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By:Seragaldin M. AbdulqaderClinical pharmacology for nursesUniversity of Raparin/school of nursingThe lecture for undergraduate students:

2015 -2016

Bio-demography:Personal information from the client, e.g.:

Patient's full name:

Sex: Age:

Residential area: Occupation:

Hospital: Ward/Unit:

Level of education:

Date of admission: Date of interview:

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Chief Complaint:

Subjective date Objective date Duration

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Headache Hypertension 5 days

The main problem that made patient to come to you.

•Subjective date: The data that the patient will tell you.

•Objective data: The data that you will get it from the patient via the examinations. For example:

Medical History: Medical Diagnosis:

Past Medical History (PMH):

Past Surgical History (PSH):

Smoking History:

Drug allergy:

Social History (SH):

Diet:

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Vital signs:

Blood pressure: 000

000mm Hg.

Radial pulse: bpm.

Apical pulse: beat per minute (bpm).

Respiration Rate: breath per minute (Bpm).

Body temperature: 00.0oC. (By axillary + 0.5oC)

(By rectally – 0.5 oC).

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Vital signs:

Pain:

oDegree of the pain:

oLocation of the pain:

oDuration of the pain:

oRadiation of the pain:

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Physical examination:

Inspection: using eyes to found morphological abnormalitiesof the bodies organ.

Percussion: using finger taping to detect the structure ofthe body organs.

Palpation: using hands to determined the texture ofthe body’s organ.

Auscultation: using stethoscope to check body’s sound abnormalities.

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Current problems:Any problem that founded in patient’s body systematically.

For example:

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Related system Problem

Cardio Vascular system Tachycardia

Nervous system Convulsion

Renal system Polyuria

Problem assessment:

A. Etiology

B. Risk factors

C. Stability

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Lab investigation:

A. Chemical tests

B. Hematology

C. Others

Therapeutic InterventionTherapeutic intervention is dependent on progression of the condition. For example;

Women identified in intervention clusters as having severehypertension (systolic greater than 160 mmHg) by the communityhealth worker during visiting will be given 750 mg of oral methyldopaprior to transfer to a nearby facility for further care interventions.

Therapeutic objectives Accounting the goals that reduce the health barriers and enhance the healing of the disease.

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Current medication

Any medications that patient get it on hand.

For example;

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Medication Type Dosage Route Frequency

Dextrose 5% Solution 500cc IV 1 x 2

Piperacillin/Tazobactam Vial 4g/0.5g IV 1 x 3

Furosemide amp 40mg IV 1 x 2

Pantoprazole Tab 20mg PO 1 x 2

Index of drug related problem

The medication information that patient get it on hand.

For example;

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Drug Side effect Alternative Teaching point

Dextrose 5%

Carbohydrate

Caloric product

Fluid replacement

Nil Non - Explain needs for drug.

- Tell patient to notify adverse

effects promptly

Piperacillin/Tazobactam

Antibiotic

Anti-bacterial

Thrombophlebitis The physician suggest to change Pipracillin to Ampiclox

- Do not use this drug if it contain

particles or if the vial is cracked

or damaged.

- Tell the patient use the drug as

soon as possible if she misses it.

But don't use two doses at once.

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Thanks