that pain reduced from 4/10 to 2/10__________________SMG
520 Above IVF consumed and 2nd IVF of PNSS 1L @ 120 cc/0 replaced__SMG
9 Spiritual care Continued in providing with an environment conducive for sleeping, spiri-
tual care done: prayer offered_________________________________SMG
11 Endorsing Assessment Endorsed with ongoing 2nd IVF of PNSS 1l @ 120 cc/o @ 800 cc level, with
BP – 120/80 mmHg, HR – 65bpm, RR- 18 cpm, Temp 37.50c__She Gersava
January 28, 2018 11pm Receiving Assessment Sleeping on bed in semi-fowler’s position with ongoing IVF #2 of D5LR 1L
@ 80 cc/o @ 200 cc level infusing well @ right metacarpal vein_______SMG
January 29, 2018 12 Pain D- reports of sharp pain on the abdominal incision area with a pain scale of
8/10, facial grimacing and guarding behavior noted, restless & irritable___GP
1210 A-referred to POD, administered Celecoxib 200 mg IV as ordered, encouraged
deep breathing exercises & relaxation techniques, kept comfortable&safe_GP
1 R-reported pain was relieved____________________________________GP
3 Hyperthermia D- temp of 38.9 oC via axilla, skin flushed and warm to touch___________GP
305 A- Administered 300 mg IV paracetamol per doctor’s order, encouraged ade-
Adequate oral fluid inatake______________________________________GP
4 R- Temperature decreased from 38.9oC to 37.1 oC___________________GP
5 A - Morning care done, bed linens changed_________________________GP
6 Above IVF consumed and 3rd IVF of PNSS 1L@120 cc/o replaced____GP
7 Endorsing Assessment Endorsed with ongoing IVF # 3 of PNSS 1L @950 cc level with BP110/70
mmHg, HR-70bpm, RR-20cpm, Temp of 37.3oC___________George Park
 SAMPLE NURSE’S NOTES

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Last Name, First Name MI) Age Sex Rm. # Attending Physician