NURSES' NOTES

PATIENT NAME: Lilibeth AGE: 36 year old HOSPITAL NO. N/A

PHYSICIAN: N/A SEX: F WARD/ROOM: N/A

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

04/15/2021 Fatigue D- The patient verbalized extreme fatigability and dizziness occurring at times
D- V/S taken as follows: T- 37.2C; RR-19; PR- 100; O2 Sat- 96%; BP-150/89;
FHT- 155 bpm
A- Assessed frequency of fatigue, the ability to perform ADLs, interference
with social and role function, times of increased energy, ability to
concentrate, mood, usual pattern of physical activity, and typical sleep cycles.
A- Evaluated adequacy of nutrition and fluid status to assess for dehydration.
A- Evaluated the patient’s sleeping pattern for quality, quantity and observe
alteration in thought process and attitudes.
A- Limited exposure to environmental stimuli, particularly during planned
time of sleep and rest.
A- Helped the patient in creating a normal routine and rest schedule.
Emphasize the necessity of taking regular breaks.
R- The patient verbalized that her energy increased and her vitality improved
her sleeping routine improved, her fatigue decreased and is able to perform
her usual routine.
K.M. COLLADO, Student
Nurse