how can i write nursing note?give me samples?

TazziRN, RN · Apr 10, 2006

This is something best taught in a classroom, not on a website. It's hard to make it understandable without being able to talk about it and explain as you go.

bethem · Apr 10, 2006

I'm a student and I was having trouble with them, too. A nurse suggested to me that you do "head-to-toe" notes:

Head: How was the patient behaving? eg, pt settled/unsettled/sleeping long periods this shift.

Mouth: Intake and output: Good oral intake/tolerating selective diet/NBM for surgery. Adequate urinary output. (Include IV fluids, catheter outputs, drains, etc). NG feeds given as charted.

Chest: Obs: Obs satisfactory. Afebrile. Nil respiratory distress. Limb obs satisfactory.

Body: Cannulas, medications. IV site satisfactory: nil redness, swelling or pain at site. IV abx given as charted. Medications given as charted.Panadol given for fever of 38.9 © and discomfort with good effect. Wound intact, staples removed as per doctor's orders. Dressing intact.

Feet/legs: How does the pt move? Where did they go? Ambulant with 1/2/FASF/ whatever. CT attended. X ray attended.

Anything else? Asthma education attended by Asthma Educator. Mother concerned that pt is being "overdosed" on Ventolin. Reassured mother regarding dose. Pt sat in Tumble Tilt chair for 1 hour as ordered. SaO2 remained satisfactory, > 90%.

Those are suggestions from a paediatric medical ward. I might have missed things that would be included for surgical, mental health, cardiac, or other types of nursing. Like the PP said, it's better to do it in person, but I hope this gives you something to be going on with. :lol2:

Daytonite, BSN, RN · Apr 10, 2006

http://www-isu.indstate.edu/mary/chart.htm - this is a sample of how to do a narrative charting of a head to toe assessment. it is for a patient with a recent cva.

http://www2.nursingspectrum.com/ce/self-study_modules/course.html?id=393 - "document it right: a nurse's guide to charting".

https://nursing.advanceweb.com/common/ce/content.aspx?courseid=251&creditid=1&cc=36532&sid=1095 - an article on documentation

https://allnurses.com/forums/1595750-post3.html - this is a post that has internet links to several sites that have samples of nursing care plans that you can look at