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  • Nurses Notes

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    Elva Borlado Bilocura
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    The nurses notes document the care of patient Princess Daniella Poliran over two days. On the first day, the nurse found the patient weak with an IV and encouraged safety measures like keeping the bed rails up. No falls were recorded. The next day, the nurse noted the patient was sleeping with rails down and instructed the mother on using bed rails and changing linens for safety, while encouraging increased activity tolerance. The patient reported no falls and increased activity.

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    nureses notes

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    The nurses notes document the care of patient Princess Daniella Poliran over two days. On the first day, the nurse found the patient weak with an IV and encouraged safety measures like keeping the bed rails up. No falls were recorded. The next day, the nurse noted the patient was sleeping with rails down and instructed the mother on using bed rails and changing linens for safety, while encouraging increased activity tolerance. The patient reported no falls and increased activity.

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    © All Rights Reserved
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    5 views3 pages

    Nurses Notes

    Uploaded by

    Elva Borlado Bilocura
    The nurses notes document the care of patient Princess Daniella Poliran over two days. On the first day, the nurse found the patient weak with an IV and encouraged safety measures like keeping the bed rails up. No falls were recorded. The next day, the nurse noted the patient was sleeping with rails down and instructed the mother on using bed rails and changing linens for safety, while encouraging increased activity tolerance. The patient reported no falls and increased activity.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 3

    Date Time Nurses Notes Signature

    Sept.14,202 6:00am FOCUS:


    3 Risk for fall

    DATA:

    Received patient on bed awake, weak in


    appearance with side rails down, with IVF at right
    metacarpal vein of D5LR .03% 0 at IV level 270ml,
    regulating 80cc/hr, flowing well.

    ACTION:

    - Encouraged the mother to be alert.


    - Instructed to side rails up at all times for patient
    safety.
    - V/S taken and recorded.
    - Bedside care done, removed unnecessary things on
    bed, all bags placed at the cabinet.

    RESPONSE:
    - Patient asleep, comfortable and relaxed.
    - No falls recorded.

    Patients Name: Poliran, Princess Daniella


    Date Time Nurses Notes Signature

    Sept.15,202 8:00am FOCUS:


    3 Activity Intolerance

    DATA:

    - Received patient on bed asleep with her mother


    and own linen used.
    - Side rails down while patient sleeping.
    - Patient has a newly hooked D5LR 1L regulating
    80cc/hr at right metacarpal vein, flowing well.

    ACTION:

    - Instructed mother to ask another linen.


    - Adviced mother to side rails up for patient safety.
    - Encouraged patient/mother for techniques to
    enhanced activity tolerance.
    - Pt. instructed to report measurable increase in activity
    Tolerance.

    RESPONSE:
    - Have linen and bedside care done.
    - No falls noted.
    - Pt. reported increased in activity tolerance

    Patients Name: Poliran, Princess Daniella

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