NURSING 

ACTION 
 
PATIENT NAME : Mrs NN       
AGE : 60 Years
REGISTER NO. : xxx  
 
NO NO.DX DATE/HOUR NURSING ACTIONS SIGN
HAND
1        1 16/07/19 1. Monitor vital signs   
    10.00 Temperature : 36.7 ° C    
      Pulse : 80 x/minute   
      Blood Pressure : 140/90mmHg
      Respiration : 19 x/minute   
        
          10.10 2. Observing: Location, characteristics,
      duration, frequency, quality, intensity of
      pain, Identify pain scales, Identify non-
      verbal pain responses, Monitor side effects
    of using analgetic
   
    10.20 3. Provide non-pharmacological techniques
      to reduce pain (eg TENS, hypnosis,
      acupressure, music therapy, biofeedback,
      massage therapy, aroma therapy, guided
      imagination techniques, warm/cold
      compresses, play therapy)
   
    11.00 4. Controlling the environment that
      aggravates the pain (eg room temperature,
    lighting, noise)
     
    11.05 5. Facilitates rest and sleep
   
    11.10 6. Explain the causes, periods, and triggers
    of pain
   
    11.20 7. Explains a pain relieve strategies
 
   11.25 8. Encourage self-monitoring of pain

 11.30 9. Advise use of analgetics appropriately

11.45 10. Teach non-pharmacological techniques

  to reduce pain

12.00  11. Collaboration giving analgetics.

   
   
 
     
2 2 16/07/19 1.Monitor vital signs 
10.00 Temperature : 36.7 ° C    
  Pulse : 80 x/minute   
  Blood Pressure : 140/90mmHg
Respiration : 19 x/minute    
     
      10.10 2.Monitor wound characteristics (eg
  drainage, color, size, odor)

      10.20 3. Monitor for signs of infection

  Therapeutic:

      10.25 4. Cleaning with NACL liquid or non-toxic

cleaner, as needed

    10.30 5. Cleaning necrotic tissue

    10.50 6. Give the appropriate ointment on the

skin / lesi
 
    11.10 7. Applying a dressing according to the
  type of wound

   11.15 8. Maintain sterile technique when treating

  wounds

    11.20 9. Change the dressing according to the

  amount of exudate and drainage

    11.30 10.Encourage eating foods high in

  potassium and protein

    11.45 11. Teach wound care procedures

  independently

    12.00 12. Collaboration giving antibiotics

 
 
 
 NURSING ACTION 
 
PATIENT NAME : Mrs NN     
AGE : 60 Years
REGISTER NO. :  
 
NO NO.DX DATE/HOUR NURSING ACTIONS SIGN
HAND
1 1 17/07/19 1. Monitor vital signs   
    10.00 Temperature : 36°C    
      Pulse : 84 x/minute   
    Blood Pressure: 130/90mmHg
      Respiration : 20 x/minute
             
          10.10 2. Observing: Location, characteristics,
      duration, frequency, quality, intensity of
      pain, Identify pain scales, Identify non-
    verbal pain responses, Monitor side effects
      of using analgetics
     
    10.20 3. Provide non-pharmacological techniques
      to reduce pain (eg TENS, hypnosis,
      acupressure, music therapy, biofeedback,
      massage therapy, aroma therapy, guided
      imagination techniques, warm/cold
    compresses, play therapy)
     
    11.00 4. Controlling the environment that
      aggravates the pain (eg room temperature,
      lighting, noise)
   
    11.05 5. Facilitates rest and sleep
   
    11.10 6. Explain the causes, periods, and triggers
      of pain
   
    11.20 7. Explain pain relieve strategies
   
    11.25 8. Encourage self-monitoring of pain
   
11.30 9. Advise use of analgetics appropriately
 
      11.45 10. Teach non-pharmacological techniques
  to reduce pain
 
12.00  11. Collaboration giving analgetics.
 
   
       
        
2 2 17/07/19 1.Monitor vital signs 
  10.00 Temperature : 36 ° C    
    Pulse : 84 x/minute   
    Blood Pressure: 130/90mmHg
  Respiration : 20 x/minute   
        
        10.10 2.Monitor wound characteristics (eg
    drainage, color, size, odor)
 
        10.20 3. Monitor for signs of infection
   
        10.25 4. Cleaning with NACL liquid or non-toxic
    cleaner, as needed
 
        10.30 5. Cleaning necrotic tissue
 
        10.50 6. Give the appropriate ointment on the
    skin / lesi
 
        11.10 7. Applying a dressing according to the
  type of wound
 
        11.15 8. Maintain sterile technique when treating
    wounds
 
        11.20 9. Change the dressing according to the
    amount of exudate and drainage
 
        11.30 10.Encourage eating foods high in
    potassium and protein
 
      11.45 11. Teach wound care procedures
  independently

12.00 12. Collaboration giving antibiotics