SAMPLE NARRATIVE NURSES NOTES with Head to Toe
Date/Tim Nurses Notes
e
1/28/202 Fifty-seven year old female admitted today @ 0730 with weakness, malaise for 3-4 days.
0
0800 She complains of thirst but is unable to drink because of nausea and vomiting. -------------
Chief VS- T-101.5F oral, P-86, R-24, and BP 102/84. Height 5’3”, Weight 146 lb. ------------------------
Complaint ------------------------------------------------------------------------------------------------------N. Nurse RN
0830 Alert and oriented to person, place, and time. PERRLA. Speech clear.
Head to Heart sounds S1& S2,regular, moderately strong. -----------------------------------------------------
Toe Lungs clear x all five lobes and lungs expand equally. ----------------------------------------------------
Abdomen soft and rounded with hyperactive bowel sounds 1-3 seconds apart in all 4 ---------
quadrants. Bowel movements reported as large, loose, 2-4 times per day x 5 days.-------------
Urine scant and dark. One void only since 3am. -----------------------------------------------------------
Arms with strong grip, warm, 1+ bilateral pulses, tenting turgor, cap refill 4 seconds. --------
Legs strong, warm, 1+ bilateral pulses, cap refill 4 seconds, no edema. -----------------------------
Skin warm, dry, and intact. No Scars, bruises, rashes, or breakdown. Sacrum and heals -------
without breakdown. ------------------------------------------------------------------------------N. Nurse RN
Nursing Fluid Volume Deficit RT decrease intake and increase output, secondary to inflammatory
Diagnosis- process AEB loose turgor, fever, loose stools, vomiting, 1+ Pulses, cap refill 4 seconds x 4
extremities. N. Nurse, RN----------------------------------------------------------------------------------------
0930 Urine specific gravity slightly elevated at 1.035, serum sodium slightly elevated at 155,
Labs serum potassium slightly decreased at 3.2. Chest xray negative. Temp. now 101 F orally.
1000 IV started with 20 gauge angiocath in right forearm. Dextrose 5% with 0.45% Normal
Saline with 20meqs of KCL per liter infusing at 125ml/hour. No antipyretic or antiemetic
ordered at this time. Currently resting without vomiting or abdominal cramping. Closing
eyes an states she wants to sleep. Rails up x 2 and call bell within reach.----N. Nurse, RN
1200 Resting quietly. States she slept the last 2 hours.T-100.5, P80, R22, BP 108/78N.Nurse,RN
1400 New orders for stool culture specimen, IV Zofran PRN, call for temperature greater than
103F orally. Able to void 200 ml of orange urine, no stool at this time. Instructed to use
hat to collect stool only in bathroom for culture. Reported off to oncoming shift. --------------
Cap refill now 3 seconds and pulse 2+ x 4 extremities, fever down 1 degree, ---------------------
States she feels a lot better since IV started. No other changes in physical assessment. -------
Stable without stools or vomiting this shift. Bed low, locked, rails up x 2 and call bell within
reach. N. Nurse, RN------------------------------------------------------------------------------------------------
Date/Tim Nurses Notes
e
1/28/202 Fifty-seven year old female admitted today @ 0730 with weakness, malaise for 3-4 days.
0
0800 She complains of thirst but is unable to drink because of nausea and vomiting. -------------
Chief VS- T-101.5F oral, P-86, R-24, and BP 102/84. Height 5’3”, Weight 146 lb. ------------------------
Complaint ------------------------------------------------------------------------------------------------------N. Nurse RN
0830 Alert and oriented to person, place, and time. PERRLA. Speech clear.
Head to Heart sounds S1& S2,regular, moderately strong. -----------------------------------------------------
Toe Lungs clear x all five lobes and lungs expand equally. ----------------------------------------------------
Abdomen soft and rounded with hyperactive bowel sounds 1-3 seconds apart in all 4 ---------
quadrants. Bowel movements reported as large, loose, 2-4 times per day x 5 days.-------------
Urine scant and dark. One void only since 3am. -----------------------------------------------------------
Arms with strong grip, warm, 1+ bilateral pulses, tenting turgor, cap refill 4 seconds. --------
Legs strong, warm, 1+ bilateral pulses, cap refill 4 seconds, no edema. -----------------------------
Skin warm, dry, and intact. No Scars, bruises, rashes, or breakdown. Sacrum and heals -------
without breakdown. ------------------------------------------------------------------------------N. Nurse RN
Nursing Fluid Volume Deficit RT decrease intake and increase output, secondary to inflammatory
Diagnosis- process AEB loose turgor, fever, loose stools, vomiting, 1+ Pulses, cap refill 4 seconds x 4
extremities. N. Nurse, RN----------------------------------------------------------------------------------------
0930 Urine specific gravity slightly elevated at 1.035, serum sodium slightly elevated at 155,
Labs serum potassium slightly decreased at 3.2. Chest xray negative. Temp. now 101 F orally.
1000 IV started with 20 gauge angiocath in right forearm. Dextrose 5% with 0.45% Normal
Saline with 20meqs of KCL per liter infusing at 125ml/hour. No antipyretic or antiemetic
ordered at this time. Currently resting without vomiting or abdominal cramping. Closing
eyes an states she wants to sleep. Rails up x 2 and call bell within reach.----N. Nurse, RN
1200 Resting quietly. States she slept the last 2 hours.T-100.5, P80, R22, BP 108/78N.Nurse,RN
1400 New orders for stool culture specimen, IV Zofran PRN, call for temperature greater than
103F orally. Able to void 200 ml of orange urine, no stool at this time. Instructed to use
hat to collect stool only in bathroom for culture. Reported off to oncoming shift. --------------
Cap refill now 3 seconds and pulse 2+ x 4 extremities, fever down 1 degree, ---------------------
States she feels a lot better since IV started. No other changes in physical assessment. -------
Stable without stools or vomiting this shift. Bed low, locked, rails up x 2 and call bell within
reach. N. Nurse, RN------------------------------------------------------------------------------------------------
