Question

1.write nurses for wound dressing .
2.write nurses on recording fluid intake and output.

nurses note*

Answer 1

Nurses note is an essential record in health care while writing a nurses note the nurse has to follow the given rules atleast

1 Use a consistent format always.

2 Write notes timely.

3 Use only standard abbreviations

4 Include only objective data as far as possible

5 Note all communication happend on time

6 Ignore trivial information.

7 Keep it simple and write clearly

Answer 1 Nurses notes for wound care

When writing wound care notes the nurse must include the following notes

External appearance of dressing : dry,intact, moist etc.

External appearance of wound and periphery: Clean or dirty, Dry or moist, Erythematous or endurated, infected or non infected.

Temperature and pulse rate of periphery: such as warm or cold.

Record the procedure and intra procedure findings: wound care given by which and which medications. What were the findings observed during the procedure.what where the patient's responses: like pain,verbalization,change in vital signs etc.Record pre procedure and post procedure vital signs,closure of dressing and any other relevant finding.

Answer 2 Nurses note on fluid intake and out put

The nurses notes on fluid intake and out put must include all type of fluid intake and amount such as Oral, IV,RTF if any by time to time. Out must be recorded considering all fluid loss including urine, loose stools, vomiting,blood loss insensible water loss like perspiration wound bed water loss etc. Finally close the report by calculating and findings fluid deficit or excess.

Nurses record must contain date time an must be duly signed.