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University of San Carlos

College of Nursing
Cebu City

Discharge Plan and Instruction Format

Name: Marilou Alcover Age: 5months old Sex: F Religion: Roman Catholic
Diagnosis: Pneumonia Surgery Undergone, if any NONE
Hospital: Jesus Paras Memorial Hospital
Rm/Ward-bed No. Physician: Pedia Ward; Dr. Pozon

A. Objectives (SMART/ KVSA Format)

1. The patient SO will verbalized the need of their child to take medication on time.

2. The patient will demonstrate the proper breathing pattern.

3. The patient will continue to be breastfeed as prescribed by his doctor.

4. The patient SO will develop a sense of optimism.

I. Medication

Name of Dosage Route Curative Major Side

Drugs Effects Effects
Sabutamol Taken 3-4x a Inhalation/ ●relaxes ●CNS:
day nebulizer bronchial and weakness,
uterine smooth headache
muscles by ●CV:
acting on beta tachycardia,
2-adrenergic palpitation,
blocker hypertension
Nausea and

II. Exercise/ Activity

●Type of activity allowed/ to be continued: continue bed rest

●Procedure or Step: none

●Use of Equipments: (if any) none

●Restriction: none

III. Treatment

(Prescribed treatment to be continued at home or to a referred health institution)

1. Continue taking medication for the prescribed number of days

2. Adhere to the prescribed diet ( breastfeeding) to regain strength and energy

IV. Health Teaching

[♥] clinic appointment schedules

[ ] uses of alternative medication

[♥] follow-up laboratory examinations

[ ] Relapse prevention measures

[♥] understanding and knowing what to do with side effects and medications

[♥] others: Medication should be taken on the time and for the prescribed period of time
even if the patient feels better.

A. Observation signs and symptoms that need reporting:
● Extreme palpitations and difficulty in breathing
● The baby is always crying
● Fever of 38ºc

B. Intervention/ homes remedies that may be done immediately prior to seeking


VI. Diet (prescribed by the doctor/ dietians)

1. prescribed diet: Breastfeeding

2. restriction: none

VII. Spiritual and Psychological Needs

[♥] spiritual counseling

[ ] confession

[♥] supportive counseling

[ ] grief work

[♥] family therapy

[ ] join organizations/ church activities

[ ] anger management

[ ] reconciliation of conflicted relationship

B. Discharge Details

a. Date of Discharge:

b. Time of Discharge:

c. Accompanied by:

d. Mode of transportation:

e. General condition upon discharge:

Simeon Alcover
Patient /Relative
(Signature over Printed Name)


Mekko Mae Villamor and Guada Vergara

(Signature over Printed Name)

(Signature over printed Name)