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Nursing data base:

* Patient's name :

* Hospital record No :

* Room No :

* Bed No :* Age :

* Sex :

* Accompanied to hospital by :* Admitted from : home, emergency room,

clinic, other

*

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Previous hospitalization and illness:

Allergies : YES NO:* Type of allergy :

* Immunization received :

* If any family member has health problem

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Feeding pattern : breast feeding / bottle

feeding / gavages' feeding

Activity pattern : Normal bed rest

restricted

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Name Dose Frequency Route Action

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NORMAL VALUEMY CHILDNAME

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Finding

Length / height

- Weight- Head Circumference (HC)

- Chest Circumference

- Arm circumference- Skin Fold thickness

1/11/20112/11/20111/11/2011

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Finding

-Temperature- Pulse

- Respiration

- Blood pressure

1/11/20112/11/20111/11/2011

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Finding

- Facial expression (happiness, frightened,)- Posture (position, type of body movement.)

- Hygiene (cleanliness, body odor, nails, teeth, feet, andclothing condition).

- Nutritional status (Normal body wt., overweight,underweight).

- Behavior (child personality, level of activity,

- State of awareness (conscious, semi conscious,unconscious).

2/11/20111/11/2011

NAD

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NAD( NO ABNORMAILTY DETECTED )

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Nursing Data base :

* Infant's name :

* Birth Date :

* Gestational age of birth :

* Apgars :* Birth weight :

- Present gestational age :

- Present length :

- Head circumference :- Chest circumference :

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Temperature :

Respiration :

Diagnosis : Heart rate :

B1ood Pressure

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Patients

Name: Sex Age Weight

Admission

Date

Diet

Nursing Database:

Students Name:Group:

Section:

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ASK

Diagnosis:

Diarrhea Habits Frequency DurationAmount Odor Color

Vomiting Fever Urine Out put

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Medication Received:

Name Dose Frequency Route Action

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Immunization Received:

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FEEL

Anterior Fontanel NormalSlight

DepressedVery Depressed

Mouth, Tongue

TearCapillary Refill

Moist

NormalLess than 2Seconds

Dry

May present orNOT2 3 Seconds

Very Dry

No TearMore Than 2-3 Sec.

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SIGNSA B C

No signs ofdehyd. (loss 10%

GGeneral

ConditionWell, Alert

Restless,Irritable

Lethargic,floppy

unconscious

E Eyes Normal SunkenVery sunken,

dry

M ThirstDrinks

Normally

Thirsty,Drinkseagerly

Drinks poorly,or unable to

drink

S Skin PinchGoes back

quicklyGoes back

Slowly

Goes backvery slowly (>

2 seconds)

Select Treatment Plan Plan A Plan B Plan C

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Treatment

Where

What TypeHow Much

How Given

Feeding

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Thank

you