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

Student name;

Group;
Total Score
/ 15 Supervisor DR.