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Nursing Notes Sample Narrative

Nursing Notes Sample Narrative

Narratives are a type of nursing note that’s written in a narrative fashion, meaning that it tells the story of your patient’s illness. This gives you a chance to take the time and write down all of the details about what happened during their hospital stay so that they can be read by other healthcare team members (such as doctors).

Situation:

  • Situation:

The patient is a 67-year-old male with a history of heart disease and diabetes who was admitted to the hospital for chest pain. The nurse is providing education about diet and exercise to promote weight loss, which is one of the goals of his care plan.

Assessment:

Assessment:

Patient’s general appearance: The patient is a young adult female. She appears to be in her mid-twenties and is dressed in casual clothes. She has a pale complexion, with no medical devices or bandages noticed upon initial observation. Patient’s skin color is normal for the time of year (July).

Patient’s temperature: The patient’s temperature was recorded at 97 degrees Fahrenheit when she arrived at the emergency department by ambulance. Her vital signs are stable and within normal limits for her age group and gender; however this may change as she becomes more ill over time as partanters enter their third trimester of pregnancy, so it will be important to take note of any changes throughout your shift today.

Pulse and Respirations: The patient’s pulse rate was recorded at 70 beats per minute upon arrival and respirations were measured at 16 breaths per minute which are both within normal limits for someone who is not pregnant yet still requires close monitoring by nursing staff due to potential complications that may occur during delivery such as preeclampsia/eclampsia which can cause high blood pressure levels if left untreated.”

Plan:

  • What is your plan?
  • How will you know if you are meeting the goals and objectives of your plan?
  • How will you know if you are achieving expected outcomes of your plan?

Action/Intervention:

An Action/Intervention is a specific action taken by the nurse to address a patient’s health condition. An Action/Intervention may be successful or unsuccessful.

  • Successful Action/Intervention: The nurse identified that the patient had hypothermia and provided warmth and support to the patient through comfortable bedding and blankets. This intervention was effective in restoring the patient’s core temperature to normal range, which allowed him to regain consciousness within 24 hours.* Unsuccessful Action/Intervention: The nurse failed to identify that her patient was hypothermic due to an incorrect assessment technique.*

Takeaway:

The main takeaway from this article is that nursing notes are important because they can be used to track the progress of a patient’s care.

The patient is an 85-year old female with a history of hypertension and type 2 diabetes mellitus. Her lab results are as follows: HbA1c = 7.8; creatinine = 1.4; LDL cholesterol = 100; HDL cholesterol 400. She has been prescribed metformin for her diabetes and aspirin for blood pressure control but does not take these medications regularly because she has suffered from multiple falls at home due to dizziness and unsteadiness on her feet after taking them in the past.