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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

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

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)

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 ______________________________________

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