Medical surgical Nursing Department

‫قسم التمريض الباطنى و الجراحى‬ Nursing Notes

Student name:………………………………………………
Patient name:…………………………….. Age:……………. Date of admission:………… Room No:…………….
Diagnosis:………………………………… Sex:…………….. Operation date:……………. Bed No:……………….
Diet:………………………………. Level of activity:…………………………………… Hospital No:……………..

Date Nursing diagnosis Patient’s goal Nursing interventions Evaluation

Moderate pain in the head. The patient will state 1- Respond immediately to complaint of
that the pain is pain.
decreased. 2- Eliminate additional stressors or sources Not solved
of discomfort whenever possible.
3- Explore non-pharmacological methods
for reducing pain/promoting comfort: -
• back message
• slow rhythmatic breathing
• imagination
4- Diversion activities such as music, TV.
5- Provide rest periods to facilitate comfort,
sleep, and relaxation.
6- Provide rest periods to facilitate comfort,
sleep, and relaxation.
7- Teach patient to request analgesics
before pain becomes severe.

Nursing Student’s Signature

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Medical surgical Nursing Department

‫قسم التمريض الباطنى و الجراحى‬ Nursing Notes

Student name:………………………………………………
Patient name:…………………………….. Age:……………. Date of admission:………… Room No:…………….
Diagnosis:………………………………… Sex:…………….. Operation date:……………. Bed No:……………….
Diet:………………………………. Level of activity:…………………………………… Hospital No:……………..

Date Nursing diagnosis Patient’s goal Nursing interventions Evaluation

Disturbed sensory perception The patient will regain the 1. Encourage the patient to see an
related to visual impairment. optimal vision possible
ophthalmologist at least yearly.
and will adapt to Not solved
permanent visual changes. 2. Provide sufficient lighting for the
patient to carry out activities.
3. Provide lighting that avoids glare
on surfaces of walls, reading
materials, and so forth.
4. Provide night light for the patient’s
room and ensure lighting is adequate
for the patient’s needs.
6. Provide information about laser
surgery.

Nursing Student’s Signature

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Medical surgical Nursing Department
‫قسم التمريض الباطنى و الجراحى‬
Student name:………………………………………………
Patient name:…………………………….. Age:…………….
Diagnosis:………………………………… Sex:……………..
Diet:………………………………. Level of activity:……………………………………
Date Nursing diagnosis
Anxiety related to
hospitalization as evidenced. able to state that
by restlessness and
inability to concentrate,
nervousness and tension.
Nursing Notes
Date of admission:………… Room No:…………….
Operation date:……………. Bed No:……………….
Hospital No:……………..
Patient’s goal Nursing interventions Evaluation
The patient will be 1- Use simple language and brief statements when
instructing patient
anxiety is decreased. about self-care measures or about diagnostic and Not solved
surgical procedures.
2- Encourage patient to talk about anxious feelings.
3- Assist patient in assessing the situation
realistically and recognizing factors
leading to the anxious feelings.
4- Discuss alternate strategies for handling anxiety.
5- relaxation techniques and exercises: -
• deep breathing exercises.
• listen to music.
• take a warm shower.
6- Provide reassurance and comfort.
7- Provide calm relaxed environment.
8- Speak slowly and calmly.
9- Orient patient to the environment and new
experiences or people as needed.
10- Give brief explanation about disease process
and patient progress.
Nursing Student’s Signature
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Medical surgical Nursing Department

‫قسم التمريض الباطنى و الجراحى‬ Nursing Notes

Student name:………………………………………………
Patient name:…………………………….. Age:……………. Date of admission:………… Room No:…………….
Diagnosis:………………………………… Sex:…………….. Operation date:……………. Bed No:……………….
Diet:………………………………. Level of activity:…………………………………… Hospital No:……………..

Date Nursing diagnosis Patient’s goal Nursing interventions Evaluation

Relative Constipation The patient will pass - Encourage a regular time for elimination.
soft formed stool at a - Provide adequate fluid intake 1500:2000
Related Factors: - frequency perceived as cc/ day unless contraindicated. Not solved
Inadequate fluid intake, normal by the patient. - Encourage patient to consume high fiber
Pain, diet to promote digestion vegetables and
Inactivity, immobility fruits.
- Encourage physical activity and regular
As evidenced by: Passage exercise as tolerated.
of hard formed stool, - Encourage isometric abdominal and
decreased bowel sounds gluteal muscle exercises.
- Promote patient privacy.
- Avoid dehydration by avoiding
dehydrating liquids such as soda, coffee, tea
- Encourage patient to have regular
mealtime.
- Encourage patient to use bathroom
at a regular time.

Nursing Student’s Signature

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Medical surgical Nursing Department

‫قسم التمريض الباطنى و الجراحى‬ Nursing Notes

Student name:………………………………………………
Patient name:…………………………….. Age:……………. Date of admission:………… Room No:…………….
Diagnosis:………………………………… Sex:…………….. Operation date:……………. Bed No:……………….
Diet:………………………………. Level of activity:…………………………………… Hospital No:……………..

Date Nursing diagnosis Patient’s goal Nursing interventions Evaluation

Excessive accumulation of
fluid (pitting edema, grade 2)
Evidenced by: - increased
body weigh
the patient will - Assess vital signs and breath sounds
state that edema is
every 4 hours. (BP and HR)
decrease and retain Not solved
normal body - Monitor intake and output every 4 hours.
weight
- Change patient position every 2 hours
- Elevate the edematous part
- Put patient in semi fowler position in
case of ascites
- Restrict fluid intake
- Limit sodium intake
- Increase protein intake

Nursing Student’s Signature

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Medical surgical Nursing Department
‫قسم التمريض الباطنى و الجراحى‬
Student name:………………………………………………
Patient name:…………………………….. Age:…………….
Diagnosis:………………………………… Sex:……………..
Diet:………………………………. Level of activity:……………………………………
Date Nursing diagnosis
sleep pattern disturbance
Related to hospitalization,
Pain, change patients
lifestyle, anxiety
Evidenced by decrease
concentration, fatigue
Nursing Notes
Date of admission:………… Room No:…………….
Operation date:……………. Bed No:……………….
Hospital No:……………..
Patient’s goal Nursing interventions Evaluation
the patient will 1- Provide calm, clean, and comfortable
report optimal
environment
balance of sleep Not solved
2- Encourage warm bath and back care
before sleep
3- Limiting intake of caffeine and tea prior
to sleep
4- Arrange nursing care to provide
uninterrupted sleep.
5- Avoid eating heavy meals before sleep
6- Encourage day time activities
Nursing Student’s Signature
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Medical surgical Nursing Department

‫قسم التمريض الباطنى و الجراحى‬ Nursing Notes

Student name:………………………………………………
Patient name:…………………………….. Age:……………. Date of admission:………… Room No:…………….
Diagnosis:………………………………… Sex:…………….. Operation date:……………. Bed No:……………….
Diet:………………………………. Level of activity:…………………………………… Hospital No:……………..

Date Nursing diagnosis Patient’s goal Nursing interventions Evaluation

High risk for infection Patient will be free from 1. Monitor temperature 9 hrs.
as iv-line infection. sight and symptoms of 2. Report abnormal changes in WBC
infection as evidenced by count. Not solved
level of WBC and normal 3. Good hand washing techniques.
body temperature. 4. Observe and report sings of infection
such as readiness warmth and Inc in body
temperature.
5. Assess skin for color moisture texture.
6. Use proper hand washing techniques
before and after giving care to Clint.
7. Follow standers percussion and wear
gloves during any contact with blood.
8.vistors and health care providers with
active infection are to avoid contact with
patient.
9. Encourage high protein high
carbohydrates food when indicated.
10. Encourage fluid intake of 2000 to
3000ml per day unless contraindicated.
Nursing Student’s Signature
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Medical surgical Nursing Department

‫قسم التمريض الباطنى و الجراحى‬ Nursing Notes

Student name:………………………………………………
Patient name:…………………………….. Age:……………. Date of admission:………… Room No:…………….
Diagnosis:………………………………… Sex:…………….. Operation date:……………. Bed No:……………….
Diet:………………………………. Level of activity:…………………………………… Hospital No:……………..

Date Nursing diagnosis Patient’s goal Nursing interventions Evaluation

Knowledge deficit Patient will acknowledge 1. Administer basal and prandial insulin.
about diabetic diet key factors that may 2. Watch out for signs of morning
contribute to hyperglycemia. Not solved
unstable glucose levels 3. Teach the patient how to perform home
glucose monitoring.
4. Instruct the patient to avoid heating pads
and always to wear shoes when walking.
5. Instruct patient on the proper injection
of insulin.
6. Educate patient on the correct rotation of
injection sites when administering insulin.
7. Instruct the patient on the proper storage
of insulin.
8. Instruct patient that insulin vial that is in
use should be kept at room temperature.
9. Stress the importance of achieving blood
glucose control.
10. Explain the importance of weight loss
to obese patients with diabetes.
Nursing Student’s Signature
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Medical surgical Nursing Department

‫قسم التمريض الباطنى و الجراحى‬ Nursing Notes

Student name:………………………………………………
Patient name:…………………………….. Age:……………. Date of admission:………… Room No:…………….
Diagnosis:………………………………… Sex:…………….. Operation date:……………. Bed No:……………….
Diet:………………………………. Level of activity:…………………………………… Hospital No:……………..

Date Nursing diagnosis Patient’s goal Nursing interventions Evaluation

Anorexia the patient will
Imbalanced nutrition less than return to normal
body requirements Related to eating habits.
hospitalization, anxiety and
stress, medications Evidenced
by weakness and fatigue
1- Provide small frequent high caloric meal.
2- Avoid drinking fluids 2 hours before eating.
Not solved
3- Provide favorite food and encourage oral.
hygiene 4- Provide variety of different foods
to stimulate appetite.
5- Provide clean, odorless, and well-ventilated
environment.
6- Serve food in attractive manner
7- Encourage eating in groups as family,
friends.
8- Administer appetizers as doctor order.

Nursing Student’s Signature

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