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How to Write an Effective Nursing Note: A Comprehensive Guide

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Taking nursing notes is a regular practice in patient care. But writing nurses notes can be hard to know where to start, or how to make your notes stand out from the rest of your peers.

You want to be able to capture all the information you need in as few words as possible, but you also don’t want to leave out any important details.

Writing nursing notes, like building effective nursing care plans , is one of the core responsibilities of being a nurse, and learning how to write them effectively and quickly will set you up for success in your future career.

The most effective nursing notes include terminology, observance, detail, and readability. Whether you’re in clinicals or on the job, it’s important to understand why and how they’re crucial to providing quality care.

We’ll show you what goes into nursing notes and how to write them effectively for the best patient care.

But first, let’s get into how they’re relevant to charting.

The Basics of Nurse Notes

A nursing note is a detailed record that captures the comprehensive care provided by nurses. It includes the nurse’s observations, assessments, nursing diagnoses , care plans, interventions , and evaluations of patient outcomes ( ADPIE ).

Nurse notes are a key part of patient care documentation. They track the progress of a patient’s condition over time and facilitate communication between healthcare providers.

Accurate and thorough nursing notes are essential for delivering high-quality care and maintaining legal and regulatory compliance.

The Role of Nursing Notes in Documentation and Charting

Nursing students learn charting (along with notes) early and often to better paint a picture of the patient’s health at the time of the visit or for the duration of the time. Charting includes the notes made by nurses and put into a computer.

Charting information is purely objective (IV site documentation, alarms, test results, etc.), and this nursing documentation is set up specifically for each working medical facility. 

Making quick notes when evaluating the patient will enable you to chart more quickly and provide more accurate nurses’ notes immediately.

Read here to learn how notes and charts fit into the nursing process .

How Are Nurses’ Notes Used?

The first thing to know about nursing notes is that they’re not just for patients but also for nurses. Nurses notes fill documentation gaps between doctors, patients, and other providers.

The primary purpose of a nursing note is to track the progress of the patient’s condition over time. 

You also may share notes with other team members, depending on their role within the department. This allows them to adjust treatments accordingly if necessary (e.g., increasing dosage).

How to Write Effective Nursing Notes

To write effective nursing notes, follow these guidelines:

• Verify the Correct Patient’s Chart: Ensure you are documenting in the correct patient’s record.
• Tell the Patient’s Story: Use your notes to provide a clear and comprehensive narrative of the patient’s condition and care.
• Document Real-Time Observations: Take notes in real-time or as soon as possible to ensure accuracy.
• Use Complete Phrases: Avoid abbreviations that could lead to misinterpretation.
• Document Safety Checks: Include any safety measures in place to protect the patient.
• Use Standard Acronyms: Familiarize yourself with common acronyms like SOAPIE (Subjective, Objective, Assessment, Plan, Intervention, Evaluation) and DAR (Data, Action, Response).

In short, you write everything you observe as a nurse and any significant medical information. Nursing notes include information about how the patient feels, what they need, and what’s going on with their health in a short, detailed summary. 

When you put every piece of information together, make sure that everyone who needs to know about a patient’s care can access that information quickly and easily.

What To Write in a Nursing Note?

The information included in a nurses note varies depending on the facility’s needs and the type of care being provided. Nurses notes are often filled with abbreviations and medical jargon – which you and staff will know, but the patient most likely won’t.

Generally, here’s what you can expect from your nurse’s notes:

• General patient information: name, gender, age, address.
• Reason for their visit & Chief complaint: What they came in for and how long they’ve been under your care.
• Observations: What you’ve observed during your time with them (what they look like when they’re awake or asleep, their breathing patterns and heart rate, etc.).
• Treatment plan : A care plan layout based on the collection, analysis, and organization of nurses’ clinical data.
• History: Patient history including present and past ailments.
• Medication(s): Any medications given to the patient (including dosage details ), along with medication history.
• Ending summary: An overall evaluation of their condition at the time of discharge.

Ideally, you should take brief notes while you’re in the same room as the patient, and add more detail as soon as you leave the patient’s room while the information is still current and fresh in your mind.

Nursing Notes Examples

The following are four nursing notes examples varying between times of a patient’s admittance:

Acute Pancreatitis Nursing Note (Example)

Patient Name and Age: Kane Schneider, 33

Date: May 14th, 2022

Chief Complaint: The patient’s chief complaint is acute pancreatitis, which they developed after eating a large amount of greasy food. The patient also reports that they have been experiencing nausea and vomiting since they arrived at the hospital.

Diagnosis: Acute Pancreatitis

History: The patient reports that they have had similar symptoms in the past and have had several episodes of acute pancreatitis over the past few years. The patient has had all of their gallbladders removed in attempts to treat this condition.

The patient has not been taking any medication for nausea, but has been receiving IV fluids for hydration due to their vomiting.

Physical exam: Vital signs are stable — pulse = 72 beats per minute, respirations = 16 breaths per minute, temperature = 98.2 degrees Fahrenheit (F). Physical examination reveals a pale and diaphoretic person in moderate distress with abdominal tenderness on palpation in the epigastric area. 

No jaundice or bruising is present on examination of the skin or mucous membranes. Abdominal distention is present with peripheral edema noted around the umbilicus area as well.

Urinary Tract Infection Nursing Note (Example)

Patient Name and Age: Elaina Hassan, 77

Date: January 29th, 2022

Chief Complaint: She has been experiencing fever, chills, and dysuria for two days. 

History of Present Illness: Patient has previously experienced mild hypertension and heart failure.

Physical exam: Vitals – The patient’s temperature is 99 degrees Fahrenheit. The pulse is 100 beats per minute and regular. The blood pressure is 140/90 mm Hg.

Diagnosis: Urinary tract infection .

Assessment: She appears to be in moderate distress and is slightly tachycardic at 104 beats per minute. Patient demonstrates evidence of right lower quadrant tenderness on palpation as well as suprapubic tenderness on deep palpation. The patient’s urine dipstick test reveals 1+ blood and no white blood cells or nitrites present in her urine sample.

Evaluation: She has been treated with antibiotics and fluids, and can now urinate without discomfort.

Alcohol Withdrawal Nursing Note (Example)

Patient Name and Age: Willie Brandt, 41

Date: March 21st, 2022

Diagnosis: Alcohol withdrawal

Assessment: Patient was brought in by his family for alcohol withdrawal. When they brought him in, he was experiencing tremors, hallucinations, and confusion.

History: Patient has been drinking alcohol for 24 years, and his family noticed that he started to drink more heavily over the past few years.

Plan of care: Monitor vital signs every 15 minutes; check urine output every hour; administer IV fluids as ordered; administer medication as ordered (e.g., benzodiazepines); monitor electrolytes every 6 hours or as ordered; provide emotional support to patient and family; educate patient on how to avoid future episodes.

Upper Respiratory Infection Nursing Note (Example)

Patient name and Age: Jazmin Adkins, 25

Diagnosis: Upper respiratory infection, including rhinitis and pharyngitis.

Assessment: Patient presented with symptoms of a cold, including runny nose, sore throat, cough, and congestion. Symptoms have persisted for 2 weeks.

History: Patient works as a bartender at a local restaurant. Two evenings per week she works late into the night and does not get enough sleep; she also drinks alcohol on these nights (about 4 drinks). 

She washes her hands frequently at work but does not use hand sanitizer before touching his face or putting his hands in his mouth. Patient often smokes cigarettes outside work hours and is always around cigarette smoke when out with friends or family members who smoke regularly.

General Tips for Writing Nurse Notes

When writing a nurse note, you must first think about what is important for the patient. But it’s also important to ask yourself: what’s important for the rest of your team? 

Here are some simple tips for writing the perfect nursing note:

• Stay on point and be specific . 
• Use shorter sentences when possible for easier reading.
• Include interdisciplinary team members . 
• Use bullet points when possible (it’s much easier to scan through a list than long paragraphs).
• Sign each entry of your note with your name and credentials .
• Use correct grammar and spelling (and avoid autocorrect). 
• Add new information throughout the patient’s visit .
• List a patient’s most important condition and its severity level (for patients with multiple conditions).
• Don’t forget the smaller details .

Include patients’ room and bed numbers at the top of the page (if you’re writing a note for an inpatient).

Take Your Nursing Learning to the Next Level

Taking nurses notes will be one of many, many job responsibilities you’ll have. You’ll be better prepared for success in your future work if you can write them efficiently, promptly, and with the maximum amount of detail.

You’ll have great nursing notes when you can quickly balance medical terminology, writing skills, detail, and observation.

To get all of that down easier and more efficiently, you’ll need a supplemental nursing school resource . SimpleNursing offers just about everything you need (study guides, question banks , assessments, and more) to perfect your nursing process.

Get the most out of your nursing courses and effectively put them together in your studies.

Unlock these resources with a free trial today and check out our NCLEX prep course as you prepare for your nursing exams .

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Nursing Notes Template

Table of contents, what are nursing notes .

Nursing notes are written records detailing the care provided to a patient, including observations, treatment plans, and interventions. They are essential for continuity of care and are a legal document. 

How to write nursing notes 

Good nursing notes provide a detailed legal record of a patient’s status, treatment, responses, and outcomes.

All nursing notes must be: 

• Factually correct
• Accurate and detailed
• Current with exact time information
• Professional

Tips for writing nursing notes: 

• Be sure to document the correct patient, and under your own name and login.
• Document as soon as possible. Don’t wait until the end of the shift.
• Report and document missed or late entries immediately.
• Document the issue, what you did about it, and the patient’s response.
• Document only what you see, hear, touch, smell, and do—avoid opinions. 
• Document often enough and with enough detail to tell the entire story.
• Document all communications—include names, titles, time, statements, and actions taken.

Free-form notes: nursing narrative notes

Writing nursing notes in a narrative format means telling the patient’s story chronologically. The note will provide the information in free, written-out sentences.

An advantage is that notes in this format provide context and a fuller picture of the client’s situation, but they can be time-consuming to read and write. 

Nursing note template: SOAP nursing notes

“SOAP” is short for “Subjective, Objective, Assessment, and Plan”. 

• Subjective: complaints and symptoms
• Objective: vital signs and other measurable data
• Assessment: clinical judgment 
• Plan: treatments/intervention plans

Giving nursing notes this structure creates easier reading to scan quickly and reduces the possibility of errors and oversights by providing a standardized, focused documentation. 

SOAPIE nursing note example  

The SOAP-format is often expanded to “SOAPIE”: Subjective, Objective, Assessment, Plan, Intervention and Evaluation. 

An example for this format would be: 

• Subjective: Patient states: ‘I feel short of breath’
• Objective: Vitals signs showed: BP 110/75; HR 100; RR 22; SpO2 89%
• Assessment: Patient displays fatigue and is pale, states “tiredness”..
• Plan: This RN contacted the charge RN, rapid response nurse, and primary care physician.
• Intervention: Oxygen 2 L placed on the patient via nasal cannula.
• Evaluation: SpO 2 increased to 95%, respiratory rate slowed to 18. The patient was transferred from the med-surg unit to the ICU due to unstable condition per healthcare provider order. Report given to ICU nurse; family notified of transfer.

Nursing note template  (SOAPIE)

• Subjective: What did the patient report?
• Objective: Vital signs/lab values 
• Assessment: What were your findings? 
• Plan: Who did you contact? 
• Intervention: Action/intervention(s) the nurse performed 
• Evaluation: What happened after the interventions? 

Good nursing note example: dos and don’ts

Following are examples of nursing note excerpts that show the dos and don’ts of how to follow the requirements of a good nursing note: 

Make sure the nursing note is factual  

Don’t: Patient seems like they are in pain.

Do: Patient grimaced and moaned when their leg was touched. 

Interpretations and assumptions are not facts. 

Make sure the nursing note is accurate  

Don’t: There was a large amount of drainage.

Do: There was 150 mL of serosanguineous drainage.

“Large amount” as a quantifier leaves the information open to the reader’s interpretation. Stick to the facts and give them in the most detailed way possible. 

Make sure the nursing note is complete  

Don’t: Patient was taught how to check their blood sugar.

Do: Patient was able to correctly return-demonstrate how to check their blood sugar.

Include how the teaching was done and the proof that it was successful. 

Make sure the nursing note is current  

Don’t: Patient had an elevated temperature after breakfast.

Do: Patient had a temperature of 39.1°C (102.4°F) at 0900. 

This example shows again that it is important to be specific, precise, and to give all the available information. 

Make sure the nursing note is organized  

Don’t: Patient had altered mental status, stomach pain, and could not recall their name.

Do: Patient had altered mental status with inability to recall their name and complained of dull stomach pain at a level of 5 out of 10.

Group related information together. 

Make sure the nursing note is professional  

Don’t: Patient uncooperative and would not take meds. 

Do: Patient refused 0900 meds. 

It is inappropriate to label patients as difficult, uncooperative, or use a negative description  – simply state the actions, what happened, quotes stated and everything that may have kept you from taking measures you were supposed to. Leave out any personal perspectives, reactions, or feelings.

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Knowing how to take notes in nursing school is an absolute must. In this post we’ll go over two methods, depending on whether or not your instructor provides the lecture slides ahead of time. If they do, then you are in luck! If they don’t…no worries, you will be fine!

Method #1 for taking notes in nursing school

If your professors provide the lecture slides in advance, then count yourself as super lucky! You have a couple of options here. Do your professors allow laptops in class? Then what you will do is take that PowerPoint file and open it up. View it in “outline” format, which converts all the slides into an outline. Copy this outline by selecting the entire thing and using “control-C”. Next, you want to paste this outline into a Word document. Now, as you sit in class and the professor goes through the slides, you can take notes right into the outline you’ve created.

If the professor doesn’t allow laptops in class, no problem! Just print out the slides (about 4-6 to a sheet) and take notes directly onto this printout.

Whichever method you use, your notes are going to be a mess by the time you leave class. That’s fine, because you’re not done, yet! You are NOT going to try to study off these disjointed PowerPoint notes. That would be a disaster. So, later on that day if possible (or the next day…but try not to wait too long), you are going to RE-DO your notes. Yes, you read that right.

You are going to go back through your notes and type them up into a beautiful, organized format that you can use to study for exams. Fill in incomplete thoughts, supplement with additional information, augment things you didn’t quite understand, and add examples.

What you will end up with is a thorough study guide…and guess what? Re-writing those notes is a form of studying as well. This method will help  you retain key information, understand difficult concepts and feel confident when it comes time to take the test.

Method #2 for taking notes in nursing school

So, what if your professor doesn’t send out lecture notes or provide slide handouts in class? Well then buckle up…it’s gonna be a bit bumpy! If you can type quickly, and the proffessor allows laptops, then just type type type your heart out. You’re going to have to go back and re-do this as they will be a giant mess!

You can also handwrite notes, and to do that I highly recommend the Cornell method. In the Cornell method, you draw a line down the left side of your page to create about a 2.5 inch margin on the left. You’ll write your notes on the larger section along the right, and then use the area on the left for labeling the specific topics.

Here’s an example of how I used the Cornell method to take notes and study!

The nice thing about the Cornell method, is that if you can write fast enough, you may not have to totally re-do your  notes. After class, go back through them and add key information and expand on concepts as needed. Write those cues in the left-hand column, and you should end up with serviceable notes you can use to study from. Simply cover up the right-hand side of the page and go through each topic listed along the left-hand side…when you can talk through all the concepts thoroughly, you’ve got the material down!

One tip for taking quick hand-written notes is to get proficient at using abbreviations and symbols, like these shown here:

Write notes like a rockstar!

Taking your nursing school notes to the next level

Once your notes are beautiful and you’ve used them to study for awhile, you’ll notice you’re reviewing information you already know. This is a giant waste of time and we’re going to stop doing it, mkay? Instead, we are going to focus on studying the information we are still struggling with…and that’s when the next level of notes comes into play.

Get an 8.5×11 piece of paper and write the topic at the top. Now, take your key concepts and write just a few key words or reminders about each one…keep the details to the information you don’t know. What you will end up with is a VERY distilled down form of your notes containing JUST the information you need to review in the days before the exam. Here’s a sample of one of my study sheets…they are all one page, even the difficult ones!

Using this one-sheet study guide made a HUGE difference in my ability to relegate information from short term to long-term memory. Give it a try and I guarantee it will help…heck, it may even Change Your Life. Ok, maybe not…but I do feel strongly about this method!

A note about highlighting

It’s imperative that you establish a good system for highlighting. For starters, don’t highlight everything…otherwise it loses its impact. A helpful tip is to use various colors of highlighters for different types of information…blue for signs/symptoms, green for interventions, orange for meds…you get the idea.

For even more tips, check out my book (#ad)! Want to see what other have to say? Our testimonials speak for themselves!

Do you have an awesome note taking tip to share? Let your fellow nursing students know in the Thriving Nursing Students Facebook group !

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The information, including but not limited to, audio, video, text, and graphics contained on this website are for educational purposes only. No content on this website is intended to guide nursing practice and does not supersede any individual healthcare provider’s scope of practice or any nursing school curriculum. Additionally, no content on this website is intended to be a substitute for professional medical advice, diagnosis or treatment.

Last Updated on August 15, 2024 by Maureen Osuna, MSN, RN

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Career Advice > Professional Development > Upskilling and Promotions > How to Write a Good Nursing Note: Example and Tips

How to Write a Good Nursing Note: Example and Tips

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A nursing note describes the reason for a patient’s care, interventions, their response to the interventions, and their overall progress. Documentation is an integral part of healthcare , so honing this skill is definitely worth your time. Keep reading to learn about why nursing notes are important, tips for drafting your own, and a nursing note example.

Why Write Nursing Notes?

Nursing narrative notes facilitate communication between the healthcare team by detailing a patient’s progress. Having proof of a patient’s care can be useful for a variety of reasons. Oncoming nurses can read them to learn more about their assignments, the nurse who wrote the documentation can refresh their memory, and other healthcare workers can see the results of their interventions.

These notes are also used for other activities indirectly related to patient care, such as health insurance companies using them to assess the cost of care, or as a written record in the event that legal action is taken against an individual nurse or facility.

Nursing Note vs. Charting: What’s the Difference?

Nursing notes are a form of charting, but not all charting equates to a nursing note. Nursing narrative notes include more details than routine charting because they provide a general overview of the situation on top of patient progress.

Sometimes, charting places more emphasis on day-to-day changes. An oncoming nurse who’s unfamiliar with the patient will likely still have plenty of questions after reading the specific bits of information and data described in typical charting, but would get a more thorough idea of the situation from a nursing note.

What to Include in Nursing Notes

• Patient’s name and demographic information
• Objective and subjective data
• Interventions
• Outcome and evaluation
• Treatment plan
• Chief complaint
• Relevant history
• Medications

What to Avoid in Nursing Notes

• Non-specific wording
• Premature charting
• Symptoms without an intervention
• Personal assumptions

How to Write a Good Nursing Note

With all this background on what to include in a good nursing note example, you must be wondering about how to realistically draft one. Below, we describe how to write a nursing narrative note.

1. Be Specific and Detail-Oriented

Notes are an essential part of team communication. Coworkers will rely on your note, so it’s important for you to be as clear as possible. On top of that, nursing notes can be used as legal documents in the event of a malpractice suit . If you’re called to testify, you may not remember many details. You’ll have to rely on your documentation to do much of the speaking on your behalf.

2. Name the Colleagues With Whom You Interacted

Identifying your coworkers will save other team members time and energy. Instead of trying to figure out who did what, they’ll know exactly whom to approach when they have any questions or concerns about decisions regarding the patient’s care.

3. Keep It Simple

Short sentences and simple words are easier to understand than long sentences with elaborate language. This is especially important when you consider all of the stressors that can arise in healthcare environments.

4. Prioritize Objective Data

Your coworkers will be the most concerned with the facts, so ensure you include them in your note. The patient’s subjective experience is important, but information such as vital signs, lung sounds, and the patient’s visible appearance are the main drivers of the care plan . Why? Because they show what the body is communicating to you and what the patient may not be able to articulate.

5. Address the Chief Complaint

It’s important to describe progress, or lack thereof, regarding the reason the patient needs medical assistance in the first place. It can’t hurt to include other health-related details, but make sure to prioritize their chief complaint and anything directly related to it.

6. Remember to Sign Your Name

This seems like a no-brainer, but it’s a detail people may forget when in a hurry. For the sake of clear communication, it’s important for your coworkers to know who wrote the note. On top of that, a nursing narrative note isn’t complete without a signature.

Nursing Narrative Note Sample

Reading a nursing note example will help you gain a better understanding of what’s expected of you. Check out our sample below for some guidance.

XX/XX/20XX X:XXpm

The patient is a 64 year old female whose chief complaint is an exacerbation of chronic migraines. Patient reports an 8/10 pain level that decreases to 7/10 on the current prescription of 600mg of ibuprofen once a day. Patient states she feels nauseous, which is a common symptom of her migraine exacerbations. She describes the quality of migraine as a “stabbing, throbbing feeling.” Patient states she struggles with bright lighting and loud sounds because they worsen her migraines. In these instances, she says her pain score rises to 9/10.

Patient is AAOx3. HR=95 bpm, RR=20 bpm, T=98.6, BP=130/90, PO2=98%. Bowel sounds present and bowel movements remain regular. No complaints of impaired vision nor memory. Patient states there are no life stressors adding to her current migraine exacerbation. Patient states her sleep schedule is normal.

Mayowa Okumba, APRN, ordered a basic metabolic panel (BMP) and an MRI scheduled for tomorrow. Patient is aware and consents to these procedures. Will continue to monitor vitals and for any other signs of discomfort.

Cherise McDonald, RN

Nursing Note Useful Tips

Here are some tips to keep in mind to help you write a useful nursing note example of your own.

1. Record Key Details Throughout the Day

You’re responsible for juggling a lot of information, and it’s perfectly normal for small details to slip your mind. Those seemingly little details could be important to the big picture. Jot down any details that stand out to you as soon as possible.

Even if your reason is just a hunch, it can’t hurt to have it written somewhere until your mind understands why it was important. Write on something you won’t lose such as your report sheet or a small notepad. Just make sure you properly dispose of them to protect the patient’s private health information.

2. Create a System That Works for You

To avoid missing key details, build a nursing note routine. Do you prefer to include vital signs first or the patient’s chief complaint? Do you include objective data followed by subjective descriptions, or will both be intertwined throughout the note? Is there a specific nursing notes template you prefer? Having a system makes it easier to ensure you don’t miss anything.

3. Imagine Reading Your Own Note With Fresh Eyes

If you feel like you don’t have a clear picture of the current situation and impending actions after reading your note, why would anyone else? When you’re finished documenting, reread your note to ensure others can readily understand the most valuable information from your shift.

What Did You Learn From Our Nursing Note Example?

We showed you what to do, now it’s your turn! Strengthen your documentation skills so you can feel confident in your next role. Get connected with personalized nursing job matches in your location and specialty today.

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5 Perfect Nursing SOAP Note Examples + How to Write

One of the most important parts of a nurse’s job is documentation, and there are several types of nurses' notes used in nursing care today. Nursing notes are the way healthcare providers communicate and promote continuity of care. In this article, we will discuss one type of nursing notes, SOAP nursing notes. I will answer the question, “What is a nursing SOAP note?” I will also share the steps to writing a good SOAP nursing note and provide you with 5 perfect nursing SOAP note examples + how to write them.

What is a Nursing SOAP Note?

Who developed nursing soap notes, what is the purpose of writing a nursing soap note, what is the difference between a nursing soap note and a nursing progress note, 4 advantages of nursing soap notes, advantage #1: nursing soap notes facilitate clinical reasoning., advantage #2: soap nursing notes promote active listening., advantage #3: soap nursing notes help create a detailed medical history., advantage #4: nursing soap notes help facilitate communication between nurses and doctors., 3 disadvantages of nursing soap notes, disadvantage #1: many nurses and healthcare providers question the order of the soap nursing note format., disadvantage #2: patients may have several complaints that must be addressed., disadvantage #3: gathering information to determine patient progress can be time-consuming with soap nursing notes., what elements should be included in a nursing soap note, 1. subjective data (s):, 2. objective data (o):, 3. assessment findings (a):, 4. plan of care (p):, what elements should not be included in a nursing soap note, 1. information that is irrelevant to the patient’s current condition:, 2. speculations about the patient’s symptoms or feelings:, 3. confusing pronouns:, 4. avoid judgmental statements:, 5. avoid using slang terms or unprofessional phrases:, how to write a perfect nursing soap note, what are the perfect examples of nursing soap notes, 5 most common mistakes to avoid while writing nursing soap notes, mistake #1: not naming the source of information, about the mistake:, how to avoid:, mistake #2: not providing supporting objective data, mistake #3: repeating subjective and objective data in the assessment section, mistake #4: rewriting the whole treatment plan, mistake #5: assuming the first complaint is the “chief” complaint, bonus 5 expert tips for writing nursing soap notes faster, tip #1: write your note at an appropriate time., tip #2: use direct statements, avoiding overly wordy content., tip #3: be specific and to the point., tip #4: document each patient encounter as soon as possible., tip #5: connect interventions with your diagnosis., my final thoughts, frequently asked questions answered by our expert, 1. who can write a nursing soap note, 2. when to write a nursing soap note, 3. do nurses write soap notes every shift, 4. ideally, how long should nursing soap notes be, 5. what’s the most important part of a nursing soap note, 6. can i use abbreviations in a nursing soap note, 7. what tense do i write a nursing soap note, 8. are nursing soap notes handwritten or printed, 9. how to sign off a nursing soap note, 10. what happens if i forget to write a soap note on the time it should have been written, 11. can a nursing student write a nursing soap note.

Sample Notes

Effective Nursing Notes: Examples & Templates

Nursing notes serve as a vital component of patient health records, meticulously capturing various medical assessments conducted by nurses. These evaluations frequently encompass documentation of crucial details such as changes in a patient’s condition, vital signs, and the type of care administered. As a result, nursing notes offer an in-depth account of the medical examination process, as recorded by the attending nurse. To simplify this process, nursing notes templates are pre-designed forms that can be easily accessed online or downloaded for immediate use, enabling nurses to quickly input their assessment observations.

These notes are indispensable in facilitating effective communication among healthcare practitioners, as they supply pertinent data that informs exceptional treatment and healthcare delivery. By utilizing these pre-designed templates, nurses can eliminate the laborious and time-consuming task of creating nursing notes from scratch, allowing them to focus on providing optimal patient care.

What Should be Included In a Nursing Notes Template

Efficient documentation is crucial in nursing practice, as it ensures the continuity of care and fosters seamless communication among healthcare professionals. Pre-designed nursing notes templates can streamline the process, allowing nurses to focus on patient care rather than paperwork. However, a template must include certain critical elements to be truly effective. This article will outline the essential components that should be incorporated into a nursing notes template to promote comprehensive and accurate documentation.

• Patient Demographics: An effective nursing notes template should begin with a section for patient demographics, including the patient’s name, date of birth, age, gender, medical record number, and admission date. This information helps healthcare providers quickly identify the patient and provides context for the assessment findings.
• Chief Complaint or Reason for Visit: The template should have a dedicated section to document the patient’s chief complaint or the primary reason for their visit. This section provides a concise summary of the patient’s presenting problem, which guides the nurse’s assessment and subsequent care planning.
• Vital Signs and Measurements: A comprehensive nursing notes template must include a section to record vital signs such as temperature, pulse, blood pressure, respiratory rate, and oxygen saturation. Additionally, it should provide space for documenting other relevant measurements, such as height, weight, and pain levels.
• Head-to-Toe Physical Assessment: The template should facilitate a thorough head-to-toe physical assessment by providing distinct sections for each body system. These sections can include the integumentary, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and neurological systems. Space for documenting the patient’s general appearance and mental status should also be provided.
• Medication Administration and Response: An essential component of a nursing notes template is a section for recording administered medications, including the drug name, dosage, route, and time. Additionally, the template should provide space for documenting the patient’s response to the medication and any side effects observed.
• Nursing Interventions and Patient Education: The template should include a section to document nursing interventions performed, such as wound care, IV insertion, or catheter placement. Moreover, it should provide space to record patient education topics discussed, the teaching method used, and the patient’s understanding or questions.
• Plan of Care and Progress Notes: A well-designed nursing notes template should have a dedicated section for documenting the patient’s plan of care, including ongoing assessments, treatments, and referrals to other healthcare professionals. Furthermore, space for progress notes should be provided to record any significant changes in the patient’s condition, response to interventions, or updates to the plan of care.

Tips for Crafting Exceptional Nursing Notes

Maintaining clear, accurate, and comprehensive nursing notes is crucial for effective communication among healthcare practitioners and ensuring optimal patient care. To enhance the quality of your nursing notes, consider these key tips and best practices:

• Adhere to a Consistent Format: Utilize a consistent format aligned with your healthcare system’s standards to ensure easy comprehension by other healthcare professionals. A uniform approach enables seamless collaboration and minimizes the risk of misunderstandings.
• Prioritize Timely Writing: Complete your nursing notes promptly, ideally within 12 to 24 hours after the assessment, to minimize the possibility of forgetting crucial details. Aim to document your observations during the medical evaluation, as the information will be fresh in your memory.
• Ensure Legibility: Write clearly and neatly, ensuring that your nursing notes are well-organized and easily readable by other healthcare providers. Legible documentation promotes efficient communication and prevents errors due to misinterpretation.
• Keep Notes Concise and Relevant: Nursing notes should be succinct and focused, enabling quick review by other healthcare professionals. Avoid lengthy, unnecessary, and irrelevant information unrelated to the patient’s current health condition.
• Minimize Abbreviations: Refrain from using abbreviations, except for universally recognized terms, to avoid confusion or misinterpretation. Different facilities may use varying abbreviations, which can lead to complications in the treatment process.
• Document All Communications: Record every relevant detail regarding the patient’s health, including the sources of information and their names for future reference. This comprehensive documentation ensures that all pertinent data is readily available for other healthcare professionals.
• Use Objective Language: Stick to objective descriptions of your observations, avoiding subjective or biased language. This practice maintains professionalism and helps other healthcare providers understand the patient’s condition without personal opinions or assumptions.
• Verify and Double-check: Before finalizing your nursing notes, double-check your entries for accuracy and completeness. Ensure that all information is correct and up-to-date, as inaccurate documentation can adversely impact patient care.
• Maintain Confidentiality: Respect patient privacy and follow your healthcare facility’s guidelines for maintaining the confidentiality of patient records. This adherence to ethical standards protects both patients and healthcare professionals.

By implementing these tips and best practices, you can create exceptional nursing notes that foster effective communication among healthcare professionals, ultimately contributing to the delivery of high-quality patient care.

How to Write Nurses Notes (Step-by-Step)

Nurses notes are an essential component of patient care and play a critical role in the healthcare process. They provide a comprehensive and accurate record of a patient’s condition, treatment, and progress. Follow these steps to write effective nurses notes:

Recognize the importance of nurses notes in the healthcare process. They are crucial for communication among healthcare providers, legal documentation, and facilitating care planning and evaluation.

Each healthcare facility may have its guidelines, policies, and protocols for writing nurses notes. Understand and adhere to these guidelines to ensure consistency and accuracy.

There are several formats for writing nurses notes, such as SOAP (Subjective, Objective, Assessment, and Plan), PIE (Problem, Intervention, and Evaluation), or DAR (Data, Action, and Response). Determine the most suitable format for your institution and the specific patient situation.

Ensure that your handwriting is clear and legible, and use concise, objective language to convey your observations and actions. Avoid using unnecessary jargon, abbreviations, or slang.

Document your observations and assessments in an objective and factual manner. Refrain from using personal opinions or assumptions. Be specific and descriptive about the patient’s condition, behavior, or symptoms.

Include the patient’s verbalized concerns, complaints, or expressions of feelings. Use quotations to capture the patient’s words accurately.

Objective data should consist of vital signs, physical examination findings, and any diagnostic test results. Be accurate and thorough when documenting this information.

Based on your subjective and objective findings, provide an assessment of the patient’s condition and develop a care plan accordingly. Record any interventions performed or initiated and the rationale behind them.

Monitor the patient’s response to interventions and document their progress or any changes in their condition. Adjust the care plan as necessary and document any modifications.

Ensure that each entry in the nurses notes includes the date and time, as well as your full name, credentials, and signature. This provides accountability and verifies the accuracy of the information.

Protect the patient’s privacy and maintain the confidentiality of their personal and medical information. Follow your institution’s guidelines for handling and storing patient records.

How Nursing Note Examples Empower Your Practice

Nursing notes are an integral part of the healthcare system, as they serve as a vital communication tool among healthcare providers and a record of patient care. A well-documented nursing note can enhance patient safety, support clinical decision-making, and ensure continuity of care. However, creating comprehensive, accurate, and concise nursing notes can be challenging, especially for novice nurses. This is where nursing note examples come to the rescue. In this article, we will explore how nursing note examples can help you improve your documentation skills and elevate your nursing practice.

Understanding the fundamentals of nursing notes

Nursing note examples can provide you with a clear understanding of the essential components of nursing documentation. By examining these examples, you will gain insight into the structure, content, and language used in professional nursing notes. You can use this knowledge to create accurate, objective, and relevant documentation that adheres to established guidelines and standards.

Enhancing clinical decision-making

Well-written nursing note examples can demonstrate how to effectively communicate clinical observations, patient needs, and nursing interventions. By studying these examples, you can learn how to present information in a logical, organized, and concise manner. This will help you to develop critical thinking skills, support your clinical decision-making, and facilitate interdisciplinary collaboration.

Minimizing errors and improving patient safety

Nursing note examples can help you identify common documentation errors and omissions, such as incomplete or vague descriptions, inconsistent terminology, and lack of patient-specific information. By learning from these examples, you can avoid making similar mistakes in your own nursing notes, thereby reducing the risk of miscommunication and improving patient safety.

Enhancing professionalism and legal protection

In the healthcare setting, nursing notes serve not only as a communication tool but also as legal documentation. Nursing note examples can help you understand the importance of accurate, complete, and timely documentation, which is crucial for protecting both yourself and your patients in the event of legal proceedings. By studying these examples, you can learn how to create defensible documentation that demonstrates your professional competence and adherence to standards of care.

Streamlining the learning process

Nursing note examples can be particularly beneficial for nursing students and newly graduated nurses, as they offer a practical way to bridge the gap between theoretical knowledge and real-world application. By analyzing these examples, you can gain valuable insights into the documentation process and quickly develop the skills needed to create effective nursing notes in a clinical setting.

Nursing note examples are a valuable resource for nurses at all levels of experience, offering insights and guidance to improve documentation skills and enhance patient care. By studying these examples, you can learn how to create accurate, concise, and relevant nursing notes that support clinical decision-making, facilitate interdisciplinary collaboration, and protect both yourself and your patients legally. Embracing the power of nursing note examples can help you elevate your nursing practice and contribute to better patient outcomes.

Nursing Notes Examples

Reviewing nursing note examples can be an incredibly helpful exercise for both novice and experienced nurses alike. By examining real-world examples, you can gain a better understanding of how to structure and write clear, concise, and comprehensive notes. Some common types of nursing notes examples include admission notes, progress notes, and SOAP notes. Familiarizing yourself with these various examples can enhance your documentation skills, ultimately contributing to improved communication among healthcare providers and overall patient care.

Nursing Notes Template

Nursing notes example, soap note example – nurse practitioner, nursing admission notes example, general information.

Vital Signs

Medical History

Current medications, assessment findings.

Plan of Care

Discharge Planning

Nursing progress notes example.

Patient Information

Patient Name: Kevin Mickel Age: 55 Gender: Male Admission Date: 03/01/2026 Room Number: 123

History of Nursing Notes

The history of nursing notes can be traced back to the origins of nursing as a profession. The practice of documenting patient care has evolved over time, influenced by various factors such as the development of nursing theories, advancements in healthcare, and changes in legal and ethical standards. Here’s an overview of the history of nursing notes:

• Florence Nightingale’s influence: Widely considered the founder of modern nursing, Florence Nightingale recognized the importance of documentation in nursing care during the Crimean War (1853-1856). She emphasized the need for accurate record-keeping to track patient progress, identify patterns, and improve care.
• Emergence of nursing theories: In the mid-20th century, the development of nursing theories, such as Virginia Henderson’s Nursing Need Theory and Dorothea Orem’s Self-Care Deficit Theory, underscored the importance of systematic and accurate documentation in nursing practice.
• Legal and ethical considerations: As nursing practice evolved and legal and ethical standards became more stringent, the importance of accurate and comprehensive nursing notes for protecting patient rights and safeguarding nurses from legal issues became more evident.
• Advancements in healthcare: Technological advancements and increasing complexity in healthcare led to the development of new documentation methods, such as the problem-oriented medical record (POMR) and the nursing process (assessment, diagnosis, planning, implementation, and evaluation), which further emphasized the importance of clear and accurate nursing notes.
• Standardization and guidelines: Over time, various professional organizations, such as the American Nurses Association (ANA) and the Joint Commission, have established guidelines and standards for nursing documentation, promoting consistency and accuracy in nursing notes.
• Electronic health records (EHRs): The widespread adoption of EHRs in the late 20th and early 21st centuries revolutionized nursing documentation, making it easier to maintain, access, and share patient records. This has led to increased efficiency, improved communication, and better patient outcomes.
• Ongoing education and research: The importance of nursing documentation continues to be a focus of research, education, and professional development. Nursing schools, healthcare facilities, and professional organizations emphasize the need for ongoing training and education in nursing documentation best practices.

Nursing notes are an indispensable tool for healthcare professionals to ensure seamless communication, continuity of care, and accurate documentation. The examples and templates provided in this article serve as a valuable starting point for nurses to create clear, concise, and comprehensive notes that adhere to the standards of their respective institutions. As a nurse, mastering the art of writing effective nursing notes not only contributes to the overall quality of patient care, but also safeguards your professional integrity and bolsters your ability to work as part of a cohesive healthcare team. By utilizing these examples and templates as a foundation, you can further hone your skills in crafting accurate, relevant, and timely nursing notes that ultimately enhance the patient care experience.

Home > Career Advice > Healthcare Talent > How to Write Nursing Notes: A Guide for Nurses and Nursing Note Examples

How to Write Nursing Notes: A Guide for Nurses and Nursing Note Examples

What are nursing notes? Nursing notes are an important part of patient care documentation. It consists of a record of patient condition, treatment, response of treatment and changes over time. Nursing notes consist of accurate communication among healthcare providers which affects the patient’s outcome.

What are the key elements for writing nursing notes?

The key elements that are important to write nursing notes are as follows:

• Date and time.
• Patient information such as name, ID, and other information.
• Objective data such as heart rate, blood pressure.
• Subjective data such as concerns and feelings.
• Treatments and actions during treatment.
• Patient’s response to medications and treatments.
• Follow up actions.

Format for writing Nursing Notes

Several formats are used to structure nursing notes as consistency is important for writing an accurate nursing note. Some commonly used formats are:

• S (Subjective): It includes patient complaints, for example he complains of headache or chest pain which is 7/10.
• O (Objective): Measurable data or document like blood pressure which can be measured by BP device such as 130/90.
• A (Assessment): To assess the patient with the information provided by subjective and objective data. For example, patients experiencing angina.
• P (Plan): Treatments or action taken to control the problem, symptoms, or diseases. For example, administering medications for angina or monitoring vitals.

SOAP Nursing Note Example

Here is an example of nursing notes using the format of SOAP.

Date: 10/07/2024

Time: 10: 30 am

Patient Name: Ross Geller

S (Subjective Data): Pain in stomach and vomiting. Rating pain 6/10.

O (Objective Data): Fever 101°F.

A (Assessment): possible gastrointestinal or stomach virus.

P (Plan): Give fluids, medication for nausea and ibuprofen.

• D (Data): Patient giving information about the situation.
• A (Action): Action taken for the patient.
• R(Response): The response of the patient after the action was taken.

DAR Nursing Note Example:

Date: 19/08/2024

Time: 11:30 am

Patient Name: Chandler Bing

D(Data): Patient is feeling nausea after IV is inserted to administer antibiotics.

A(Action): IV fluid is slowed down, the head of bed is elevated, antiemetic is given to the patient.

R(Response): The patient is feeling fine with no nausea after the above action was taken.

• P(Problem): What is the problem or issue?
• I (Intervention): What action was taken to address the problem or issue?
• E(Evaluation): What was the result of action taken or evaluation?

PIE Nursing Note Example:

Date: 12/06/2024

Time: 12:30 pm

Patient Name: Joey Tribbiani

P(Problem): Patient complain about the pain where the IV is inserted.

I(Intervention): The IV is removed and reinserted in the other arm.

E(Evaluation): The patient feels no pain this time.

Tips for writing effective Nursing Notes

It is important for nurses to write a perfect nursing note as it can help with effective patient care. Tips to write clear concise nursing documentation are as follows:

• Be accurate and include all details such as time, intervention, response to medication, patient condition including vital signs.
• Make sure to write it down on time so that there is no chance of missing the details.
• Keep professional tone while writing nursing notes.
• Never alter or erase if you make any mistake, instead make a strike through, and write the correct information.
• Avoid any assumptions.
• Sign your full name with designation such as Monica Parker, RN.
• Use standard abbreviations and terminology which is widely accepted in the facility to avoid confusion or miscommunication.
• Utilize technology such as HER or EMR systems and make yourself familiar with the system.
• Use shorter sentences and be specific.
• Use bullet points when it is possible as it is easy and quick to read.
• Protect patient’s privacy.

Importance and Purpose of Nursing Notes

Nursing notes are important to understand the patient’s conditions and help the health workers to provide effective patient care. The importance and purpose of nursing documentation are as follows:

• It is a way of communication between the healthcare providers to keep track of patient conditions.
• These are also considered legal documents, which are crucial during any kind of dispute.
• These records or documentation of the patient’s health keep the new healthcare provider updated f the patient’s condition.
• They are also used for reviewing patient care.

Another Nursing Note example

Here is another Nursing note example.

Date: 10/05/2024

Time: 1:30 pm

Patient name: Rachel Green

Sex: Female

Complaint: Patient complaints about the increase in frequency of urination and burning sensation when urinating.

History: Patient has the history of type 2 diabetes and urinary tract infection from time to time.

Physical exam of the patient:

The temperature is 100.4 °F.

Heartbeat is 94 beats/min.

Blood pressure is 130/90 mmHg.

Diagnosis: Urinary Tract Infection

Assessment: Patient is anxious and discomfort in lower abdominal region. Urine dipstick shows following results.

2+leukocytes which indicate infection.

1+ Nitrates which indicate the presence of bacteria such as Escherichia coli.

1+ blood which indicates the infection or injury to urinary tract.

Evaluation: Antibiotics are given, advised to take more fluids, and show up after 2 days if the symptoms remain. The patient feels no burning sensation after the antibiotic’s medication.

Nursing notes are an essential part of nursing, which provides detailed information about the patient’s health and condition. Nursing notes provide clear communication among the healthcare providers and serve as a legal document if there is any kind of conflict. It is important to write effective nursing notes by adhering to key elements and standard format such as SOAP, DAR, and PIE. In this blog we have discussed the importance of nursing notes, tips on how to write an effective nursing note with some nursing note examples.

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Nursing Notes Examples: A Guide to Effective Documentation

Nursing Notes Examples – Nursing notes are an integral part of patient care. They serve as a vital communication tool between healthcare professionals, ensuring that everyone involved in a patient’s treatment is well-informed. In this article, we will explore the significance of nursing notes, their key components, and the best practices for documenting patient information effectively.

Table of Contents

Why Are Nursing Notes Important?

Nursing notes are essential for several reasons:

• Communication : They facilitate communication among healthcare providers, helping the medical team understand the patient’s condition and progress.
• Legal Documentation : Nursing notes can serve as legal evidence in the event of medical disputes, providing a clear record of patient care.
• Continuity of Care : They ensure that multiple healthcare professionals involved in a patient’s treatment can pick up where the last left off.
• Quality Care : Effective documentation leads to better patient care, as it aids in the assessment and management of the patient’s condition.

Components and Structure of Nursing Notes

Nursing notes are structured documents that follow a standardized format. Here is a breakdown of the typical components that make up a nursing note:

• The header contains the patient’s demographic information, including their name, medical record number, date of birth, and contact information.

Date and Time

• This section records the date and time when the nursing note is written. It is crucial to maintain a chronological record of the patient’s care.

Subjective Data

• Subjective data includes information provided by the patient or their family, such as their description of symptoms, pain level, or concerns.

Objective Data

• Objective data is the nurse’s direct observations and measurements. This can include vital signs, physical assessments , laboratory results, and any other quantifiable data.
• The assessment section is where the nurse provides their professional judgment of the patient’s condition. This includes identifying potential issues or changes in the patient’s health.
• The plan outlines the nursing interventions that will be undertaken to address the patient’s needs and concerns. It includes medications, treatments, and any changes in the care plan.
• The evaluation is a critical section where the nurse reflects on the effectiveness of the interventions and the patient’s response to treatment.
• The nursing note is always signed and dated by the nurse, confirming their responsibility for its content.

Crafting Detailed Nursing Notes

Nursing notes examples.

Now, let’s explore some nursing notes examples to provide you with a clear understanding of how to create effective and comprehensive nursing notes. These examples are structured according to the SOAP (Subjective, Objective, Assessment, Plan) format, which is commonly used in healthcare documentation.

Nursing Notes Example: General Assessment

Subjective: The patient reports mild to moderate abdominal pain, localized in the lower right quadrant. He rates the pain as 6 out of 10.

Objective: Vital signs stable, with blood pressure 120/80, heart rate 80, and respiratory rate 16. The abdomen is tender to palpation in the right lower quadrant. No guarding or rebound tenderness.

Assessment: Likely acute appendicitis. Pain is a concern.

Plan: Notify the physician for evaluation. Administer IV fluids and NPO (nothing by mouth) status in preparation for possible surgery.

Nursing Notes Example: Postoperative Care

Subjective: The patient is groggy and reports pain at the surgical site. Pain is rated as 8 out of 10.

Objective: Vital signs stable, with blood pressure 130/90, heart rate 92, and respiratory rate 18. Dressing over surgical site intact. Minimal serous drainage noted.

Assessment: Immediate post-op period. Pain management is a priority.

Plan: Administer prescribed pain medication as needed. Monitor the surgical site for any signs of infection or complications.

The Importance of Clear and Concise Language

Using clear and concise language is crucial when documenting nursing notes. Avoid jargon and acronyms that may not be universally understood. The notes should be comprehensible to anyone reading them, including patients.

Electronic Health Records (EHRs) and Nursing Notes

Electronic Health Records (EHRs) have transformed the way nursing notes are recorded. They provide a secure and easily accessible platform for documenting patient information. Nurses can now input data directly into EHRs, improving accuracy and efficiency.

Legal Implications

Nurses should be aware of the legal implications of nursing notes. Inaccurate or incomplete documentation can have serious consequences, including legal action. Always document facts, avoid speculation, and never alter records.

Common Mistakes to Avoid

Some common mistakes in nursing documentation include illegible handwriting, skipping sections, or failing to sign entries. Nurses should take care to avoid these errors to maintain the integrity of the patient’s medical record.

Tips for Effective Documentation

To ensure effective documentation, nurses should:

• Document in real-time or shortly after an event.
• Use objective and descriptive language.
• Sign and date each entry.
• Avoid leaving blank spaces or drawing lines for future entries.

Nursing Notes and Interdisciplinary Communication

Nursing notes are not exclusive to nurses; they serve as a communication bridge with other healthcare professionals. It’s essential to share pertinent information with the entire healthcare team to ensure comprehensive patient care.

In Nursing Notes Examples conclusion, nursing notes play a vital role in patient care and healthcare communication. Clear, accurate, and timely documentation is essential to provide quality care, protect legal interests, and maintain a record of a patient’s journey to recovery.

Are nursing notes only for in-patient care?

No, nursing notes are essential for all patient care settings, including hospitals, clinics, long-term care facilities, and home healthcare.

How often should nursing notes be updated?

Nursing notes should be updated regularly, especially when there is a significant change in the patient’s condition or when interventions are performed.

Can patients access their nursing notes?

In many healthcare systems, patients have the right to access their medical records, including nursing notes. However, this may vary by location and facility.

Please note that this article is for informational purposes only and should not substitute professional medical advice.

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What Are Nurses’ Notes?

What’s the difference between nurses’ notes and charting, what are some examples of nurses’ notes, when should nurses chart their notes, what should be included in nurses’ notes, what should not be included in nurses’ notes, 11 tips for writing excellent nurses’ notes — from a nurse, how to write great nurses’ notes.

Sep 05, 2024

Nurses learn early and often that patient care is the No. 1 priority — but charting is a close second. Balancing charting and meeting your patient’s needs can be tough but is a necessity to accurately relay all updates to various providers. In fact, according to Science Direct , interdisciplinary communication is required for high-quality care, and improving communication will ultimately help improve patient outcomes.

Think about it this way: A nurse, doctor, or any other healthcare professional coming on shift is only as good as the charting they have on the patient. Nurses’ notes are an integral part of this chart, so they should be accurate, up to date, and concise. But how much detail is too much detail? And how can you balance patient interaction with writing accurate nurses notes? You’re going to do a lot of charting and notating in your nursing career. These tips will help you make these assessments thorough, helpful, and less stressful.

Since nurses are patient advocates and often have the most contact with their patients, their notes provide the most complete picture of the patient’s health to the other health professionals and specialists involved in their care. These notes are the formal documentation that nurses make when charting, based on the notations and scribbles nurses gather during a patient visit. They may also incorporate charting by exception , a shorthand way of noting the “exceptions” or abnormalities the patient is experiencing by initialing lists and charts.

Keeping thorough and accurate notes is extremely important for maintaining effective communication between nurses and the medical staff, but if a malpractice case is ever filed, these charts will be used by the legal team involved. Considering that nurses care for a number of patients at a time, the formal notes taken on a patient will help a nurse remember the events of the day, the care provided, and the specialists involved if their ever sued or called as a witness .

Nurses’ notes are part of charting. They are short-form notations on pre-established lists (charting by exception), often with a one-paragraph summary that gives a picture of the patient’s health during the visit or time period.

Here are some examples of good nurses’ notes to give you a little more context:

• “When I walked in the room, the patient was blue and having trouble breathing. I called a Code Blue and started CPR. Then Code team arrived.”
• “Lung sounds clear to auscultation bilaterally. Color pink. No signs of respiratory distress noted. VSS. Patient eating 90% of his meals and tolerating well. No abdominal distention or emesis this shift. Patient ambulating adequately. Voiding spontaneously. No BM this shift. Patient’s weight remained the same. Spouse visited patient today. Bed rails up x4. No hazards in room. Call light within reach.”

When nurses talk about charting, they are usually talking about the computer chart. Because many hospitals and clinics are going paperless, the physical (clipboard) chart may only have the patient’s history in it, while the computer chart has everything that happened during this stay.

Ideally, you make quick notations during your visit and add more depth immediately after you leave the patient’s room, when the information is fresh and top-of-mind. American Nurse Today says making brief notes while assessing the patient will help you chart faster and give more accurate (formal) nurses’ notes right after your visit. This helps you move efficiently between each patient you need to see. Visit, chart, repeat.

The three thoughts to keep in mind when you’re writing these notes are:

• Will this help all other staff members working with this patient?
• Did this summarize the patient’s current experience?
• Would this help remind me of the patient’s condition and care five years from now if I ever need to testify on this case?

Because your notes are so important, Tricia Chavez, RN, educator from Redlands Community Hospital in Redlands, California, suggests you include:

• Patient’s Name
• Nurse’s Name
• Reason for Visit
• Vital Signs
• Assessment of Patient
• Labs & Diagnostics Ordered
• Evaluation of How Medical Interventions Worked
• Instructions/Education
• Family Interactions
• Recommendations & Observations
• Anything Out of the Ordinary

Lippincott Nursing Center states you should only include the facts, rather than your personal opinion. However, your opinion can be verbalized to other healthcare professionals so they can get a better picture of the patient (e.g., Social Services notified; request for one more day of stay due to patient unable to care for self at home).

Here are some other notations that cross an ethical line when put in formal/permanent notes:

1. Personal Information Regarding the Patients’ Family Members & Friends*

While it’s OK to give very generalized information on them (e.g., they visited), nothing personal should be included (e.g., they were intoxicated, unkempt, uncaring, etc.).

2. Dialogues You’ve Had About Patients Between Providers*

Instead of conversation details, just note that you’ve informed certain physicians.

3. Anything From the ISMP List of Abbreviations *

These are often misinterpreted and lead to medication errors.

4. Your Opinion*

Instead, report on your recommendations and the systems you have put in place or staff you’ve notified (e.g., this RN recommends social worker evaluate patient’s ability to obtain supplies needed at home upon discharge).

5. Negativity About Staff That Could Be Portrayed as Defamatory*

There should be another system for reporting staff issues within your organization. But there are ways around saying what you want to say. For example:

• You want to say: “The doctor isn’t concerned about something that I’m concerned about.”
• But actually say: “MD notified. No further orders.”
• You want to say: “I’m concerned the patient’s grandmother is abusive to patient.”
• But actually say: “Please evaluate grandmother for care after discharge” in Social Services order. Then, speak freely when Social Services talks to you in person.

As an aside, you should never chart after your shift. If, for whatever reason, off-duty charting is needed and/or necessary, you should comply with your employer’s instructions or seek guidance from your supervisor on how to handle the situation.

As a nurse since 2001 and mentor at my hospital, here is the advice I give to new nurses:

Tip #1: Be concise.

Instead of a long-winded note, just add pertinent facts and keep it short.

Tip #2: State the facts.

Chart what you see, hear, and do.

Tip #3: Read other nurses’ notes.

Everyone will have their own voice. But you’ll see how veteran nurses balance their facts with their insight.

Tip #4: Find a mentor .

Look for an experienced nurse who you trust to give you constructive feedback on your notes.

Tip #5: Write shorthand.

Keep shorthand notes while talking. Keep eye contact while writing shorthand keywords for your post-visit write-up. Then chart it as soon as you can after. For example, if your patient is describing sharp stomach pains, you might write “9/10 pain/LLQ.”

Tip #6: Chart after each visit.

Take five minutes to chart and write thorough nurses’ notes right away; that way, it’s fresh in your mind.

Tip #7: Summarize.

In the hospital setting, write an end-of-the-day note in each patient’s’ chart, starting in the morning and go through the entire day. A good summary is helpful to everyone involved with the patient. In the clinic setting, there should be a summary in each patient’s’ chart with every visit.

Tip #8: Note responses.

Express how the patient responded to treatment. Chart whether they adhered to advice given by you and the doctor.

Tip #9: Describe observations.

Write down all pertinent observations with the patient. For example, “color pink, swelling to lower extremities, pain 4/10.”

Tip #10: Never speculate.

We always want to write how we feel the patient feels, but this isn’t usually accurate. Instead, chart what the patient is literally saying.

Tip #11: Use your resources.

Know that you have resources around you. Use the nurses who have been around for a long time; their experience is invaluable. There are usually charge nurses or nurse managers you can utilize. It’s always better to ask for help than to not chart enough information.

Image courtesy of iStock.com/ Hiraman

Last updated on Sep 05, 2024. Originally published on Oct 29, 2018.

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Jennifer Tomaselli, RN, MSN, RNC is a contributing writer for Berxi. She has a nursing degree and works in Labor and Delivery and NICU. Jennifer is a freelance writer and editor specializing in nursing, healthcare, and fitness. She enjoys living in southern California with her husband and teenage son.

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13.4: Blood Transfusions

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Learning Objectives

By the end of this section, you will be able to:

• Describe steps for administering blood and blood products
• Understand procedures for initiation and transfusion of blood
• Recall different blood transfusion reactions

Blood transfusions are potentially life-saving procedures that replace deficits in blood volume or blood cells with blood donated by the patient (autologous donation) or another individual (Association for the Advancement of Blood and Biotherapies [AABB], 2018). A variety of clinical conditions may require administration of whole blood and blood products, individual components of blood, such as red blood cell s, platelet s, plasma , cryoprecipitated antihemophilic factor (cryo), white blood cells , and granulocytes . They may be needed to increase circulating blood volume after surgery, trauma, or hemorrhage. Other times, blood and blood products may be necessary to increase the number of red blood cells (RBCs) to maintain hemoglobin levels for those with severe anemia or to provide cellular replacement therapy. It is critical for the nurse to learn the proper method of administering blood transfusions and be able to identify potential adverse reactions.

Administering Blood and Blood Products

When administering blood and blood products, the nurse should always verify the provider’s order, including the type of product, amount, date, time, rate, duration of infusion, and specific transfusion instructions, with another qualified provider (AABB, 2018; The Joint Commission, 2021). After verifying the order, the nurse should identify if the patient needs pre- or post-transfusion medications, assess related laboratory values, and understand why the transfusion is indicated for the patient.

The nurse may then explain the procedure to the patient and answer any questions they have. Ask the patient if they have ever received a blood transfusion in the past, and if so, how they tolerated the procedure and if they were premedicated prior to the procedure. Premedicating the patient prior to a blood transfusion may minimize the risk of allergic reaction s to blood products. Indications for premedication may include patients with a history of an allergic reaction to blood transfusions, multiple transfusions, chronic illnesses, anxiety, febrile reaction s, or autoimmune disorders.

Confirm blood type and crossmatch and await notification from the blood bank that the blood or blood products are ready to be administered. Just before obtaining the blood products, collect baseline vital signs, and notify the provider if temperature is greater than 100°F (37.8°C).

Cultural Context: Blood and Blood Products for Jehovah’s Witnesses

Jehovah’s Witnesses may refuse blood or blood product transfusions due to their religious beliefs. These individuals may refuse whole blood or primary blood components but may accept blood derivatives, such as albumin , clotting factor, and immunoglobulins. It is important to assess patient religious beliefs that may interfere with treatment by blood transfusions, but never automatically assume they will refuse the treatment. Instead, educate the patient as to why the blood transfusion is needed, ask the patient about their individual preferences, and respect their wishes if they refuse the blood transfusion. If the patient does refuse the treatment, document the refusal, and notify the provider.

Clinical Safety and Procedures (QSEN): QSEN Competency: Preparing for a Blood or Blood Product Transfusion

See the competency checklist for Preparing for a Blood or Blood Product Transfusion. You can find the checklists on the Student resources tab of your book page on openstax.org.

Blood Typing and Crossmatching

Blood typing and crossmatching ensure compatibility of the donor’s blood with the recipient’s blood. The blood typing results identify the blood type and Rh factor. And crossmatching is used to check for harmful interactions between the donor’s and recipient’s blood. Blood typing and crossmatching are essential to caring for patient safety when a blood transfusion is required.

Blood Types

Blood type depends on the antigens found in the RBCs. There are four main types of blood: A, B, AB, and O. Type A blood contains type-A antigens. Type B blood contains type-B antigens. Type AB blood contains type-A and type-B antigens. Type O blood has no antigens, making it well suited for donation.

Rh factor is determined by whether a certain protein, rhesus factor, is present on the RBCs. Blood may be classified as either Rh positive (+) or Rh negative (−). Rh+ blood contains the Rh protein on the RBCs, whereas Rh− blood lacks the Rh protein. Rh+ is the most common blood type, but Rh− blood does not indicate illness or affect one’s health.

The Rh factor is one of the key factors that determine the compatibility of blood for transfusion. For a blood transfusion to be safe and successful, the recipient’s Rh type must match the donor’s Rh type. For example, a patient who is Rh-negative should receive blood from an Rh-negative donor to avoid potential transfusion reactions . Mismatched Rh factors during a blood transfusion can lead to adverse reactions, including hemolysis (destruction of RBCs), fever, jaundice , and more serious complications. Therefore, ensuring compatibility in terms of the Rh factor is crucial to prevent these reactions.

Blood Donors

When receiving a blood transfusion, it is important that the blood of the donor is compatible with the blood of the recipient. Antibodies may trigger immune reactions against blood that is incompatible. Persons with type A blood should only receive types A or O blood. Persons with type B blood should only receive types B or O blood. Persons with type AB blood are universal recipients and can receive types A, B, AB, or O blood. While persons with type O blood are universal donors and can give to anyone regardless of recipient’s blood type, persons with type O blood may only receive type O blood. Type O blood is often used in emergent situations when blood typing cannot be performed.

In addition to the blood type, the Rh factor plays a critical role. Persons with Rh+ blood may receive both Rh+ and Rh− blood. Those with Rh− blood, however, can only receive Rh− blood. For the transfusion to be considered safe, both the blood type and Rh factor must be compatible (Table 13.2).

Blood Components

Blood may be administered as whole blood or as individual blood components. Individual blood components can treat particular conditions and allow multiple people to benefit from one pint of whole blood. Blood components include RBCs, platelets, plasma , cryoprecipitated antihemophilic factor (cryo), white blood cells , and granulocytes . For example, a patient with low hemoglobin due to anemia can receive a red blood cell transfusion that contains just the RBCs. A cancer patient receiving chemotherapy can receive a platelet transfusion to correct a low platelet count. A person with clotting factor deficiencies can receive a transfusion of fresh frozen plasma to treat their specific clotting disorder.

A red blood cell , also known as an erythrocyte, is the most administered blood component. They carry oxygen from the lungs throughout the body and take carbon dioxide back to the lungs. As the name suggests, RBCs are red in color (Figure 13.23). Commonly referred to as packed red blood cells , they increase hemoglobin and iron levels and improve oxygen levels within the body. They are most frequently administered to patients experiencing anemia.

A platelet , also known as a thrombocyte, is a small, colorless cell fragment that sticks to the lining of a blood vessel to stop bleeding. Platelets are often given to patients experiencing leukemia, blood disorders, or other types of cancer. Some patients with cancer require platelet transfusions as a side effect of chemotherapy, while other patients may have a type of cancer that itself stops the body from creating platelets.

The liquid portion of the blood that carries the red and white blood cells throughout the body is termed plasma . It helps to maintain blood pressure and volume, carries electrolytes to muscles, assists in maintaining pH balance, and supplies proteins for clotting and immunity. Plasma is yellow in color and must be kept frozen to preserve the clotting factor (Figure 13.24). Plasma transfusions are often required for those experiencing liver failure, severe infections, shock, bleeding disorders, or serious burns. During the COVID-19 pandemic, some patients with specific symptoms were treated with convalescent plasma therapy to possibly hasten their recovery.

A portion of plasma that is rich in clotting factors is termed cryoprecipitated antihemophilic factor (cryo). It helps reduce blood loss by slowing or stopping bleeding. It is white in color and must be kept frozen to preserve the clotting factor. Cryo is used for clotting disorders, such as hemophilia and von Willebrand disease.

The white blood cells , also known as leukocytes, help the body fight against disease. They destroy bacteria and create antibodies against bacteria, viruses, and diseases. While your own white blood cells help you to remain healthy, foreign white blood cells may suppress the immune system or be toxic when transfused in other persons. Some patients have very few white blood cells because of severe illness. A transfusion of white blood cells would help their body fight infection, in the same way that more soldiers are brought in to fight a battle.

The granulocytes are a particular type of white blood cell that protect against infection by destroying invading bacteria and viruses. They may be administered to treat infections that are not responsive to antibiotics.

Starting a Blood Transfusion

Before a blood transfusion, there are a number of steps nurses must take. Nurses should ensure completion of blood type determination and crossmatch, obtain baseline vital signs, and collect necessary supplies at the bedside, such as blood tubing and normal saline . The nurse must also explain the procedure to the patient and inform the patient to immediately report symptoms of a possible blood transfusion reaction, such as sweating, chills, chest pain, shortness of breath, headache, back pain, nausea, vomiting, or itching. Then it is time to obtain blood from the blood bank. As a general rule, only retrieve one package of blood or blood products from the blood bank at a time. A transfusion must be started within thirty minutes and must be completed within four hours of obtaining the blood. At the blood bank and once on the unit, the nurse must verify the identity of the patient, transfusion order, transfusion consent, blood type, and compatibility before beginning the transfusion.

Real RN Stories: Preparation Is Important before Administering Blood Products

Nurse: Jocelyn, RN Clinical setting: Inpatient orthopedic unit Years in practice: 13 Facility location: South Carolina

As a nurse for over thirteen years, I have administered blood on numerous occasions. Administering blood requires careful planning to ensure that the process goes smoothly. Over the years, I have learned that up-front preparation can save you a lot of time and effort in the end. For example, prior to obtaining the blood, always check to make sure that the patient’s IV is properly working, that you have a vital sign machine in the patient’s room, and that you have the necessary supplies, such as blood tubing and normal saline.

I encountered a situation in which the patient’s IV was saline locked; I went to hang the blood and found the IV was occluded. After two attempts to restart the IV, the IV team had to be called to restart the IV. Realizing time was ticking, I had to return the blood to the blood bank until the IV could be restarted. Another time, I was attempting to find a vital sign machine, but they were all occupied by the nursing aides. After searching the unit for over ten minutes, I finally located a vital sign machine. Then I had to find another nurse to verify the blood, which took another five to ten minutes. That left a very short window of time for the blood products to be initiated within the given twenty- to thirty-minute window. Other times, I have had the blood in hand and the second nurse waiting for me in the room only to find the blood tubing bin empty in the supply room. Thankfully, I was able to go to another department and borrow blood tubing, but it would have been more efficient to have gathered the blood tubing prior to obtaining the blood. These lessons have taught me to always plan ahead when administering blood so that everything is in the patient’s room and ready to go once the blood has been gathered from the blood bank.

Start the infusion slowly for the first fifteen minutes, rates determined per facility policy. Remain at the patient’s bedside for the first fifteen minutes and monitor for adverse reactions (INS, 2024). After fifteen minutes, retake and document vital signs. If vital signs remain stable and the patient does not display symptoms of a reaction, increase the rate of the blood according to the agency’s policy. Obtain and document vital signs every hour for the duration of the transfusion. Instruct the patient and family to report any unusual reactions immediately (AABB, 2018). Once the transfusion has ended, clamp the blood tubing above the filter, open the roller clamp for the normal saline , and flush the tubing until no visible blood remains in the IV tubing. Disconnect the blood tubing from the patient’s IV and discard the tubing in an appropriate biohazard container. Obtain and document a final set of vital signs as well as the patient’s post-transfusion status.

Verification Protocols

After retrieving the blood or blood products from the blood bank, two nurses must verify the provider’s order and ensure that the blood product label matches the information found on the patient’s blood bank bracelet (AABB, 2018). One nurse should read the information from one source while the other nurse confirms the same information on the other source. Both nurses should verify the serial number, blood component, blood type, Rh factor , and expiration date match. Confirm the identity of the patient as well, by looking at the blood product label and patient’s identification bracelet, the patient’s name, date of birth, and medical record number. Both nurses should document their verification according to the agency’s policy (Figure 13.25). If any discrepancies are noted, do not start the transfusion, and immediately notify the blood bank.

Blood Tubing

When administering blood and blood products , it is critical to use tubing that is specially marked as blood tubing (Figure 13.26). Blood tubing is a Y-tube with a special micromesh filter that prevents blood clots and particles from accidentally being administered to the patient. Make sure that all roller clamps (two above the filter and one below the filter) are closed prior to proceeding. Using one of the Y-connectors, spike a bag of normal saline, unclamp the roller clamp above the Y-site on the saline tubing, squeeze the filter chamber until the saline covers the filter and fills one-third to one-half of the drip chamber . Open the roller clamp below the drip chamber to prime the saline tubing all the way to the distal end of the tubing, then clamp the roller clamp.

Spike the blood with the other Y-tubing by carefully inserting the IV tubing into the port, being careful not to puncture any portion of the blood bag except the port area. Ensure the spike is completely entered into the blood bag. Unclamp the roller clamp on the blood Y-tubing and squeeze the filter chamber until the blood covers the filter. Write the date and time on the blood tubing because blood tubing should be changed at least every four hours to reduce the risk of bacterial growth.

Clinical Safety and Procedures (QSEN): QSEN Competency: Administering a Blood Transfusion

See the competency checklist for Administering a Blood Transfusion. You can find the checklists on the Student resources tab of your book page on openstax.org.

Transfusion Reactions

When administering blood and blood products, there is always a risk of a transfusion reaction. Reactions may be mild or severe and occur within twenty-four to forty-eight hours post-transfusion. Transfusion reactions are categorized as allergic, febrile , hemolytic transfusion, circulatory overload , or bacterial. While a reaction may occur at any point during the transfusion, most reactions typically occur within the first fifteen to twenty minutes after administration. As such, it is critical that the nurse remain with the patient for at least the first fifteen minutes of the transfusion (or longer if required by the agency’s policy) and monitor vital signs. Monitor altered vital signs, such as increased temperature or respiratory rate, closely.

If you suspect a reaction, immediately stop the transfusion, and notify the provider. If the patient experiences an adverse reaction that may be uncomfortable but generally not life-threatening, considered a mild reaction, such as a fever, itching, rash, or mild discomfort at the infusion site, stop the transfusion and notify the provider. Many times, the provider will treat the symptoms (such as administering acetaminophen for a fever or diphenhydramine for itching) and continue the transfusion with close monitoring of the patient.

Moderate reactions are characterized by more pronounced symptoms that can cause discomfort and concern, such as moderate to severe shortness of breath, significant fever, and pronounced skin reactions. Moderate reactions can result from factors like transfusion-associated circulatory overload, more severe allergic responses, or worsening of mild reactions. In the event of moderate reactions, stop the transfusion, and notify the provider. Management of moderate reactions may involve slowing or stopping the transfusion as well as symptom treatment. Severe reactions are the most serious and life-threatening type of transfusion reaction. They can include severe respiratory distress, shock, renal failure, severe hemolysis (destruction of red blood cell s), and cardio vascular collapse . Severe reactions are typically caused by major incompatibilities, such as ABO or Rh mismatches, transfusion of incompatible blood components, bacterial contamination, or acute hemolytic reactions. Severe reactions require immediate discontinuation of the transfusion, aggressive supportive care, and specific treatments tailored to the underlying cause. Management may include administering medications, providing oxygen, and ensuring hemodynamic stability.

In the event a transfusion reaction occurs and the blood is discontinued by the provider, disconnect the blood tubing and start normal saline with new IV tubing to keep the IV line open. If the patient is experiencing shortness of breath, sit the patient upright and start oxygen. Remain with the patient and monitor vital signs every fifteen minutes. Prepare to administer emergency medications, such as antihistamines, fluids, steroids, or vasopressors, depending on the provider’s orders or standing protocols that may be in place. Collect blood and urine samples according to agency policy and provider orders. Check all blood bag labels, forms, orders, and the patient’s identification band to determine whether a clerical discrepancy exists. Keep the blood container, tubing, and transfusion record and send to the blood bank for analysis. Document the symptoms, the time symptoms began, actions taken, as well as the patient’s current condition. Complete an incident report according to the agency’s policy.

Clinical Safety and Procedures (QSEN): QSEN Competency: Managing a Blood or Blood Product Transfusion Reaction

See the competency checklist for Managing a Blood or Blood Product Transfusion Reaction. You can find the checklists on the Student resources tab of your book page on openstax.org.

Allergic Reaction

An allergic reaction occurs when the immune system reacts to the donor’s antibodies. Common symptoms of an allergic reaction include flushing, hives, rash, pruritus , difficulty breathing, laryngeal edema , wheezing, and possible anaphylaxis . Treatment for allergic reaction s may include antihistamines, steroids, and epinephrine.

Patient Conversations: What If Your Patient Experiences a Transfusion Reaction?

Scenario: Provider ordered two units packed red blood cells (PRBCs). The nurse initiated the first unit of PRBCs ten minutes ago.

Patient: Nurse, I don’t feel so good.

Nurse: Mr. Jackson, can you tell me more about how you are feeling?

Patient: I’m itching all over, and I feel like my throat is tight.

Nurse: Mr. Jackson, I’m going to stop the blood transfusion for a moment until we know what is going on. I’m going to take a look at your arms, legs, and back and listen to your heart and lungs.

[Nurse assesses patient.]

Nurse: Mr. Jackson, I noticed you have a rash on your back and arms. I hear wheezing in your lungs, and your heart seems to be beating faster than usual. I think you are having an adverse reaction to the blood products. I’m going to leave the blood turned off and notify your provider.

Patient: Am I going to be okay?

Nurse: You are in good hands, Mr. Jackson. I am right here with you. Let’s check your vital signs so we can monitor your condition. If you begin to feel any worse or feel that you can’t breathe, please let me know.

Febrile Reaction

A febrile reaction occurs when there is hypersensitivity to the donor’s white cells, platelet s, or plasma proteins. Febrile reactions cause the body to build antibodies, so this is the most common reaction if the patient has received blood in the past. Common symptoms of a febrile reaction include sudden chills, fever, flushing, headache, and anxiety. Febrile reactions are treated with antipyretics, such as acetaminophen. Depending on the severity of the reaction, the provider may slow, stop, or continue the transfusion. If the transfusion is continued, carefully monitor the patient throughout the transfusion and promptly report any additional or worsening symptoms that may arise.

Hemolytic Transfusion Reaction

A hemolytic transfusion reaction is a severe and potentially life-threatening complication that occurs when a patient receives incompatible blood products. Common symptoms of a hemolytic transfusion reaction include low back pain (first sign), chills, feeling of fullness, tachycardia, flushing, tachypnea , hypotension, bleeding, vascular collapse , and acute renal failure . The patient may also experience a headache, nausea, and hemoglobinuria . Late symptoms may include fever and mild jaundice . Treatment for hemolytic transfusion reactions depends on the severity of the reaction and may include stopping the transfusion, frequently monitoring vital signs, administering IV fluids to maintain blood pressure, providing supplemental oxygen as needed, dialysis, management of bleeding, and supportive measures to manage the patient’s symptoms.

Clinical Judgment Measurement Model: Analyze Cues: Recognizing a Transfusion Reaction

The patient is receiving a unit of PRBCs. The nurse starts the transfusion at a slow rate and remains with the patient for the first fifteen minutes. Five minutes after starting the transfusion, the patient states, “Can I get another pillow to put behind my back? It is hurting a bit, and I can’t seem to get comfortable.” Back pain is a cue that requires a quick-acting response by the nurse; however, there is not enough information to analyze the significance of the cue. The nurse may promptly ask the patient additional questions, such as, “Is your back pain new or was it bothering you earlier today?” “Can you point to where it is hurting?” The nurse may also perform a quick physical assessment to learn more about the cue. Upon assessment, the patient reports that the pain is a new pain occurring in the lower back. Using critical thinking, the nurse quickly considers factors that could potentially cause the symptoms, such as sitting for too long, sleeping on the back wrong, referred kidney pain, or a hemolytic transfusion reaction.

To narrow down a potential cause, the nurse may need to ask additional questions. The nurse asks the patient, “Do you feel any additional symptoms, such as chills, feeling of fullness, nausea, or headache?” The patient reports a slight headache coming on. The nurse obtains a set of vital signs and notes the patient is slightly tachycardic and that their blood pressure has slightly dropped from the baseline vital signs. Upon physical assessment, the patient is flushed and tachypneic. By recognizing and analyzing the quick onset of cues such as lower back pain, headache, tachycardia, blood pressure dropping, flushing, tachypnea, and recent initiation of a blood transfusion, the nurse forms a hypothesis that the patient may be experiencing a hemolytic transfusion reaction , stops the transfusion, and immediately notifies the provider.

Circulatory Overload

A circulatory overload occurs when the blood is administered at a rate faster than the circulatory system can accommodate. Common symptoms of circulatory overload include a rise in venous pressure , dyspnea, crackles or rales , jugular vein distension, cough, and elevated blood pressure. Treatment for circulatory overload includes positioning the patient upright, lowering the feet in a dependent position, diuretics, oxygen, and bronchodilators.

Bacterial Reaction

A bacterial reaction occurs when the blood or blood products are contaminated with bacteria. Common symptoms of a bacterial reaction include rapid onset of chills, vomiting, marked hypotension, and a high fever. Typically, blood cultures and other laboratory tests (complete blood count, coagulation studies, assessment of organ functioning) will be collected to diagnose or confirm this type of reaction. Treatment for bacterial reactions includes antibiotics, increased hydration, steroids, and vasopressors.