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Sample Nurses Note

The nurse's notes document a patient admitted to the ward for lung cancer with difficulty breathing. Over the course of one shift from 7am to 3pm, the following care was provided: vital signs were checked regularly and recorded; oxygen therapy and IV fluids were administered; the patient received health teachings; medications were given; the patient was assessed by doctors and had tests done; and the IV site was changed when it infiltrated. The patient consumed meals and was generally stable throughout the shift.

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Dan Evanz
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4K views2 pages

Sample Nurses Note

The nurse's notes document a patient admitted to the ward for lung cancer with difficulty breathing. Over the course of one shift from 7am to 3pm, the following care was provided: vital signs were checked regularly and recorded; oxygen therapy and IV fluids were administered; the patient received health teachings; medications were given; the patient was assessed by doctors and had tests done; and the IV site was changed when it infiltrated. The patient consumed meals and was generally stable throughout the shift.

Uploaded by

Dan Evanz
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 PDF, TXT or read online on Scribd
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NURSES NOTES

NAME _________________________ WARD _________________ RM NO. ______

Case : LUNG CANCER came In due to difficulty of breathing , 2 days post admission

DATE SHIFT/TIME ENTRY


9/5/2020 7-3 7am Received awake , on moderate high back rest
Oxygen inhalation @ 2l/min via nasal cannula
With an IVF of D5lr @300cc level running @ 100 cc/hr, infusing well @ the left
cephalic vein
Clear breath sound @ left lung and wheezes heard at the right lung
8:00 VS check and recorded Bp 130/80 mmhg, CR 85/min pulse 82 beats/minute,
temperature 36.5 ⁰C, RR 20 breaths /min
Linens change and stretched
9:00 Health teachings rendered such as:
Wear mask
Wash and peel fruits before eating
Eat well cooked nutritious food and avoid red meat , fatty, sweet food sources
Observe handwashing before and after toileting and before eating
Report immediately for any unusualities
10:00 Due medications given
IVF consumed and followed up with same, D5lLr at 100 cc/hr , gtts regulated
11 :00 Seen and assessed by Dr. Zee several orders made
Above IVF decrease to 80cc/hr as ordered, gtts regulated
For repeat chest Xray today, requested
12:00 Nebulization with Berodual 2cc administered by RTOD
Meals serve, consumed ¾ of the served meal
VS checked and recorded
1:00 Send to Xray department per wheelchair with O2 and same IVF on
1:30 Back to room, assisted back to bed IVf site infiltrated, removed and set kept sterile
Seen by Dr. Y , oxygen inhalation discontinued as ordered
IVF reinserted by same with venflon g.22 at the right cephalic vein , regulated at
80cc/hr as previously ordered
2:00 I & O checked and recorded
3:00 Asleep with siderails up
AFFIX SIGNATURE
Liza Lo St.N / Mila Cruz RN MN / Lory Chiu RN
STUDENT CI STAFF NURSE

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