KARDEX

Name Age Sex: M Admitted on Tentative Diagnosis Final Diagnosis Health History: Present Health History DOCTORS ORDER: key. [/] carried out [x] not carried out REFERRAL: key. [/] carried out [x] not carried out. LABORATORY/ DIAGNOSTICS: key: [/] done, with result. [+] done, without result. [x] request made, not yet done [ ] urinalysis [ ] Fecalysis [ ] sputum 3x [ ] hematology:______________ [ ] blood chemistry:______________________ [ ] lipid profile [ ] blood sugar [ ] X-matching [ ] X-Ray [ ] ECG [ ] ultrasound [ ] thoracentesis [ ] paracentesis [ ] others:___________ [ ] TSB, Cold compress [ ] Deep breathing exer. [ ] Suctioning [ ] Turn to side q___hrs. [ ] Bladder training [ ] I&O monitoring: __________________ ROM exercises: [ ] Passive [ ] Active Enema: [ ] Fleet [ ] Cleansing Ultrasonic nebulization [ ] Salbutamol [ ] NSS Amt.Received______ml Endorsed:_________ ml Site: [ ] Right[ ]Left arm [ ] Main line_________ [ ] Side Drip:_________ [ ] Others:___________ Blood Transfusion: [ ] FWB__________unit [ ] PRBC_________unit [ ] Others:___________ Clysis/Drainage: [ ] Peritoneal [ ]T-Tube [ ] Cystoclysis [ ] Penrose Drain [ ] Others: Department F Civil Status at Occupation am pm Religion Admission # Attending Physician Rm.

______ [] [] [] [] [] Ambulatory from_____ _______to___________ ACTIVITY: [ ]CBR [ ]CBR w/o BRP [ ]Others: DIET: [ ]DAT [ ]soft [ ] Liquid Others:______________ Level of Consciousness [ ] coherent [ ]conscious [ ] lethargic [ ]stuporous [ ] coma [ ] obStundation A. Orientation: [ ]time [ ] place [ ]person B. Speech/ Language [ ]clear [ ]garbled [ ]expressive [ ]receptive C. Abnormal posturing [ ] decorticate [ ] decerebrate 2. Pupillary reactions: [ ] BRTL [ ] SRTL [ ] NRTL Size: R._ L._ Reflexes: [ ] babinski [ ] gag [ ] corneal [ ] DTR. 3.Motor Function: [ ] R.[ ] L. arm weakness [ ] R.[ ] L. leg weakness Cranial nerve function ____________________ Glasgow Coma Scale { } best eye opening: { }best verbal response { }best motor response ____ Total Score. [ ] Endotracheal tube [ ] Tracheostomy tube Attached to: [ ] Mechanical ventilator MV_____ TV______ml FiO2_____%RR___cpm SV_________________ [ ] Ambu bag[ ]T-piece O2 inhalation at____lpm via: [ ] nasal cannula [ ] nasal catheter [ ] venture mask [ ] Nasogastric tube [ ] Thoracostomy tube attached to______way bottle [ ] Colostomy [ ] Urinary Catheter [ ]indwelling[ ]condom Others:_____________ ___________________ [] [] [] [] [] [] [] [] [] []

NEURO VITAL SIGNS:

NURSING INTERVENTIONS: key: [/] carried out [x] not carried out

key: [/] elicited [x] not elicited

PARENTERAL FLUIDS:

TUBINGS: key : [ ] intact/patent/draining [ ]closed/ discontinued

SPECIAL PRECAUTION

[ ] Allergy___________ [ ] No BP taking______ [ ] No blood extraction [ ] Blood precaution___

MEDICATIONS key: [/] Given [x] Not given [P] Prescribed

VITAL SIGNS:

BP:_______ T.______ PR._______ RR._____

FOCUS CHARTING
DATE/TIME FOCUS PROGRESS NOTES

NURSING CARE PLAN

CUES DAIGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

__________________________________ Students Name

___________________________ Clinical Instructor