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5 views10 pagesNursing Note Records for Patient Care
The document outlines the importance of nursing notes, which are essential for recording patient observations and the evolution of their condition. It emphasizes the need for accurate documentation of subjective and objective data, as well as the legal implications of these records. A clinical case example is provided to illustrate the application of nursing notes in practice.
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0% found this document useful (0 votes)
5 views10 pagesNursing Note Records for Patient Care
The document outlines the importance of nursing notes, which are essential for recording patient observations and the evolution of their condition. It emphasizes the need for accurate documentation of subjective and objective data, as well as the legal implications of these records. A clinical case example is provided to illustrate the application of nursing notes in practice.
Translated by
ScribdTranslationsCopyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
Note Records
Nursing
(Patient Condition)
By:
Lic. Rosselyn Camarena
Social Security Fund
Rafael Hernández Regional Hospital
Concept
Notes from
Nursing
They are a About
record observations
written of the patient
your state the evolution
care
physical, mental of the
provided.
and emotional disease
Everything the patient, family member, or caregiver expresses.
All observations in a cephalocaudal direction. It is noted that
abnormal.
Conclusions reached based on the subjective and the
objective (Nursing diagnoses are made)
What we propose to do to address disturbances.
Assessment of needs
Actions taken by the nurse or another member of the
health team as part of the therapeutic plan.
Check if the actions were effective, make a
comparison between the current and what was found in the 'S' and the 'O'.
Recheck if the problems were resolved and plan
new actions.
Data Types
SUBJECTIVE OBJECTIVE
They tell us what the What we observe from the
patient feels patient
the way it
express Example: the measurements
of the vital signs, e.g.:
Example: "I feel vomiting, diarrhea
bad. I have a lot bleeding etc.
pain
Objective Data
Keep a written record of the changes made in
the condition of the patient.
Document the issues presented by
the patient and the nursing care provided.
Provide information for the medical diagnosis of the
patient.
Importance of the notes of
nursing
We can assess the evolution of the
patient's disease.
It serves as information for the health team
as a scientific and legal document.
It is possible to identify the needs of
patient.
Important
•THEY CANNOT BE erased and
tacones, do not use corrections. In case of
error to pass a line over what was corrected,
(error)
Remember the notes you made in the
Clinical histories have legal character because
that must be clear and precise.
Clinical Case
Mrs. P.M., 49 years old, hospitalized in the Medicine ward with
Medical Diagnosis of Acute Pulmonary Edema, Presenting with Edema
generalized, receiving oxygen supply via Store at 8L/min FiO2
40. Receives Furosemide by catheter at 2cc/h and drip of
Nitroglycerin at 4cc/h for MAP 70-110. With hourly vital signs.
Water Balance and Hourly Diuresis.
According to their laboratory results, it maintains a Hb: 6.9g/dl Hct: 29
Creatinina en 4.5 Na:140 K:3.4
Sus signos Vitales al momento:T:36.9 P:79 R:24 P/A: 151/98 , PAM:
98
Make a Nursing Note according to the data provided.
they have provided