Question

please complete a detailed head to toe narrative nurse note based om the information provided

Documentation Activity Upon arrival to your shift, you introduce yourself to your patient (J.F.) who was admitted yesterday for monitoring following a syncopal episode while she was walking to her car after work. When you walked into the room and turned on her bedside light, she covered her eyes with her blanket. J.F. complains of a throbbing headache behind her eyes and is a 7 on a pain scale of 0-10. Her VS are as follows: Temp 98.7, RR 20, HR 86, BP 128/62. You find no abnormalities in her physical assessment. You administer 650 mg Tylenol by mouth according to a PRN order left by the physician, help her reposition in bed for comfort and turn off the lights and TV in her room. When you return at 0800, J.F. states that her pain is at a 3 on a 0-10 scale and that the pain is tolerable at this time. Write a Narrative note about this situation

Answer 1

NARRATIVE NURSES NOTES :

its is a detail information about the patient to the doctors and nurse to analysis of patient data and provide correct information .notes should be focus on specific issues of patient .it is short and convey correct information to the health care team.

how to write the narrative nurse notes : it should be write about information of patient symptoms , how they feel the signs and objective we find in the 'patient .

head to toe assessment include in the narrative nurses notes.

if we write the notes writing should be clear and good to understand , use abbreviation used in the hospital .

notes should be presenting problem and secondary problem of your patient , how the patient feels the present problem.

objective measures such as temperature , pulse , respiration etc

medication used to patient treatment.

here they given information about patient j.f suffered with the syncopal episodes while walking at room and working area

patient feels thrombing headache behind her eyes

pain scale 7/10

temp -98

rr-20

you can assess the patients eye pupils,eyemovements ,speech, palpatations ,palpations, lung sounds, edema of extremities ,rom ,skin texture tregors etc