Nursing Report Examples and Guidelines
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ScribdTranslationsNursing Report Examples and Guidelines
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ScribdTranslations• Nursing Annotation - Example l
28/08/2012 - 10am. The patient was admitted to the pediatric unit coming from the emergency room in her mother's arms.
from the mother, maintaining a peripheral venous catheter with a splint for fluid therapy and medication.
She appears pale and tearful. Mother guided on the routines in the ward, use
bathrooms, permission for a companion 24 hours and visiting hours. At 11:10 AM
presented a temperature of 39.2°C and was medicated with antipyretics and referred
for a warm bath. At 12pm he accepted 50 ml of juice and all the jelly; refused the meal.
At 1 PM, he/she presented vomiting in moderate quantity with a jelly-like color;
Nurse Marielle was informed. Signature and stamp.
• Nursing Note - Example II
28/08/2012 – 12:30 PM. A 65-year-old patient was admitted to the OS observation.
accompanied by family members, being transferred to a stretcher and kept in a supine position
elevated. Presents moderate respiratory discomfort on oxygen mask at 10
1/min and is hypochlorous. Family oriented on observation routines: the wife,
Mrs. Carla will remain as a companion. At 1 PM, venous access was punctured.
on the back of the right hand after four attempts, blood was collected for examination and installed
controlled infusion pump therapy. At 1:40 PM, a sample was sent for
blood for the laboratory. Signature and stamp.
• Nursing Annotation – Example III
28/08/2012 - 7am. Active, communicative, flushed, walking, the patient reported that
slept well, took a shower without assistance, maintaining peripheral venous catheter
for medication on the back of the left hand maintaining heparinized, the patient reports
Present urination and no bowel movements so far. Accepted all breakfast.
9:40 AM discharged from the hospital to home in private transport, accompanied
Parents, who were advised on the medication dosage, received tests.
radiological exams were communicated along with the date for the follow-up medical consultation. Signature and
stamp.
• Nursing Note - Example IV
28/08/2012 – 7:50 AM. Patient brought in by the emergency service.
pre-hospital care presenting generalized cyanosis and absence of
respiratory movements. Attended by the emergency doctor, Dr. Paulo Novaes, and
by the nurse. Cardiopulmonary resuscitation maneuvers were performed during
20 minutes, punctured peripheral venous access in the right antecubital region and
administration of prescribed drugs by the doctor, without success. Death confirmed by
Doctor at 8:25 AM, confirmed by the ECG. Family informed by the doctor along with
with a nurse; the presence of the social worker was requested. At 9am, the catheter was removed
venous, allowed the family's entrance and the death notice was forwarded to the department.
of records. At 9:30 AM, the body was sent for the death verification service,
route taken without incident. Signature and stamp.
Read also:Examples of Nursing Annotation
These were some examples of Nursing Report. It is worth emphasizing that the
nursing notes/nursing reports change every year, that is, take
care and always study, nursing is a field that is updated almost constantly
weekly, that is, you will have to dedicate yourself and study for it always.
The nursing report is both simple and complex in my opinion.
BELOW IS A MODEL WITH REPORT INFORMATION OF
NURSING OR NURSING NOTE.
CEREBRAL FLOW
BASIC INFORMATION FOR CREATING A CLINIC REPORT
DOCTOR
Patient
Sex
page number ...............
Conscious, confused, calm or agitated,
Hydrated or dehydrated, Hypochlorous or colored,
Time and space-oriented, it presents moments of confusion.
Cold or warm extremities.
Confined to bed or resting in bed, walking with assistance, or in a wheelchair
wheel.
Relating to the environment or communicating through gestures
Acianotic or cyanotic
Normotensive, hypotensive or hypertensive
Eupneic, dyspneic, bradypneic or tachypneic
Afebrile, febrile peak, febrile (greater than 37.8 º C)
Note if there was any abnormality or if the patient reports
Note to maintain venous access
Note if the patient has an intracath in the right or left jugular or subclavian vein
Note if the patient is on a catheter or oxygen mask or if they are in
continuous nebulization
Note if the patient has a nasogastric tube or if these tubes are for drainage or
gavage
Note if the patient has SVD or spontaneous diuresis, note the aspect and
debit
Note that the patient has a dressing, type of dressing, and present secretions.
observe if the wound is clean and dry or contains serous secretions,
bloody or purulent.
Note if the patient has drains, note the area, discharge, and appearance of the drains.
secretions
Record whether the patient accepted or refused the diet.
Note: if the patient is having bowel movements and with bladder eliminations present,
note only physiological eliminations present
Use a red pen at night.
Record schedules and all occurrences of the shift.
Take medication according to the doctor's prescription and check the medication at the time of administration.
administration.
Record each procedure performed according to nursing prescription and
when changing position, note the position placed.
Posted byONLINE NURSING - YOUR VIRTUAL MANUALto the21:097
comments:
NURSING REPORT - MATERNITY - PUERPERAL WOMEN
Purpura 2° DPPC, conscious, oriented, responding to requests
verbal, ambulatory, eupneic, without complaints (hemodynamically
stable, hypochloric (+2/+4), hydrated, afebrile, secreting breasts with
presence of colostrum. Upper and lower limbs free of edema, saline AVP in
MSD without inflammatory signs and without abrasions. Accepted the fasting.
normal physiological speech. Absent physiological intestinal elimination and
diuresis present at the moment (SIC), under care and observation of the
Nursing Team. (Signs your name)
Posted byONLINE NURSING - YOUR VIRTUAL MANUALat9:05 PM4
comments:
NURSING REPORT - PEDIATRICS
BELOW IS A MODEL OF NURSING REPORT, TO BE
USED IN PEDIATRICS.
STEP BY STEP:
1) TERMINOLOGIA: ( RN, LACTENTE, CÇA, PRÉ ESCOLAR, ESCOLAR)
ACCOMPANIED BY: (MOTHER, FATHER, AUNT, GRANDMOTHER)
3) WHERE IS (BED, CRIB, COUCH)
NOTE: IF IN THE BED OR CRIB, DESCRIBE BARS, RAISED,
DOWNTURNS.
4) COMO SE ENCONTRA: (CALMA, IRRITADA, SONOLENTA, CORADA,
Uncoated, icteric, afebrile, dyspneic, etc..
5) WHAT IT PRESENTS: (SCRAPES, BRUISES, PRODUCTIVE COUGH /
SAC, ABDOMEN BLOATED / DISTENDED / PAIN OR PAINLESS
PALPATION
6) WHAT MAINTAINS: FASTING, (SOROTHERAPY, AVP (MSD - MSE / MID - MIE)
(SALINIZED) - (WITH/WITHOUT INFLAMMATORY SIGNS), SVA / SVD (WITH DEBT IN
ML), DRESSINGS (TYPE: OCclusive, ETC..)
7) WHAT IT REFERS TO: (IN THIS CASE THE FATHER AND MOTHER REFER TO (GOOD ACCEPTANCE OF
DIET...), DIURESIS, EVACUATIONS (SIC)
8) MEDICALIZED ACCORDING TO PM
9) CONTINUES UNDER NURSING CARE
10) (SIGN YOUR NAME)
IT IS VERY IMPORTANT TO REPORT EVERYTHING DURING ADMISSION, LIKE THIS CHILD
IT HAS ARRIVED FOR YOU, THE WEIGHING MUST BE DONE EVERY DAY,
ALWAYS REMEMBERING THAT MEDICATION WILL BE GIVEN ACCORDING TO
THE WEIGHT OF THE CATCH. A LOT OF ATTENTION IS NECESSARY IN CARE WITH
Pediatric Patients/Clients.
TAKE CARE WELL - AN ACT OF LOVE
Posted byONLINE NURSING - YOUR VIRTUAL MANUALto the21:022
comments:
ABOUT THE BLOG
MY NAME IS KEILA, I AM A NURSING STUDENT, I LOVE THE PROFESSION
WHAT I CHOSE AND WOULD LIKE TO PRESENT THE OBJECTIVE OF THIS BLOG TO
YOU.
OVER THE YEARS, HUMANITY HAS BEEN DEVELOPING VARIOUS
WAYS TO TAKE CARE.
CARE MANIFESTS ITSELF IN ACTIONS AND IN PRESENT INTERACTIONS
IN THE LIFE OF EACH INDIVIDUAL AND IN SOCIETY, AIMING FOR THE
GROWTH, HEALTH, WELL-BEING, PERSONAL FULFILLMENT, THE
INSERTION AND SOCIAL CONTRIBUTION.
The interaction between individuals occurs through
COEXISTENCE, OF CONTACTS, OF REFLECTIONS, OF INTERPRETATIONS AND,
FROM THERE, CARE IS GIVEN.
CONSIDERING THE ABOVE DEFINITION, I CAN AFFIRM THAT THE
NURSING IS ESSENTIALLY CARING, BUT IT'S NOT THE ONLY ONE
PROFESSION THAT PROVIDES CARE.
WHEN WE THINK OF CARE, IT IS NECESSARY TO REALIZE THE
SCOPE OF THIS WORD IS, AUTOMATICALLY, TO DO
CORRELATION WITH ALL PROFESSIONALS IN THE HEALTH FIELD WHO,
TO PROMOTE HEALTH, IT IS NECESSARY TO DEVELOP CARE FOR
PATIENT FOR THE PROMOTION OF WELL-BEING, BOOSTING,
EMPOWERING AND QUALIFYING THE LIFE OF EACH PATIENT AND THEIR
FAMILY.
IT ALSO FALLS TO THESE PROFESSIONALS TO PROVIDE DEVELOPMENT
THE POTENTIALITIES OF EACH INDIVIDUAL AND OF THE GROUP HE IS IN
INSERTED AND THE CREATION AND MAINTENANCE OF A PHYSICAL ENVIRONMENT AND
SYMBOLIC FAVORABLE TO EXCHANGES AND GROUP GROWTH AND
PERSONAL.
THUS, ANY AND EVERY PROFESSIONAL INVOLVED IN
CARE QUESTIONS ARE DIRECTLY A CAREGIVER. HOWEVER, FOR
MAY THESE NEEDS BE MET EFFECTIVELY AND
EFFECTIVE IT IS NECESSARY THAT IT HAS THEORETICAL FOUNDATION,
PROFESSIONAL DEVELOPMENT AND COMMITMENT TO CARE.
THIS BLOG WAS CREATED WITH THE AIM OF ANSWERING QUESTIONS AND PROVIDING
SUBSIDIES FOR ALL PROFESSIONALS IN THE NURSING FIELD AND
To everyone who is still graduating.
WITH AFFECTION.
Posted byONLINE NURSING - YOUR VIRTUAL MANUALat20:59Um
comment
BREATHING
BREATHING (R)
CONSISTS OF A RHYTHMIC SUCCESSION OF MOVEMENTS OF
LUNG EXPANSION, FOR THE PURPOSE OF
CARRY OUT GASEOUS EXCHANGES.
THE PROFESSIONAL, IN ADDITION TO COUNTING THE MOVEMENTS
RESPIRATORY, CAN ALSO ASSESS A
QUALITY OF BREATHING (AMPLITUDE, RHYTHM AND
RESPIRATORY SONS.
NORMAL VALUES OF RESPIRATORY RATE:
AGE RESPIRATORY RATE (MRPM)
12 OR MORE 16 TO 20 MRPM
2 A 11 YEARS 20 TO 30 MRPM
UP TO 2 YEARS 30 TO 50 MRPM
EUPNEA = NORMAL BREATHING
TAQUIPNEA = INCREASE IN FREQUENCY
RESPIRATORY
BRADYPNOEA = DECREASE IN FREQUENCY
RESPIRATORY
APNEA = ABSENCE OF MOVEMENTS
RESPIRATORY
DISPNEA = RESPIRATORY DIFFICULTY
ORTHOPNEA = DIFFICULTY BREATHING IN
Lying position
OBS = DUE TO IT BEING A VITAL SIGN
VOLUNTARILY CONTROLLED BY THE PATIENT,
ONLY IN THIS CASE THE PROFESSIONAL MUST NOT
ALLOWING THE PATIENT TO REALIZE THAT THEIR
RESPIRATORY MOVEMENTS ARE BEING
ASSESSED. IF THE PATIENT IS AWARE OF THE INTENTION
FROM THE PROFESSIONAL, MAY CHANGE
CONSCIOUSLY THE FREQUENCY AND THE AMPLITUDE
RESPIRATORY.
This signal can be well assessed immediately.
AFTER CHECKING THE PULSE WITH THE FINGERS
STILL ABOUT THE PALPATED ARTERY.
BESIDES THAT, OBSERVE THE SKIN COLOR AND THE LEVEL OF
CONSCIOUSNESS, BEING INDICATORS OF LOW
LEVEL OF OXYGEN IN THE BODY.
THE BASE OF THE NAILS AND THE LIPS CAN ALSO
PRESENT AS BLUISH OR CYANOTIC.
Posted byNURSING ONLINE - YOUR VIRTUAL MANUALto the8:53 PM2
comments:
BLOOD PRESSURE
BLOOD PRESSURE (BP)
IT IS THE EFFORT OF THE BLOOD AGAINST THE WALLS OF THE ARTERIES THAT
CONTAINS.
THE STANDARD UNIT FOR MEASURING BLOOD PRESSURE IS THE
MILLIMETER OF MERCURY (mmHG).
SYSTOLIC BLOOD PRESSURE (SBP): THE PRESSURE AT THE MAXIMUM PHASE
FROM THE PULSATION
DIASTOLIC BLOOD PRESSURE (DBP): THE PRESSURE IN YOUR PHASE
MINIMUM OF PULSE (RELAXATION OF THE VENTRICLES).
DIFFERENTIAL BLOOD PRESSURE: THE DIFFERENCE BETWEEN SBP AND DBP
PAD
HYPERTENSION: HIGH BLOOD PRESSURE
HYPOTENSION: LOW BLOOD PRESSURE.
NORMAL BLOOD PRESSURE VALUES
AGE
up to 12 years 100/70
12 or more 120/80
MATERIAL FOR MEASUREMENT:
Sphygmomanometer
STETHOSCOPE
COTTON
70% ALCOHOL