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Liceo de Cagayan UniversityCagayan de Oro City
DATA BASE HISTORY
Name of Patient: ____________________________________ Sex: _________ Age: ________ Religion: ___________________
Civil Status: ____ Educ. Level: _________________________ Income: ______________ Occupation: _____________________
Nationality: ______________ Date Admitted: _____________ Time: __________ Attending Physician:_____________________
Informant: _________________________ Admitting Dx.: ____________________________________________________________
Temp.: ___________ Pulse Rate: ____________ Resp. Rate: _____________ BP: ______________ Ward/Room: ____________
Height: _____________ Weight: _______________ Home Address: __________________________________________________
Chief Complaint and History of present Illness: (Reasons for hospitalization; outset, character, methods used to resolve problem)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date Type of Previous Illness/ Pregnancy/ Delivery
Has received blood in the past: _______ Yes _______ No If yes, indicate the dates _______________________________________Reaction: _______ Yes _______ No
Allergies:Medication Name Route, Dose &Frequency Date & Time of Last Dose Reaction
Score: _______________ Grade: _______________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________-________________________________________________________________________________________________________________________________________________
NURSING SYSTEM REVIEW CHARTName: ____________________________________________________________________ Date: ___________________Vital Signs:Pulse: ______________ BP: ______________ Temp.: _____________ Height: ______________ Weight: _____________
INSTRUCTION: Place an (X) in the area of abnormalities. Write comment on the space provided. Indicate the location of the problem in the figure using (X).
EENT[] impaired vision [] blind [] Pain [] reddened [] drainage [] lesion seen [] gums [] hard of hearing [] deaf [] burning [] edema Assess eyes, ears, and nose throat for abnormality [] no problem
RESPIRATORY [] asymmetric [] tachypnea [] apnea [] rales [] cough [] barrel chest [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing [] pain [] cyanotic Assess respiration, rate, rhythm, depth, pattern,breathe sounds, comfort [] no problem
CARDIO VASCULAR[] arrhythmias [] tachypnea [] numbness[] diminished pulses [] edema [] fatigue[] irregular [] bradycardia [] murmur[] tingling [] absent pulses [] painAssess heart sounds, rate rhythm, pulse, blood pressure, circulation, fluid retention, comfort [] no problem
GASTROINTESTINAL TRACT [] obese [] distention [] mass [] dysphagia [] rigidity [] pain Assess abdomen, bowel habits, swallowing, bowel sounds, comfort [] no problem
GENITO- URINARY TRACT and GYNE [] pain [] urine color [] vaginal bleeding [] hematuria [] discharges [] nocturia Assess urine freq., control, color, odor, comfort, gyne- bleeding, discharge[] no problem
NEURO [] paralysis [] stuporous [] unsteady [] seizures [] lethargic [] comatose [] vertigo [] tremors [] confuse [] vision [] grip Assess motor function, sensation, LOC, strength, grip, gait,Coordination, orientation, speech.[] no problem
MUSCULOSKELETAL and SKIN [] appliance [] flushed [] cool [] drainage [] Petechiae [] ecchymosis [] rash [] lesion [] prosthesis [] stiffness [] atrophy [] deformity [] poor turgor [] hot [] diaphoretic [] skin color [] moist[] wound [] swelling [] itching [] painAssess mobility, motion, galt, alignment, joint function, skin color, texture, turgor, integrity [] no problem
NURSING ASSESSMENT SUBJECTIVE OBJECTIVE
COMMUNICATION:[] hearing loss Comments: _______________[] visual change _________________________[] denied _________________________ _________________________ _________________________
[] glasses [] languages[]contact lens [] hearing aide [] speech difficulties R LPupil size: ____________________________Reaction: ____________________________
OXYGENATION: [] dyspnea Comments: _______________[] smoking history ________________________________________ _________________________[] cough _________________________[] sputum _________________________[] denied _________________________
Resp.: [] regular [] irregularDescribe: ________________________________________________________________________________________________________________________________________
R: ______________________________________________L: ______________________________________________
CIRCULATION:[] chest pain Comments: _______________ _________________________[] leg pain _________________________[] numbness of _________________________ Extremities _________________________ [] denied _________________________
Heart Rhythm [] regular []irregularAnkle edema: ____________________________________ Pulse Car. Rad. DP Fem*R:______________________________________________L:______________________________________________Comment: _______________________________________________________________________________________* if applicable
NUTRITION:Diet: ___________________________________________[] N [] V Comments: _______________Character _________________________[] recent change in _________________________ Weight, appetite _________________________[] swallowing _________________________ Difficulty _________________________[] denied _________________________
[] dentures [] none
Full Partial With Patient
Upper [] [] []
Lower [] [] []
ELIMINATION:Usual bowel pattern [] urination frequency_________________ ___________________[] constipation [] urgency Remedy [] dysuria_________________ [] hematuria Date of last BM [] incontinence_________________ [] polyuria[] diarrhea [] foley in place Character [] denied_________________
Comment:______________ Bowel sounds: __________________________________ ______________________________________________ Abdominal distention _______________________ Present [] Yes [] No_______________________ Urine * (color, consistency, _______________________ odor) _______________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ * if they are in place?
MGT. OF HEALTH & ILLNESS:[] alcohol [] denied (amount, frequency) _____________________________________________ _____________________________________________[] SBE last Pap Smear: ______________________________ LBM: _________________________________________
Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).________________________________________________________________________________________________________________________________________________________________________________________________
SUBJECTIVE OBJECTIVE
SKIN INTEGRETY:[] dry Comments: _______________ _________________________[] Itchy _________________________[] other _________________________ [] denied _________________________ _________________________
[] dry [] cold [] pale[] flushed [] warm [] moist [] cyanotic*rashes, ulcers, decubitus ( describe size, location, drainage) ________________________________________________________________________________________________________________________________________
ACTIVITY/SAFETY: [] convulsion Comments: _______________[]limited motion of joint ________________________ _________________________Limitation in ability to _________________________[] ambulate _________________________[] bathe self _________________________[] other _________________________[] denied _________________________ _________________________
[] LOC and orientation _____________________________________________________________________________[] gait [] walker [] cane [] other
[] steady [] unsteady __________[] sensory and motor losses in face or extremities: _______________________________________________________________________________________________________[] ROM limitation: _________________________________________________________________________________
COMFORT/SLEEP/AWAKE:[] pain Comments: _______________ (location _________________________ frequency _________________________ remedies) _________________________[] nocturia _________________________[] sleep difficulties _________________________ [] denied _________________________
[] Facial grimaces[] guarding[] other signs of pain: ______________________________________________________________________________________________________________________________[] side rails release form signed (60 + years)________________________________________________
COPING: Occupation: _____________________________________Members of household: ____________________________________________________________________________________________________________________________Most supportive person: ___________________________________________________________________________________________________________________________
Observed non-verbal behaviour: ______________________________________________________________________________________________________________________________________________________________________The person and his phone number that can be reached any time: ___________________________________________________________________________________________________________________________________________
DOCTOR’S ORDER SHEET
Patient: _____________________________________ Attending Physician: ________________________________Diagnosis: ______________________________________________________ Date Admitted: __________________
Date/ Time Doctor’s Order Rationale of Order
DOCTOR’S ORDER SHEET
Patient: _____________________________________ Attending Physician: ________________________________Diagnosis: ______________________________________________________ Date Admitted: __________________
Date/ Time Doctor’s Order Rationale of Order
Name of Patient: ___________________________________________________________________________
Diagnosis: _________________________________________________________________________________
LABORATORY RESULTS
Dx. Exam Results Normal Values Significant of the Result
Name of Patient: ___________________________________________________________________________
Diagnosis: _________________________________________________________________________________
LABORATORY RESULTS
Dx. Exam Results Normal Values Significant of the Result
Date Ordered Diagnostic/ Laboratory Exams Clinical Significance
Date Ordered I.V. Fluids/ Blood Clinical Significance
NURSING CARE PLANS
NURSING STANDARDSDATE/ TIME
FOCUS DAR
NURSING CARE PLANS
NURSING STANDARDSDATE/ TIME
FOCUS DAR
FLUID INTAKE and OUTPUT CHART
INTAKE OUTPUTDATE SHIFT ORAL I.V. OTHERS TOTAL URINE VOMITUS DRAINAGE OTHERS TOTAL
TOTAL FOR 24
HRS
TOTAL FOR 24
HRS
TOTAL FOR 24
HRS
TOTAL FOR 24
HRS
TOTAL FOR 24
HRS
Note: Entries will start during Duty proper.
VITAL SIGNS MONITORING SHEET
Date/ Time T PR RR BPLevel of
consciousnessIntravenous fluid
(vol. & drops/ min.)
IVF Level per
Endorsement
Remarks
ROOSTER LIST
DATESHIFT NOC AM PM NOC AM PM NOC AM PMLAST CENSUSNO. OF ADMISSIONNO. OF DISCHARGECURRENT CENSUS
STATUS RM NAME OF PATIENT C.C/ DIAGNOSIS ATTENDING PHYSICIAN
STATUS LEGEND: New Admission: Discharge: Expired: (RED) Transferred: *
MEDICATION WORKSHEET
DATE ORDERED
DRUG, DOSE, ROUTE & FREQUENCY
Indicates date & shift Indicate date & shift Indicate date & shift
Note: Entries will start during Assessment
HEALTH TEACHINGS
Name of the PatientMEDICATION RATIONALE
EXERCISE
TREATMENT
OUT PATIENT(CHECK-UP)
DIET
KARDEXName: ____________________________________________________
Address: __________________________________________________
Age: Sex: Civil Status:_____________
Ward: Room:______________________
Chief Complaints: ___________________________________________
Diagnosis: _________________________________________________
Attending Physician:_________________________________________
Date & Time Admitted:_______________________________________
Date ObservationDoctor’s
OrderIVF/
BloodMedication Nursing Diagnosis Goal Nursing Intervention Special Endorsement
DRUG STUDY
Name of Drug (Generic Name / Brand
Name)
Special Indication (Based on patients
Problem)
Mechanism of Action (Relate it to patient’s problem)
Nursing Responsibility (Based on drug’s
physiologic effects)
DRUG STUDY
Name of Drug (Generic Name / Brand
Name)
Special Indication (Based on patients
Problem)
Mechanism of Action (Relate it to patient’s problem)
Nursing Responsibility (Based on drug’s
physiologic effects)
PATHOPHYSIOLOGY
Name of Patients: __________________________________________________________________________________
Diagnosis: ________________________________________________________________________________________
REFERENCES:
Score: _____________ Grade: _____________
PONR(Problem-Oriented Nursing Records)
INTENSIVE NURSING PRACTICUM
Student Name: NOC ____________________________________
AM _____________________________________
PM ______________________________________
Area of Assessment: _________________________________________
Inclusive Date: _________________________________________
Clinical Instructor: NOC ____________________________________
AM ______________________________________
PM ______________________________________