NURSES NOTES

Patient’s Name: Jarren Clarence S. Diazon Age: 18 Sex: Male Hosp#:_________

Attending Physician: ____________________________________________________ Rm/ Ward: ______________

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

05/12/2021 10 am Dyspnea F - Ineffective breathing pattern

D - “Nahihirapan akong huminga” as verbalized by the patient.
Chest tightness, inability to take a deep breath, shortness of
breath.
A - Oxygen therapy, respiratory monitoring.
R - Patient’s respiratory rate will stay within 5 breaths/minute of
baseline.
Patient will feel comfortable when breathing.
REVISED JULY 2006 NSD - 10
 GRAPHIC SHEET
NAME: Jarren Clarence S. Diazon AGE: 18 SEX: Male RM.:__________DR:___________ HOSPITAL NUMBER: _______________________

Date 05/12/2021
HOSPITAL
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 110
PRESSURE
/70
WEIGHT 75 kg
URINE
STOOL
Body Temperature Respiration Rate

Skills Skills

99/100 x O.35 X 100 = 34.65/35 63/65 x 0.35 x 100 = 33.92/35

Knowledge Knowledge

20/20 x 0.5 x 100 = 15/15 20/20 x 0.5 x 100 = 15/15

Attitude Attitude

49/50 x 0.10 x 100 = 9.8/10 49/50 x 0.10 x 100 = 9.8/10

Total: 59/60 Total: 59/60

Pulse Rate Body Temperature

Skills Skills

63/65 x 0.35 x 100 = 33.92/35 172/175 x 0.35 x 100 = 31.45/35

Knowledge Knowledge

20/20 x 0.5 x 100 = 15/15 20/20 x 0.5 x 100 = 15/15

Attitude Attitude

49/50 x o.10 x 100 = 9.8/10 49/50 x 0.10 x 100 = 9.8/10

Total: 59/60 Total: 56/60