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Nursing Record FUNDA

The 3 sentence summary is: The nursing record document contains information about a patient's vital signs, pain levels, activities, intake and output, medications, and the nurse's signature over the course of a hospital day. It includes the patient's name, age, sex, diagnosis, admission date, activity level, hospital number, room number, bed number and diet. The chart tracks the patient's pulse, temperature, respiration, blood pressure, pain severity, position, pain site, exercises, hygienic care, fluid intake and output via various routes, medications administered, and the fluid balance total.

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56 views1 page

Nursing Record FUNDA

The 3 sentence summary is: The nursing record document contains information about a patient's vital signs, pain levels, activities, intake and output, medications, and the nurse's signature over the course of a hospital day. It includes the patient's name, age, sex, diagnosis, admission date, activity level, hospital number, room number, bed number and diet. The chart tracks the patient's pulse, temperature, respiration, blood pressure, pain severity, position, pain site, exercises, hygienic care, fluid intake and output via various routes, medications administered, and the fluid balance total.

Uploaded by

عمار ياسر
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Student's Name: ………….……………..…………………….……………..

Matrouh University Faculty of Nursing


Medical Surgical Department

NURSING RECORD
Patient’s name: ………….……………..…………………….…………….. Age: ……….……………….…………….……… Sex: ……….…………………….……………....
Diagnosis: …………………….……………..…………………….…………….... Admission date: ……….…………….activity Level: ……….……….……..
Hospital No: ……….…………….. Room No: ……….…………….. Bed No: ……….……………..……..… Diet: ……….………………….………………..
Date: ……/ …… /………… 9 10 11 12 1 2
Hospital day No: …… am am am MD pm pm NG Report
Pulse ● Temp x Resp 
BP
< 200 < 40
200 40
190 38
180 36
170 34
160 32
150 30
140 28
130 < 42 26
120 42 24
110 41 22
100 40 20
90 39 18
80 38 16
70 37 14
60 36 12
50 35 10
> 50 > 35 > 10
Pain severity
position Pain site
Exercise
Hygienic care

Fluid chart Intake Output Medications


Oral IV Others Urine Others Bowel Name Dose Route Site
9am
10 am
11am
12MD
1 pm
2pm
Balance
Signature

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