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10 Nursing Note Sample

The patient was admitted to the hospital through the emergency department for investigation of confusion with a history of confusion over the past 1-2 years. They required full assistance with daily activities and incontinence care. Over the course of their stay, the patient experienced periods of agitation requiring medication, falls from bed resulting in head injuries, low fluid intake, and intermittent confusion and orientation. Their condition improved by the 9th day when they were alert at times, eating and drinking better, though still requiring full incontinence care and assistance with activities.

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90 views1 page

10 Nursing Note Sample

The patient was admitted to the hospital through the emergency department for investigation of confusion with a history of confusion over the past 1-2 years. They required full assistance with daily activities and incontinence care. Over the course of their stay, the patient experienced periods of agitation requiring medication, falls from bed resulting in head injuries, low fluid intake, and intermittent confusion and orientation. Their condition improved by the 9th day when they were alert at times, eating and drinking better, though still requiring full incontinence care and assistance with activities.

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Nursing notes

Date / time Notes


4/4 Admitted to ward via A and E at 1800 hours. Admission for
20 30 investigation into confusion with a history of confusion 1-2 years.
Usually mobile with a stick. Patient not for resuscitation –
discussed with family and documented in notes. Lives in hostel
normally independent but recently more confused and aggressive.
Full assistance required with ADL’s on admission. Requires
incontinence aids. Catheter inserted in A and E – patient removed
balloon intact. Some bleeding as a result. Patient given
Haloperidol and Diazepam on admission to ward – reasonably
settled at time of report. Charted for PRN meds for agitation
overnight. For psych review in a.m. Encourage diet and fluid.
Attended Head CT – NAD. Temp 37.2.
5/4/ Patient settled overnight. Incontinent. Special in place no episodes
0510 of aggression so far this shift. Small amount of bleeding from
penis following self removal of catheter in A and E. Obs
satisfactory continue special.
5/4 Patient found of floor at commencement of shift. Had climbed out
1255 of bed and hit head. Assisted back to bed. Obs stable. Cut above
right eye – steri strips in place. Dr attended and sutured x3 to
laceration on scalp. Very drowsy, unable to take meds due to
drowsiness. Very poor fluid intake. ?may require IV therapy?
However, may not tolerate same.
6/4 Requiring full assistance with ADL’s. Incontinent of urine. Sat out
1455 of bed but complaining of being tired – returned to bed at 11a.m.
Complaining of pain (? Lower leg?) Dr informed. Paracetamol
given with good effect. Temp 38.
7/4 Patient restless this shift obs stable, full assist with ADL’s.
2130 Haloperidol given as charted.
8/4 Woke up panicking temp 37. Unable to measure BP Patient
0230 looked confused. Paracetamol and Haloperidol given as charted.
8/4 Patient very erratic. Trying to get out of bed. Medication given as
0700 per chart no effect. Dr informed and larger dose of haloperidol
given. Settled for a while now getting agitated again. Temp 38
managed to take Paracetamol but refused antibiotic.
8/4 Refusing most diet and fluid. Small sips of water only. Urine
1900 remains blood stained. Only passing small amounts. Refusing
medication. Discussed antibiotics with team will require does this
a.m. Very drowsy. Contact daughter if condition changes.
9/4 Much improved this am. Alert and orientated at times. Taking
1450 good diet and fluid. Incontinent still. Small bowel action will
require laxative tonight. Still sleepy. Daughter visited.

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