Nursing Notes Example

Nursing Notes Example 0730 Introduced self to patient. VS obtained. Head to toe assessment performed. Patient denies needs at this time. (It’s important to ask if they need anything. Some patients won’t tell you anything until you ask. You will learn to get in the habit of asking this) Side rails x3 up. Bed in lowest position. Call light within reach and pt. verbalizes understanding of use. (Documentation of safety is a must. Also, it’s not enough to say the call light is within reach…the patient must know how to use it as well ). 0800 Pt sitting up in bed eating regular diet. Tolerating diet well. (It is particulary important to chart if they are tolerating a diet change if we are advancing their diet…in other words, no nausea, no vomiting). 0845 Pt ambulating in hallway with assistance from PT. Pt is slightly winded but reports no difficulty in breathing. (Again, I’m including my observations on how well the patient is tolerating activity). 0900 Pt sitting in chair. Pt assisted with bath. (This tells the level of care the patient is able to do…the patient is partially dependent on us nurses for ADLS, such as baths) 1000 Pt remains in chair. Denies any needs. Educated patient regarding post operative instructions of stoma care. Patient eager to learn and verbalizes understanding. (Again, it’s not enough that you have educated the patient. You must document whether or not they 1. are receptive to learning and 2. they understood what you are educating them on. 1030 Patient assisted back to bed without difficulty. No distress. Side rails x 3 up. Bed in lowest position. Call light within reach. 1115 Patient report “I’m aching in my belly”. Patient rates pain 9 of out of 10. Patient is guarding abdomen. Heart rate= 110. Blood pressure= 170/89. Respiratory rate=24. Patient is sweating. (I’m painting a picture of the situation. Heart rate, respirations and blood pressure are all elevated which backs up the patient’s report of pain) 1120 Patient given 2 mg morphine IV push. Patient repositioned for comfort. Lowered lights in room. Decreased TV volume. (Notice how I included both the pharmacological intervention as well as all of the other nursing interventions I can do to decrease pain. Nursing interventions are just as effective, if not sometimes even more effective, as pharmacological interventions.) 1145 Patient reports a decrease in pain. Pain is a 2/10. Patient is resting comfortably with eyes closed, no signs and symptoms of distress. Heart rate= 73, respirations= 18, Blood pressure= 135/ 75. Denies needs at this time. Yay! We cured the pain….well, almost. While we may not be able to completely solve problems (in this case pain) the goal is to at least make it manageable, which we have. Our interventions have worked in that the pain level is heading in the right direction and that is VERY important to document. Also, any time you do an intervention, whether it is pharmacological or nursing, be sure to evaluate the interventions in a timely manner in your nurses notes. 1230 Patient is awake, alert and visiting with family. In good spirits. Denies any needs at this time. (Documenting that we are checking on the patient again and that he denies needs. Also, this note speaks to his mental state, which is just as important as his physical state. If a patient has anxiety or is depressed, it makes it that much harder for the body to heal. It’s important to identify any potential mental barriers to a patient’s recovery so that we can quickly use nursing interventions to help correct the problem. )