Charting Notes

FOCUS NURSE’S NOTES
 Ineffective social interaction  Assessment:

patient manifests flat affect, answers what’s ask
bluntly & poor eye contact.
 Intervention:
Encourage verbalize feelings, explore about
client’s background/story, let client identify
object’s color and name, introduce some video
presentation and film viewing activities, play
therapy and self-awareness activity, reinforce
recognition and rewards for every achievement,
show pictures of person, picture of animals and
family member, assess orientation.
 Poor hygiene / Self-care deficit, Impaired  Assessment

skin integrity Poor oral hygiene, patient scratches skin.
 Intervention
Advise and teach proper hygiene like:
Handwashing, Proper brushing of teeth,
Trimming of finger nails, ear cleaning.
Teach skin hygiene like moisturize skin
 Supportive care Received patient inside the ward asleep on bed.
D- Patient’s calm and manageable
A-Encouraged verbalization of feelings, assisted
in his activity of daily living, conducted on activity
to enhance self-awareness, provided positive
reinforcement and recognition.
R-Patient is remained calm and manageable, had
good appetite while eating, and participate
during the activity, patient returned to ward and
took a rest.

in his activity of daily living, assisted in grooming,
encouraged the patient to avoid stressful
thoughts, participation
Received patient inside the male ward asleep on
bed.
D-Patient is calm and manageable.
patient while taking breakfast, conducted health
teaching and proper hygiene, encouraged
socialization with others and avoid stressful
thoughts, advised to participate in the
psychotherapies activities and provide positive
reinforcement and recognition
 Pain D: Reports of sharp pain on the abdominal
incision area with a pain scale of 8 out of 10
Facial grimacing
Guarding behavior
Restless and irritable
A: Administered Celecoxib 200mg IV

Encouraged deep breathing exercises and
relaxation techniques
Kept patient comfortable and safe
R: Patient reports pain was relieved
 Hyperthermia D:
Temperature of 38.9 OC via axilla
Skin is flushed and warm to touch
A:
Tepid Sponge Bath (TSB) done
7:30pm
Administered 250mg IV Paracetamol as per
doctor’s order
Encouraged adequate oral fluid intake
Encouraged adequate rest
R: 10:00pm
Temperature decreased from 38.9 to 37.1 OC
 Impaired Physical Mobility Received patient lying on bed asleep with PNSS IL
at 390 cc fluid level at left radial vein with O2
inhalation via nasal cannula at 3L/ min with
heplock via Right accessory cephalic vein with
retained urinary catheter draining well.
D- Right sided body weakness. Limited range of
motion
A- Assessed patient’s condition. Provided
comfort measures: Conducted afternoon
care. Advised to perform passive ROM on
bed. Encouraged turning to sides at
intervals.
 Impaired skin Integrity Received patient asleep on bed with IV fluid of
PLR IL at 90 cc with 114 cc per soluset via left
saphenous vein regulated at 20 gtts/min and O2
therapy via face mask at 6L/min.
D- Disrupted skin surface evidenced by vesicular
lesions at the neck, upper and lower extremities.
A – Identified underlying condition involved;
obtained involved; obtained history of current
skin condition; Inspected skin regularly; Noted
unusual discharges and odor emilted from the
skin; Inspected skin regularly; Advised to use non
adhesive soft covering and clothes. Discouraged
frequent stimuli to the affected skin areas.
 Difficulty of breathing D- came in because of difficulty of breathing “ta
hipa gat le” verbalized by wife with labored
breathing, flaring of mostrils. R,R – 40
breaths/min O2 sa= 88%
A- Placed on high back rest, O2 inhalation
administered 8-9L/min via facemask.
Nebulization done, hypercortisone 250 mg
through IVT. Monitored vital signs
 Elevated Body Temperatures D- Skin warm to touch, warm breath, teary eyes,
flushed skin, T- 39.9 C
A- Loosen clothing: tepid sponge bath done, cold
compress applied on forehead, Paracetamol 300
mg administered thru IVT per donctors oder.
 Transport of patient D- Ready for transport
A- Placed on stretcher bed, maintained on high
back rest and with O2 inhalation…
R- Latent O2 saturation 94%, latest temp 38.2 C,
Transported to Ward 5-A with O2 inhalation at 3-
4 L/min via nasal cannula…
 Chest pain D – Received patient on stretcher bed, conscious,
coherent “ ta duele mi petcho” as verbalized by
the patient, restless. Facial grimace, pain scale
6/10, BP 90/60 mmHg, with clammry skin and
perspiration.
A- Placed in a calm, comfortable position, O2
inhalation. Administratered 2-3 L/min via nasal
prong, medicated with Isordil 25 mg SL as
ordered…
 Persistent escalating Chest pain D- “dwele gayot mi pecho” as verbalized by

patient. BP 90/60 mmHg, becoming more
restless, pain scale 9/10…
A- Referred to ROD, administered Morphine 4 mg
via IV, access maintained on O2 inhalation
R- “Poko ya lang el dolor na mi petcho” pain scale
from 9/10 to 2/10, becoming comfortable, O2
saturation 96% endorsed…
 Pain at the injured site Received patient on bed, awake and responsive
with on going IVF of PNSS Il at 600 ml fluid level
running at 20 ggts/min infusing well via R
antecubital vein with O2 inhalation via nasal
cannula at 21 pm.
D- “Masaki tang sugat ko” as verbalized by
patient. Gunshot wound at 6 -7th intercoastal
space upper R trunk anterior axillary line and R
inner arm with intact and dry dressing. Pain scale
of 4/10 mild facial grimace, guarding behaviour.
A- Advised rest and provided quiet environment.
Encouraged verbalization of feelings above the
pain kept R arm supported with pillow.
Maintained semi-fowler’s position. Checked
wound dressing from time to time. Encouraged
diversional activities like communicating with
others. Administered by NOD medication of
Dexketoprotein (kelese) lamp.
R- No unsualities noted.
 Abdominal Pain D- Patient verbalized “sakit gyod akong tiyan”,

pain scale 8 out of 10, facial grimacing, guarding
behaviour, irritable, Temperature 37.4 C , pulse
70 beats per minute, respiration 18 breaths per
minute
A- Administered Hyoscine N-butyl bromide 20 mg
Intravenously as per doctor’s oder, encouraged
and demonstrated deep breathing exercises,
placed in semi fowlers position with side rails up
and locked.
R- Ptient reports pain was relieved. Pain scale
5/10
Received a 20 year old female patient, awake and
conscious, in semi fowlers position with ongoing
ivf of LR 1 liter via right metacarpal vein at 20
ml/hr fluid rate infusing well, with O2 inhalation
via nasal cannula at 5 Lpm. -vital signs assesses
and noted. -kept on semi fowlers;padded side
rails up -assessed general condition -inspected IV
site for any unusualities

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FOCUS NURSE’S NOTES

 Ineffective social interaction  Assessment:

 Poor hygiene / Self-care deficit, Impaired  Assessment

A-Encouraged verbalization of feelings, assisted

A: Administered Celecoxib 200mg IV

 Persistent escalating Chest pain D- “dwele gayot mi pecho” as verbalized by

 Abdominal Pain D- Patient verbalized “sakit gyod akong tiyan”,

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