NURSES NOTES

Patient’s Name: Adhyma Claire Fetros Age: 19 yrs Old Sex: Female Hosp#:_________

Attending Physician: ____________________________________________________ Rm/ Ward: __________________

F - Focus
D - Data
NURSING
DATE TIME A - Action
DIAGNOSIS
R - Response

05/12/21 11: 00 AM HEADACHE F- Headache

D- "I feel like my head will explode anytime" as verbalized by the
patient. With a pain scale of 9/10, and facial grimace noted.

A - Maintain a calm and quite environment

- Encouraged adequate rest.
- Administered paracetamol 300mg IVTT as per doctor's
order.
- Encouraged to increase oral fluid intake.
R - The patient recovered from headache as evidence by normal
vital signs.
- The patient verbalized "I feel better now" with a pain scale of
3/10. Goal partially met.
REVISED JULY 2006 NSD - 10
 GRAPHIC SHEET
NAME: Adhyma Claire Fetros AGE: 19 SEX :Female RM.: DR: HOSPITAL NUMBER:

Date 05/12/2021
HOSPIT
AL DAY
POST OF
DAY
HOURS
OF DAY AM PM3 AM PM AM PM AM PM AM PM

10 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 1 4 8 1 4 8
2 2

ᵒ c 41

40

39

38

37

36

140

120

100

50 80

30 60
20

16

10 40
BLOOD 120
PRESSU
RE /70
WEIGHT 55 kg
URINE
STOOL
NAME: JUVEN EAN O. Respiration Rate
FAJARDO BSN 1B
Skills
VITAL SIGNS
62/65 x 0.35 x 100 = 33 /35
COMPUTATION SCORE
Knowledge
Body Temperature
10/20 x 0.5 x 100 = 8/15
Skills
Attitude
99/100 x O.35 X 100 =
34.65/35 50/50 x 0.10 x 100 = 10/10

Knowledge Total: 50/60

20/20 x 0.5 x 100 = 15/15 Body Temperature

Attitude Skills

49/50 x 0.10 x 100 = 10/10 171/175 x 0.35 x 100 = 34/35

Total: Knowledge

59/60 19/20 x 0.5 x 100 = 14/15

Attitude

Radial 50/50 x 0.10 x 100 = 10/10

Pulse Rate Total: 58/60

Skills

79/80 x 0.35 x 100 = 34/35

Knowledge

20/20 x 0.5 x 100 = 15/15

Attitude

49/50 x o.10 x 100 = 9.8/10

Total: 59/60