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    Uhan Medical Hospital: Nurses Observation Sheet

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    pius troy macapaz
    The nurses observation sheet documents a patients condition over time. The patient presented with bilateral hip pain rated 7/10, fatigue, and skin lesions. Intravenous fluids and medications were administered including sodium phosphate injection, calcium supplements, antihistamines, and antacids. After 8 hours of nursing interventions the patients pain had reduced to a 4/10 scale and vital signs were stable except a slight temperature decrease. The nurse endorsed the patient to the on-duty staff and recorded the latest observations.

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    Uhan Medical Hospital: Nurses Observation Sheet

    Uploaded by

    pius troy macapaz
    24 views2 pages
    The nurses observation sheet documents a patients condition over time. The patient presented with bilateral hip pain rated 7/10, fatigue, and skin lesions. Intravenous fluids and medications were administered including sodium phosphate injection, calcium supplements, antihistamines, and antacids. After 8 hours of nursing interventions the patients pain had reduced to a 4/10 scale and vital signs were stable except a slight temperature decrease. The nurse endorsed the patient to the on-duty staff and recorded the latest observations.

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    NURSES_NOTES(11) Macapaz

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    The nurses observation sheet documents a patients condition over time. The patient presented with bilateral hip pain rated 7/10, fatigue, and skin lesions. Intravenous fluids and medications were administered including sodium phosphate injection, calcium supplements, antihistamines, and antacids. After 8 hours of nursing interventions the patients pain had reduced to a 4/10 scale and vital signs were stable except a slight temperature decrease. The nurse endorsed the patient to the on-duty staff and recorded the latest observations.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    24 views2 pages

    Uhan Medical Hospital: Nurses Observation Sheet

    Uploaded by

    pius troy macapaz
    The nurses observation sheet documents a patients condition over time. The patient presented with bilateral hip pain rated 7/10, fatigue, and skin lesions. Intravenous fluids and medications were administered including sodium phosphate injection, calcium supplements, antihistamines, and antacids. After 8 hours of nursing interventions the patients pain had reduced to a 4/10 scale and vital signs were stable except a slight temperature decrease. The nurse endorsed the patient to the on-duty staff and recorded the latest observations.

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    of 2

    W UHAN MEDICAL HOSPITAL

    NURSES OBSERVATION SHEET

    DATE TIME DIET OBSERVATION & SIGNATURE

    S“while walking I feel pain bilaterally in my hip and has muscle


    weakness. If I’m going to rate the pain its 7/10”
    0 received patient lying on bed, conscious, coherent and with
    oriented with ongoingIVF bottle number 1 DSW 1L plus sodium
    phosphate sodium phosphate 15 mmol via soluset in 20mmol
    regulated at 20gtts/min and on 02 @2LPM via nasal prong
    initial vital signs are as follows:
    T: 37.0C PR:98bpm RR: 21cpm BP: 150/95mmHg
    O2:94%
    - pain scale of 7/10
    - fatigue
    - brown, infiltrative lesions over the trunk and back
    - bilateral hip pain when walking, fatigue, muscle weakness
    A Acute pain relate to injuring agent
    P Within 8 hours of nursing interventions, the patient will be
    able to report pain is relived/controlled, with the pain scale of
    4/10 from 7/10
    I -v/s taken and recorded
    -infused 12 Sodium Phosphate Injection @ 15 gtts
    -Capillary refill checked
    - TS Rocaltrol given at 0.25 MCG TID cap, PO
    - Fexpfenadine given att 120 mg HS, Tab, Po
    -TS bismuth subsalicylate given at 262 mg BID tab PO
    -encourage pt to increase intake of fluids
    -encourage pt to take bed rest
    E – After 8 hours of nursing interventions, the pt was able to
    demonstrate pain si relived . as evidenced the pt stated “ thank
    you my pain has subsided pain scale 4/10”
    - Endorsed pt on staff on duty with the lastest v/s as follows:
    T-36.6 celsius
    P-95 bpm
    BP- 150/90 mmHg
    R-19 cpm
    O2 sat- 96%
    PT.MACAPAZ,FSUU/SN

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