NURSINGNOTES

Isitawretinrecordpreparedbyhtenursnigsatfregardnighteobservaoitnsofhte
ofnieuvtohletasw
lasele,attsem
andonm
ailo,tale,ntpcalhyisrheitacountinagkit ,entipat
.eracndaesaesdi
Thedaylinursnigcaresiofetnrecordedonaspecaislheedtesginaetdfohtrsi.
nisrun ,noi tcnuf

Subejvcites
Objectives

.tahniodhw
esxyeptslfrentiphaw teushsatleltadvatS eiuectbj
m
heitlohbfetsonfbivgesratnis,unm
adlcietvesuioaecbhtusjr
m
ousaepsoenrnetiptanadn,gsdifcpahoigrdairnadyortaborlm aeht,thlae
[Link]

objectives
ocnhis.K
etadncroeim
gnd'fw
rtpehisaetpniarde
Leavearecordoftheproblemspresentedbythepatientandthecareof
[Link]
Colaboratewiththedoctorinthediagnosisofthepatient.
Sevreasniofm r oaitnotnhoitediflohfehatladsocument
.cinseorf
Researchstudies.

M
IP
O
N
R
N
A
U
TO
G
N
R
IC
T
S
F
E
S
nelslise'nphitaetoehvnieuftT
oaleso
pIorvdiedniofm r oaitnohtehehaetlamasceicnafintdelgdalocumen.t
psiotIsbiodetlenyfhitepeansite'teds

COMPONONESDELASNOTASDEENFERMERA
I
D
eta
Hour
Content
Company

THECONTENTOFNURSINGNOTESMUSTCOMPLYWITHASPECTS
FOLLOWING:
Observations made at the time of the patient's admission
General condition of the patient taking into account their physical and emotional state.
Medication and treatment reactions
Hygiene condition and care provided
Objective and subjective observations
Effectiveness of certain medications or treatments
Teaching delivered and support provided and evaluation of learning.
 osnm
[Link]'entiphaetcnordgyvielipdtiecsranesoT tnheus'r
hosnIpgast,liennearu,lnsrignoetrscodrhteoflwnigytpeonsifom
r oaitn:
nkhse)itdrPoneafglse,.(fantsueginorfvbutneidP
aylitat
[Link] ,ecaf
gnisrun tnednepednI
[Link],iaotf
i gnisrun tnednepD e
adocot.r
Evaluationoftheefectivenessofeachnursingintervention.
Measurements taken by the doctor (e.g. shortening of a postoperative drain tube).
Vsotihfeahtelammembers(egd..ocotscro'nsuatolinp,hysoihterapsos,itcaw
ilorker)
.)laoics
Insummarya,nursnigapproachfocusesonhtereasonsandacviteitsofcare.
csdeng,viiecrsi nteitpahet thatngisnur
.sisongaidlacm ideht fotluser

A
hITECNN
IEFO
ER
S H
SMA
T NCOI
E
S
GIUEINTE:

Anychangenibehavoir:

snoi tm
oe gnor ts fo snoi tacidnI
Importancthangesinmood
Achangeinthelevelofconsciousness
Anychangeniphysciafulncoitnnigsuchas:
L baonlfcse
Lernstghotsf
Auditory-visualdifficulty
Anysginorphysciaslympotm:
Seagarvneiet:njsepani
Anincreaseinbodytemperature
Gardw uaolgseiht
gyuserertafenatiurotytinlaIbi
Anynursnignietrvenoitnprovdiedsuchas:
Medications administered
m T eatrsent
Educaoitn

PLEASE
FL
IL
OUTHE
COMPLETE
FORM
BY
ANSWERN
IG
LASSIGUENTESPREGUNTAS:

ng?doinetiptahetH
sow
i

?refer netiptahetdosew
nadhtavereobsyoW
udohta

do?hesh/eW
dosehta

?tiyastih/H
esh/eow
dose
 THEASPECTSEVALUATEDINTHEWRITINGOFNURSINGNOTES
SON:

SystematicQuestions
Lcsogi
Clear
Concrete
Youned
Briefs
Objectives
oL
niodagtroiecgali
Thevocabualryhtasitechncial
angulageC earl
Avodiabbrevaioitns

IMPORTANTASPECTSWHENWRITINGANOTE

m
[Link]
ikedarhw
oadntesianitoA tll
TheycadniehynfticethangT [Link] subeslgtbaielndundeasrtndabel.
,yl lauU s .esaE
Youshoudlnowaskanohteprersonwhohasnoethsactorespondotyousni,ce
Them r aybaenheontrieorfm
roahitne;osehtoudblm
[Link]
.nteitpahet orferachet
[Link].
fo s t ruoc ehT
Regsiethrteniformaoitnaccordnigothtesequenceniwhcihoticcuredht,[Link]
hw etyohdpmrfetponrdcevairde.
s i t I
nm ofestraknhigtsuebsequegrachnepsyrom
taideortfb,sliaknigm
asktiaensd
[Link]
urlsifvm
oarw
nfoinm ascuihtgm
ensiiatul
Frequentnursingnotesandrespecthospitalproceduresin
aht lavretnm im
uniehtot evitaler
w eoadnbitroatneodm lnoaihfpgtenriate.
Sginficannitformaoitnregardnightepaeitnsc'tondoitnandsatetofheahtlhasbeenrecorded.
OmitwordslikeOneorhe.
Thepatients' nameisomited,eachpageofthefilehasthepatients' nameand
nhetodtsurndesi tI .atdaonitacifintdei
.entipat
choetm
onfeialcpohafonm
[Link],aeikrlerehinetoutlF li
hetm
[Link]
Donootverwretiwordsn,orwretiabouhtemb,eetrdrawasrtagihnilteoverhteword.

ACCURACY

s i t I
nopofdaetnsi o,nsivtaorebsxetcaorstcafoftsocinsylxetca
AnoA [Link]
[Link].
.yornaitcdkiachew
houdlshoetw
rursitr
 INTEGRITY

YoucannogitnorehtedaathtaatnursecoelcstabouatpaeitnH
.t owevehtr,e
aht noi tm arofnI
owrvencatsisaerachtlahenidvenvoli sw rkendaorsesnur
erT
coscdyarhnbetpuA
do'iecastm
[Link]
ooclhetm ahe,outnm
i,ethetudenlci(vdeom
w
thsahionetiptaaorfocem tepl
.)netiptahet baoutadtahreotnaynadng,ivom ti

ImporatnR t emnider:
Fromalegalpointofview,anursingnotewelwritenandtimely
m
oiethet tatuporssaveres lw
liti
catnbidaeoubel-dgedswohdrctathnesiarvyeounoicm
riniayetonsiuch,tencirlcaoldr
arecordnisrutmenw thteilgm ailpcilaoitnsandhtenursnignoetsheseit
dedulcni ni het

ExampelsofNursn
igNotes:
 PhysciaE lxamniaoitnofHeadandNeck
Head
Anaotmy
[Link]
om
[Link]
googpidghlerit,folheyrcoatfliderfnsaicyha,tejundm csieaskedbghyitlhet
.alciifitar

uechostadeqrxnib:codupnafhtlriesm
tclnoIni,ait
INSPECTIONS
:hape(symmetrcias)zli,etu,morh
s,ariatleratoinsk
,n
iatleratoins,
ndhsahbothm
w
tordfierpesiA
PLA
tPO
T
.IIrNaul:csvandabone,ounseautbcs
obfospitregnifehthtw ignilevart
t la roylm oana yadot
g i d a
seacrhnigofborlwhctsatnervecaolmpelxmaoflm
roaitn.

SKN
I
 T om
exhnm
[Link],ot
Cautiouslyeverycentimeterofthefacen,ecke,arsandbehindthelobesinsearchof
onvierntiorscabrnurn,saitsylarculiptarosm n,iesle
.esiguersouevpsir

TheHAIRBODY

plap dna tcepsni W e

zeiS
sym
Shap,oesram
n,ypairhew
toutym
ielcanrfosvelksulyrhai
Characteristics
of
the
scalp,
whether
is
itnormally
implanted,
if
there
are
scars.

SCALPLESIONS:

Aolpecai:IsitnfalmmaoitnandolssofharifocilelsC
. nilciaylsitu,suaylobserveda
ilolfofnum herbtniesaercdeahw tib,odyyriha
detceffahoem
rtfm
asseoypsblinivdeorbsyonleraonsitaretlaofseacThe

ELOJO
xanm
dnetipathetofonrtfnhiem
tvoenslistpoihdsulodrhctet ey:shetgnm
iofalnodentitPois
[Link]
iofalnodneittpois

het fi ,eursif labrpelpahet ofudetm aiEhpelytdeim lxaeni

cm
badnehsyietlow
fvhiedctm
av,nuedahl,tsyielocfhoertlde,syiel
ocoum lanadbIndvIeourtcneV vers.I
Conjunctviaandscelrao:w loutkhepaw
ntskiathdehlsciends
owT
eht tcepsni W e
W T [Link],sudniohejvntsiecm
[Link]
tilbipaceraerhet fi tcpensi lw lieC ng,irghtyistalC lqueieloblahrw ti
obncorc
i s eht tcepsnP iupsW :lie
Thabdcnokm [Link]
apbcdvhew
radm
[Link] rsient
.scahisroutsdnihcaoeW stnrhpvaoisteaylhvautel
f e yE
utatislacogiolnuerousiresyllapices ,sebatedion,inesthypre
niartcarnhailypetrnosin.

an
E
u
aesd
b
jiryn
eoersm
itial

nhem
tudesyalnci seusacstI [Link] ofsPiostsP
:it
nevroimootorcualcrommonanddamageosfympahtcenitnevroaitnH
( onrsye'rndorme.)

Nystagmus:Isitarhyhtmcioscalioitnofhteeyesa,naolgousotrtemorsofohterbodyregoins.
csItauseasremupiatelm
, ongohtevrsoindsuitrbancenhistnseaitglieosf
m
dopiarni tceobjnataokslonsrpew
anhesurcontvA
en
 HEARD

TheexetrnaelarsiexamniedasparotfhtegeneraelxamniaoitnofhteskniofhteheadandneckP
.oainvli
aurciualrWneeodtebsciw
reyhtpadoetfom
rhntsheiy(taiphcanotesuhifpaop,claofw
eifle)r
nuntcsdfyeroti,n
ga)ueslrovm
tehc:salorobsel ,sraehetof(aihsaypoloraiganes
k a T
[Link]:n,sgm
oeham
rorh,yas,lpinoysaech-rypesrevnitesi.
externaaludtiorycana(E l AC)Thaelsneridexpolerdbacukp,andoudsite.
ohectsop tedescribethecolorofthemucosa,thepresenceorabsenceofhyperemia,andrugosities.
hemohragelosi,nsesc,oeritnw
(soudlgaronot,hrea.)

Otorrhea:nonh-emohroalgfw
cioM
([Link],asm
,urenl,)tohuaontsm
t oer
abundan.t

Otorrhagia:Otitismedia,traumatic(scratched,foreignbody,wounds)
huthm
[Link]
oinahuetdi
t s der iuqer ehT
em
norlahet saounds,drhaangiorvcesdiorf ntellexc
movement of the fingers.

Nose

ObsevrcstoeinotuarndsymmW [Link],lhetepeahsinte'tadgislhyl.t
dsoinbeatIckwadrnhtdeispnhow
tesiboncatsfevlrnheidtIogew
[Link]
noi tanm uilsnart hguorht
um
[Link]
Thetm r nipalem r [Link]
hntzem
aireancriseotmevpnrytiehasw ltceohfnidows.
PATHOLOGE IS

ngilefaon,itR
osngcelh asnaiontosrefrerhgenaeiaadr:N
lasa
doetnoiuabritncst.

Nap saloylps:oft masses that develop in the nasal mucosa or in the sinuses
[Link]

n eht fo noi tR
m
aahlinfitnis:i

LABOCA
Inhtemouhtarehteotngueht,eetehtht,egumsht,esavilarygalndsare:
usbeuidm
rpt,ioA
asdrtnuishgbeavs3nud,lt.be2au,lirl
hcaenI .orirenfi rhenotaom
cndaopm tonrteirupesani
m an6pem
[Link],slcnaro2e,sil,osnrci4de:si

,ym
lascibem
rm
tetusti ,yhtum
ndaiioroclstivereobsyouTfp
h
ils:e
t dias s i t i
 BucaL aolfphaelm
tandgm
ihitgsou
w
hlodtu'cenoitexpahm
tetnei
hptearsndqhlciuseptogc,[Link],arl

s mu G
nig eht tcepsnI
ucleraoitn.

ni sngheaceraerhet fikcheoteblisposT iheth tI:

decnaoltnpeluglayhrnteidexnim entsti
.
Thotenogtnu hgW
crtoekuiw
:[Link]
eripastnkiaetcetsm ayr,et
hypongT oevlsarw
[Link] tnege,auolhtcnoegsaofuespahtseaokfs
hydoaritT [Link],eneeasredescbired
.snlguaiubls

Larynxw kom
ethrpatneskiatoouhptoew
bntckuhngiw
rtoesuie,atske
ofcenastheO
[Link]
hnarxletelesoteablbelyw oulioB s,ndag"[Link]"bots
e,patvhlW
aetgX
[Link],patlostf
a roi retna eht
ung,ilw
sle,extudeasierhet fivereobsndyam sym rte
ornidiautromfearobpulhcoaisnepuw
m
ytirepnatIle,nt
[Link]

ORALCAVITYLESIONS

w cansc,[Link]
tvrioham
lretoiensflopatsnotr
cum
re,caitaelvlaplaheitofonrtfangluihagetboafhcketspectrylgeanm lbrhuetho,ut
hetndasdeisheteraonsitaoclderrefeprhet
ofnciupsiesairhsdounlm
iA
[Link] tho,ut
.nacre

oecafursThegum .hest ofytviitinseshrypendasdnerG bydeziniregtcaivrhacitis:i

het ofnm girhaeom trfdeblotysaesi tI
oepardw
oslbacn([Link]
)eulanreti
gum
[Link]
w
btleiyym
leltaladeozintihornedsxethtathsyaigr

THENECK
Headandneckexamsshouldbecomplementedwiththefrequencywithwhichsome.
ro ,ecaf ,daH e
nsietIededotersotesxamnihetenecakm
s, uscaelps,oneuoracliyteasrndurstcuters.
erayhetnda,gnsis lachoiw
psysesaesdinousgialiC tra
.seosecprlacogiholptahw ti

noitcepsnI
Starbtyexaminingtheneckforsymmetrys,welingp,ulsationsf,istulasor
fo snoi tat m ii l
ezognicerotysaesi ti d,oidm
tisealnocrets
 Isitmporatnotdienfityhtefoolwnigsrtucutresht:esetrnoceldiomasotdimuscelht,ebone
hyodibonhtey,ordicalgiartceh,ecalv,ceialndpuselof
bublocaodrainthdtrpioitnhroseufbcalvainaetyr.

n
Iu
esjri

ToT [Link].
Thntepocnahstrfcilkndoasctreigudftom
cuieanrdt,panedi.
asyam
fclim nehaifgctdrm eaisyre;tnshied.

ThyroidGland

Thethyroidcanbepalpableinthinpeople,oneithersideofthetrachea,asamass.
mrniosfw
ktylsolawnigmovem
noibenps;etow
pesnhlaeotcirk
[Link]
otghtii

Whenobservnightenicreasenivoulmesti,hape,xetnsoina,ndconsietncymusbtedeetrmnied.
vascularization. The examiner positions themselves behind the patient and does their best to identify
hcraes neeuqar taL
ThL
yd
orn
ies

[Link]
-oretna eht ni m
ruot