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