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  • Sample Nurse's Notes

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    Nicole Sherry M. CHEE
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    The patient was awake in bed receiving IV fluids and antibiotics for a post-operative infection. Their dressing was changed and found to be soaked. Vital signs and blood glucose levels were monitored and found to be stable. The patient reported pain and was given an oral pain medication, which relieved their pain. Their IV fluids continued and dressing remained intact as they rested.

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    Sample Nurse's Notes (1)

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    The patient was awake in bed receiving IV fluids and antibiotics for a post-operative infection. Their dressing was changed and found to be soaked. Vital signs and blood glucose levels were monitored and found to be stable. The patient reported pain and was given an oral pain medication, which relieved their pain. Their IV fluids continued and dressing remained intact as they rested.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    21 views1 page

    Sample Nurse's Notes

    Uploaded by

    Nicole Sherry M. CHEE
    The patient was awake in bed receiving IV fluids and antibiotics for a post-operative infection. Their dressing was changed and found to be soaked. Vital signs and blood glucose levels were monitored and found to be stable. The patient reported pain and was given an oral pain medication, which relieved their pain. Their IV fluids continued and dressing remained intact as they rested.

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    © All Rights Reserved
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    of 1

    09/05/20 8am Awake on bed c D5LR x 80cc/H, infusing well @ L

    metacarpal, 200cc, c dressing @ RLQ soaked with


    serosanguinous discharges, c foley catheter draining to
    100cc of yellowish urine, NPO maintained.
    9am Dr. __________ made rounds, orders noted.
    Dressing Changed by same, made comfortable after.
    9:15am
    D5LR 1L x 80cc/hr As follow-up, gtts. Regulated.
    Done, with result of 130mg/dL, SNOD_____ informed.
    10:30am CBG
    Afebrile, BP-110/90mmHg, PR-20bpm.
    12pm
    Complained of pain at the post-operative site.
    12:30pm
    Pain scale 8/10. Referred to SNOD___.
    Given PRN as advised.
    12:40pm Tramadol 100mg/tab 1tab
    Relieved of pain as verbalized.
    1:10pm
    Resting on bed, c foley cather in place, dressing intact.
    3pm
    Student Signature
    Robeanna M. Diesto CPUSN/ CI signature

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