NURSES' NOTES

PATIENT NAME:
lilibeth AGE: 36 yrs HOSPITAL NO.:
PHYSICIAN: Dr. X SEX: Female  WARD/ROOM:

NURSE
DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE  SIGNATURE

03/30/21      
Risk for D - received patient conscious, coherent; with elevated temperature and she in pain.
4:15 pm infection  
     

     
A - TSB was provided if client’s temperature keeps on increasing to be monitored via
    digital thermometer  

4:55    

6:00    
     

     
R - the client verbalized comfortability and sense of well feeling as manifested by
    cheerful attitude and good affect.. Referred to Dr. X for reassessment  

       
 NURSES' NOTES
PATIENT NAME:
lilibeth AGE: 36 yrs HOSPITAL NO.:
PHYSICIAN: Dr. X SEX: Female  WARD/ROOM:

NURSE
DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE  SIGNATURE

03/30/21      
Deficient fluid D - received patient conscious, coherent; with excessive blood loss and blood
4:15 pm volume pressure dropped rapidly.   
     

     
A - Maintain a bed rest with an elevation of the legs by 20-30° and trunk
    horizontal  

4:55   A - blood transfusion was given as per doctor’s order  

6:00    
     

    A - IV fluids was given as physician ordered  

R - the patient was able to maintain fluid output, cardiac output and stable vital
    signs. Referred to Dr. X for reassessment  
       

NURSES' NOTES
PATIENT NAME:
lilibeth AGE: 36 yrs HOSPITAL NO.:
PHYSICIAN: Dr. X SEX: Female  WARD/ROOM:

NURSE
DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE  SIGNATURE

03/30/21      
Decreased cardiac D - received patient conscious, coherent; with excessive blood loss and
4:15 pm output blood pressure dropped rapidly.   
     

     
    A - Provided adequate rest and reposition client  

4:55   A - Provided Elevated head of the bed  

6:00    
     
     
R - .The patient was able to maintain cardiac output and stable vital signs.
    Referred to Dr. X for reassessment