NURSES' NOTES

PATIENT
NAME: B.E.A AGE: 19 years old HOSPITAL NO.:
PHYSICIAN: SEX: Female WARD/ROOM:

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

04/06/2021      
Decrease Fluid D - received patient conscious, coherent and responsive to the questions; noted with increase blood
4:15 pm Volume pressure and appeared ankle edema and the vital signs as follow: BP-145/100mmHg, PR-120 bpm  
     

     
    A – Vital signs taken and recorded  

4:55   A – Provided environment without simulation and promote relaxation  

6:00    
A – Demonstrated relaxation techniques and guided imagery
     

7:00    
A – Methyldopa, Nifedipine, hydralazine was given as physician’s ordered
     

    R – Decreased or maintained blood pressure and patient feel relax and comfortable.  

       
 NURSES' NOTES
PATIENT
NAME: B.E.A AGE: 19 years old HOSPITAL NO.:
PHYSICIAN: SEX: Female WARD/ROOM:

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

04/06/2021      
Excess Fluid D - received patient conscious, coherent and responsive to the questions; noted with increase blood
4:15 pm Volume pressure and appeared ankle edema and the vital signs as follow: BP-145/100mmHg, PR-120 bpm  
     

     
    A - Vital signs taken and recorded  

4:55   A – Reported fluid volume input and ouput  

6:00    
A – Elevated the affected area by putting pillow
     

7:00    
A – Diuretic drug was given to treat excess accumulation of fluid
     

    R – Patient B.E.A was able to maintain the fluid volume  

       
 NURSES' NOTES
PATIENT NAME:
B.E.A AGE: 19 years old HOSPITAL NO.:
PHYSICIAN: SEX: Female WARD/ROOM:

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

04/06/2021      
D - received patient conscious, coherent and responsive to the questions; noted with increase blood
4:15 pm Anxiety pressure and appeared ankle edema and the vital signs as follow: BP-145/100mmHg, PR-120 bpm  
     

     
    A – Vital signs taken and recorded  

4:55   A – Established rapport to build trust  

6:00    
    A – Demonstrated relaxation techniques  

7:00    
    R – Patient B.E.A showed relax and comfortable after the nursing intervention