W UHAN MEDICAL HOSPITAL

NURSES OBSERVATION SHEET

DATE TIME DIET OBSERVATION & SIGNATURE

S“while walking I feel pain bilaterally in my hip and has muscle

weakness. If I’m going to rate the pain its 7/10”
0 received patient lying on bed, conscious, coherent and with
oriented with ongoingIVF bottle number 1 DSW 1L plus sodium
phosphate sodium phosphate 15 mmol via soluset in 20mmol
regulated at 20gtts/min and on 02 @2LPM via nasal prong
initial vital signs are as follows:
T: 37.0C PR:98bpm RR: 21cpm BP: 150/95mmHg
O2:94%
- pain scale of 7/10
- fatigue
- brown, infiltrative lesions over the trunk and back
- bilateral hip pain when walking, fatigue, muscle weakness
A Acute pain relate to injuring agent
P Within 8 hours of nursing interventions, the patient will be
able to report pain is relived/controlled, with the pain scale of
4/10 from 7/10
I -v/s taken and recorded
-infused 12 Sodium Phosphate Injection @ 15 gtts
-Capillary refill checked
- TS Rocaltrol given at 0.25 MCG TID cap, PO
- Fexpfenadine given att 120 mg HS, Tab, Po
-TS bismuth subsalicylate given at 262 mg BID tab PO
-encourage pt to increase intake of fluids
-encourage pt to take bed rest
E – After 8 hours of nursing interventions, the pt was able to
demonstrate pain si relived . as evidenced the pt stated “ thank
you my pain has subsided pain scale 4/10”
- Endorsed pt on staff on duty with the lastest v/s as follows:
T-36.6 celsius
P-95 bpm
BP- 150/90 mmHg
R-19 cpm
O2 sat- 96%
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