Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020

(Nur 458 )

Nursing Record

Student name: Student ID

Pt name: Medical diagnosis:
Age: Preoperative:
Sex: Postoperative:
Date of admission: Name of surgery:
Level of consciousness:
 Score:………………………………………….
 Description:……………………………………
Vital
signs Time
BP B 8a 9a 10am 11am 12pm 1pm
T
P m m
Blue R P
4 21
2 0
4 20
1 0
4 19
0 0
3 18
9 0
3 17
8 0
3 16
HR 7 0
3 15
Gree 6 0
n 3 14
5 0
3 13
4 0
3 12
2 0
3 11
0 0
Temp 2 10
8 0
Red 2 90
6
2 80
4
1
 Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020
(Nur 458 )
2 70
2
2 60
0
1 50
8
Resp 1 40
6
Black 1 30
4
1 20
2
1 10
0
C
VP
Level of mobility Ambulated Move with assistance Immobilized

8a 9a 10am 11am 12pm 1pm

Change position m m

Defecation
(bowel
movement)
Stool criteria Formed Diarrh
stool ea

2
 Hard stool Fecal impaction

Physician
prescription Time distribution
Name of Prescribed Drugs Dose Frequenc Route
y

Physician
prescription Time distribution
Name of Prescribed Fluids Dose Frequenc Route
y

Inta
ke
Intravenous Infusions Cumulati
Time NGT Oral Tota
ve
l
balance

8am
9am
10am
11am
12pm

Outp
ut
Urine output Drai
ns Cumulati
Tim NG Vomi Tota
Us ve
e W.C Cath 1 2 3 T t l
e balance
 urin
. .
al
8am
9am
10a
m
11a
m
12p
m
Fluid Balance Equation:………………………………………………………………..
………………………………………………………………..

Student signature: Instructor signature