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    Nursing Care Record: - Pain Assessment

    Uploaded by

    Mohamed Mahmoud
    This nursing care record summarizes a patient's vital signs, medications, interventions, pain assessment, connections/tubes, fluid balance, wounds, and Glasgow Coma Scale over a period of time in a hospital. It includes the patient's name, date of birth, gender, medical diagnosis, hospital name, and dates of care.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nursing Care Record: - Pain Assessment

    Uploaded by

    Mohamed Mahmoud
    63 views2 pages
    This nursing care record summarizes a patient's vital signs, medications, interventions, pain assessment, connections/tubes, fluid balance, wounds, and Glasgow Coma Scale over a period of time in a hospital. It includes the patient's name, date of birth, gender, medical diagnosis, hospital name, and dates of care.

    Original Description:

    Care planning for the summer

    Original Title

    4_5823163827247647756 (1)

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    This nursing care record summarizes a patient's vital signs, medications, interventions, pain assessment, connections/tubes, fluid balance, wounds, and Glasgow Coma Scale over a period of time in a hospital. It includes the patient's name, date of birth, gender, medical diagnosis, hospital name, and dates of care.

    Copyright:

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

    Nursing Care Record: - Pain Assessment

    Uploaded by

    Mohamed Mahmoud
    This nursing care record summarizes a patient's vital signs, medications, interventions, pain assessment, connections/tubes, fluid balance, wounds, and Glasgow Coma Scale over a period of time in a hospital. It includes the patient's name, date of birth, gender, medical diagnosis, hospital name, and dates of care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    NURSING CARE RECORD

    Patient Name;
    Date; / / 2021
    Date of Birth; / /
    Hospital Name;
    Gender; ‫جامعه الزقازيق‬
    ‫كليه التمريض‬ Medical Diagnosis;
    Word;

    Time Vital signs Medications Nursing Interventions &


    Observation
    Temp. HR. BL. P RR. Name Dose Route Freq. Notes
    ºc / Q hr
    ºc / Q hr
    ºc / Q hr
    ºc / Q hr
    ºc / Q hr
    ºc / Q hr
    ºc / Q hr
    ºc / Q hr
    ºc / Q hr
    ºc / Q hr
    Iv fluid O2 therapy Mechanical ventilator
    Name Additives Volume Rate Frequency Nasal Cannula Mode
    Face Mask Fio2 Rate
    Non-Rebreather Tidal volume Peep
    Face Mask P supp
    NIV-CPAP
    • Pain Assessment;
    Pain Intensity; Location; Radiation; Frequency And Timing;

    Reliving Factors; Precipitating Factors;


    Pain description;
    Aching Cramping Sharp
    Throbbing Burning Stabbing
    Shooting Squeezing Tingling
    Dull Tearing Sickening
    • Last Bowel Movement;
    • Connections;
    Peripheral cannula Central venous line Endotracheal tube Others;
    Urinary catheter Mahokar Tracheotomy
    Wound drainage Colostomy Chest tube

    Fluid Balance Chart


    Intake Output
    Time Wound drain
    Water / juice Solutions Urine Vomiting
    Drain 1 Drain 2 Drain 3

    Total fluid balance;

    • Wound/ Burn / Ulcers/ Bed Sores Assessment;

    Number ( ) Number ( )
    Site; (mark) Site; (mark)
    Grade; Grade;
    Drainage; Yes Drainage; Yes
    No No
    If yes, Color; Consistency; If yes, Color; Consistency;
    Amount Amount

    GCS
    Eye Student Name
    Total
    Verbal Group
    / 15
    Motor

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