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Nurse notes outline

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Dane Delion
BSN 3
Nursing notes outline:
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Review of anatomy and physiology
Major systems & organs involved
Their functions
Free anaphy resource:
Crash course anaphy playlist: https://
•
bit.ly/3cyVFid
Etiology
Causative agents (bacteria, fungi, virus)
Risk factors (lifestyle, fam hx, etc)
Pathophysiology
What happens to the organs affected
How does it change their normal functions
Search diagrams, watch YouTube videos
My favorite pathpophysio resources:
armandoh.org / YT: https://bit.ly/
•
36cb4UE
osmosis.org / Yt: https://bit.ly/
•
3mUwKKL
Free pathophysio charts: https://
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bit.ly/3j8uGMO
Clinical manifestations
Signs and symptoms (s/sx)
(ex: nausea, vomiting, diarrhea, etc)
Review the pathophysio & connect how/why these s/
sx occur.
diagnostic procedures
• Tests conducted to confirm a diagnosis
• (Ex: Blood tests, x-rays, cardiac monitoring, and so
on.)
6.
Medical management
• Need a doctor’s order
• Medications
• Surgeries
7.
Nursing management
• Don’t need doctor’s order
• examples:
• change client’s position
• encourage fluid intake
• monitor vital signs regularly
• monitor for signs of adverse reactions
• Nursing interventions resources:
• nurseslabs.com
• registerednursern.com
Note taking tips:
1.
Use abbreviations
• Highly recommend Learning & using medical
abbreviations
• source: https://bit.ly/345Vwz1
• But you can create your own— so it’ll help you
understand.
2. Simplify your notes
• Use bullet points
• Draw diagrams when applicable
• Use mnemonics
• ex: MoNA for Mi treatment
• M- morphine
• O- oxygen
• N- nitroglycerin
• A- aspirin
3. Highlight important info
• Lab values
• Drug dosages
• Adverse reactions
4. REVIEW, REVIEW REVIEW REVIEW REVIEW
• ALWAYS REVIEW, INTERNALIZE, AND UNDERSTAND
YOUR NOTES.
5. Look for outside resources to supplement your
learning.
• Information is out there! You just need to
learn how to find it.
padayon, future nurse!
— your Nursing ate
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