Nursing Notes
Date of admission: 18/02/2024
Date of Clerking:20/02/2024
Time: 08:30AM
S:
Name: Mrs. X, day 2 in ward
Age: 33yrs old.
Sex: Female
Address: Ekwendeni village near primary school
Presenting complaints: Cough, Vomiting and Headache
History of Present Illness:
The patient says she was well until 2 days prior to admission when she developed
cough which was followed by headache and vomiting the next day. She reports
having non-productive cough associated with chest pains; has generalized moderate
headache. She vomited yellowish vomitus 2x yesterday and 3x today. Eating spicy
foods aggreviates her vomiting. She took paracetamol 2 tablets at home with only
short time relief.
Past Medical History: she is HIV positive and on medication. She reports good
compliance to medication. She has no history of Hypertension, Diabetes, Heart
Disease, Asthma, Renal Disease, Thyroid Disease.
Surgical History: she has no history of operation, injury or blood transfusion.
Medication allergies: She has no known allergy to medications, or food stuff
Other histories…………etc
O:
General Survey: Well appearing, well nourished, in no distress. Oriented to
place, time and person, normal mood and affect. Ambulating without
difficulty.
Vital Signs: T-39.5oC, P-80beats/min, R-24 breaths/min, BP-110/60mmHg
Height: 166cm, Weight: 60kg BMI: 22kg/m2
Skin: Good turgor, no rash, no unusual bruising or
prominent lesions
Hair: Normal texture and distribution.
HEENT:
Head: Normal size, no bruises, no visible or palpable masses, depressions, or
scaring.
Eyes: pink conjunctiva, no jaundiced sclera, no discharges or hemorrhages,
able to see clearly
Ears: no discharges, hearing intact.
Nose: No external lesions, mucosa non-inflamed, no discharge
Mouth: Mucous membranes pink & moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease. No gingival
inflammation
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged
and non-tender
CHEST
Inspection: Symmetrical chest movements
Heart: regular rate and rhythm, no murmur or gallop
Lungs: Clear to auscultation in all lung fields and resonant to percussion
Upper Extremities: No amputations nor deformities, no cyanosis, edema or
varicosities, peripheral pulses intact
Abdomen: not distended, active bowel sounds, no tenderness, no
organomegaly (spleen & Liver), no masses, nor hernia
Back: Spine normal without deformity or tenderness
Lower Extremities: No amputations nor deformities, no cyanosis, edema or
varicosities, peripheral pulses intact
Genetalia: clean, no abnormal discharge, no painful urination
A:
Assessment
Problems identified:
1. Tachypnea (24breaths/min)
2. Fever (39.5oC)
3. Vomiting
4. Headache
Nursing Diagnoses
1. Altered thermoregulation (hyperthermia) related to antigen-antibody reaction as
evidenced by temperature of 39.5oC
2. Altered breathing pattern (Tachypnea) related to diseases process as evidenced
by respiratory rate of 24 breaths/minute
3. Altered body comfort (headache) related to disease process as evidenced by
patient verbalization.
P:
Date/time Nursing Nursing Nursing Goal Nursing Scientific Evaluation signature
Problem Diagnosis interventions Rationale plan/criteria
20/02/24 Fever Altered By the end of Explain the To promote Check body Y.S
9:00AM thermoregulation 30 min of condition to the understanding temperature
(hyperthermia) nursing patient/guardians after 30
related to interventions minutes of
antigen-antibody Mrs. X will Reduce clothing nursing
reaction as reduce body intervention
evidenced by temperature To reduce then 2 hrly.
temperature of by 1-2oC and heat through
39.5oC maintain Do tepid convection
effective sponging
temperature To reduce
of 36.5oC to heat through
37.4oC evaporation
Administer
Paracetamol To reduce
(Panado) 1 gram heat through
orally as vasodilation
prescribed
Tachypnea Altered breathing Mrs. X will Explain the To promote Assess Y.S
pattern have condition to the understanding respiratory
(Tachypnea) effective or patient/guardians rate and
related to improved effort every
diseases process breathing Nurse patient in To create 15 minutes
as evidenced by pattern semi-fowlers adequate for the first
respiratory rate within 15 position and space for hour the
of 24 min of loosen tight chest/lung hourly until
breaths/minute nursing clothing expansion normal
interventions ranges are
and achieved.
thereafter
Administer To help tissue
oxygen therapy oxygenation
4litres/minute if and meet
need arises metabolic
needs
associated
with illness.
Progress Notes:
9:05am Explained the condition to the patient/guardians and they demonstrate
understanding.
Bed making done
Nursed patient in semi-fowlers position.
Reduced clothing and tepid sponging done.
Cannular inserted, blood sample collected and sent to Lab.
Intravenous artesunate 144mg administered as prescribed
Paracetamol 1gram administered orally
_________________________________Y.Sikwese (ECOHS YR1 Student)
9:20am reassessed the patient she says is breathing better.
Checked Respiratory rate: 22 breaths/minute.
Maintained in semi-fowlers position.
_________________________________Y.Sikwese (ECOHS YR1 Student)
9:30am Temperature recheck 38.0oC
Pulse rate 88 beats/minute
Respiratory rate 20 breaths per minute
Blood pressure 108/65mmHg
Kept reduced linen and clothing
Encouraged to take frequent oral fluids and took 200mls of water.
Left the patient to rest.
_________________________________Y.Sikwese (ECOHS YR1 Student)
12:00pm Encouraged the patient to eat and took 1 cross of nsima with vegetables
well.
Allowed patient to chat with friends and family who came to cheer her.
02:00pm Vital signs recheck T-36.8oC P- 80beats/min R-18breaths/min BP-
111/68mmHg
She report no vomiting
Assisted the patient to take a bath.
_________________________________Y.Sikwese (ECOHS YR1 Student)
04:30pm Vital signs recheck T-36.5oC P- 82beats/min R-19breaths/min BP-
115/70mmHg
She report no vomiting, and reduced headache
Hand over given to Night shift staff
_________________________________Y.Sikwese (ECOHS YR1 Student)
Nursing review/notes
21/02/2024 7:30am
Day 3 in ward
Admitted with complaints of: Cough, Vomiting and Headache
Today:
S: complains of mild cough, no vomiting and no headache
No new complaint
Eating well
Passes stool and urine well
Has eaten porridge this morning and taken bath
O:
General Survey: fully conscious, well nourished, in no distress. Ambulating
without difficulty.
Vital Signs: T-36.5oC, P-80beats/min, R-18breaths/min, BP-110/60mmHg
Skin: Good turgor, no rash, no unusual bruising or
prominent lesions
HEENT:
Eyes: pink conjunctiva, no jaundiced sclera, no discharges or hemorrhages,
able to see clearly
Ears: no discharges, hearing intact.
Nose: No external lesions, mucosa non-inflamed, no discharge
Mouth: Mucous membranes pink & moist, no mucosal lesions.
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged
and non-tender
CHEST
Inspection: Symmetrical chest movements
Heart: regular rate and rhythm, no murmur or gallop
Lungs: Clear to auscultation in all lung fields and resonant to percussion
Upper Extremities: No amputations nor deformities, no cyanosis, edema or
varicosities, peripheral pulses intact
Abdomen: not distended, active bowel sounds, no tenderness, no
organomegaly (spleen & Liver), no masses, nor hernia
Back: Spine normal without deformity or tenderness
Lower Extremities: No amputations nor deformities, no cyanosis, edema or
varicosities, peripheral pulses intact
Genetalia: clean, no abnormal discharge, no painful urination
A:
Assessment: Improved
Plan: educate patient on balanced diet (6food groups)
Drug adherence
Rest and exercises
Follow up dates
Report back any danger signs.
8:30am education done to patient on
Balanced diet (6food groups)
Drug adherence
Rest and exercises
Follow up dates
Report back any danger signs.