College of Nursing

USSO Building
Visca, Baybay City, Leyte, Philippines
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

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N U R S E S N O T E S
Name Reason for Admission

Age Sex Medical Impression

Date F = Focus D = Data A = Action R = Response

VSU's Vision: A globally competitive university for science, technology, and environmental conservation.
VSU's Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and
innovative technologies for sustainable communities and environment.
 College of Nursing
USSO Building
Visca, Baybay City, Leyte, Philippines
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

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NURSING CARE PLAN # ______

Name Reason for Admission
Age Sex Medical Impression

PLANNING NURSING INTEVENTIONS

NURSING OUTCOME
ASSESSMENT CUES RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION INTERVENTIONS
(with references)
Subjective Sleep deprivation Goal Independent After 4-8 hours of
“Di ko katulog dire”” as related to changes of Within 4-8 hours of - Observe and rendering
verbalized by the environment rendering appropriate assess for appropriate nursing
patient. nursing intervention, progress of intervention, the goal
Scientific Basis the patient will be able sleep is met.
Environment can to: deprivation or - Patient is able
Objective promote or hinder feeling to maintain
- Yawning during sleep. Any change- General Objectives discomfort proper sleep
assessment noise in the Adopt environmental - Determine and reduce
- Daytime environment-can inhibit changes client’s usual yawning
sleepiness sleep. The absence of sleep pattern - Patient is able
observed usual stimuli or the Specific Objectives and to sleep
presence of unfamiliar -Maintain proper sleep expectations. comfortable to
stimuli can prevent to reduce yawning - Provides the
people from sleeping. - Reduced comparative environment
uncomfortable sleep baseline - Patient is able
Reference environment - Determine to understand
Fundamentals of - Verbalize interventions the
nursing eight edition, understanding of sleep client has tried occurrence of
vol. 11 Kozier and disorder in the past. sleep disorder
Erb’s, pp. 1170 - report improvement in - Report
sleep and rest pattern improvement

VSU's Vision: A globally competitive university for science, technology, and environmental conservation.
VSU's Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.
 - Helps identify in sleeping
appropriate and resting
options
- Recommend
quiet activities,
such as
reading,
listening music
- Reduce
stimulation so
client can relax

Collaborative

Dependent

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 College of Nursing
USSO Building
Visca, Baybay City, Leyte, Philippines
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

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DRUG THERAPEUTIC RECORD # ______

Name Reason for Admission
Age Sex Medical Impression

MECHANISM OF CONTRA- SIDE EFFECTS/ NURSING

DRUG NAME DRUG CLASS INDICATIONS
ACTION INDICATIONS ADVERSE EFFECTS CONSIDERATION
Generic: Therapeutic: Anti-inflammatory, Patient’s Side Effects: Observe 15 rights of
Mefenamic Acid analgesic, and Indications: - Contraindicated - Swelling of hands, drug administration
Nonsteroidal anti- antipyretic with legs, or feet
inflammatory activities related to Relief of hypersensitivity - Sore throat Before:
drugs (NSAIDs) inhibition of moderate pain to Mefenamic - Seizure - Assess for any
Brand: prostaglandin when therapy will acid, aspirin - Constipation history of drug
Ponstel synthesis; exact not exceed 1 allergy and as - Headache allergy
mechanism of week. treatment - Stomach upset - Obtain vital
Pharmacologic action are not preoperative pain - dizziness signs for
Complete known. with coronary baseline data
Prescription: Fenamate General: artery bypass Adverse Reactions: - Explain to the
Mefenamic Acid 1 grafting patient and SO
cap TID. CNS: the drug
- Use cautiously -headache, dizziness, action, dose,
with asthma, somnolence, insomnia, and side
Date of Rx: renal, or hepatic fatigue. Tiredness, effects.
(not indicated in impairment, tinnitus, ophthalmic - Check for the
the sample) peptic ulcer effects right drug
disease, GI DERMATOLOGIC: - Check the
bleeding, doctor’s order
hypertension,

VSU's Vision: A globally competitive university for science, technology, and environmental conservation.
VSU's Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.
 heart failure -Crash, pruritus, dry
pregnancy mucus membrane, During:
lactation. stomatitis - Take drug with
GI: food and with
-Nausea, dyspepsia, GI the prescribed
pain, diarrhea, vomiting, dosage.
constipation, flatulence, - Take
GI blade, ulcers medication
Pregnancy around the
Category: GU: clock
-Dysuria, renal - Give
impairment medication to
the right
HEMATOLOGIC: patient.
- Bleeding, platelet - Instruct patient
inhibition with to notify the
higher doses, health care
neutropenia, professional if
neutrophilia, signs and
leucopenia, symptoms
pancytopenia, occur.
thrombocytopenia, - Administered
agranulocytosis, the right dose.
ranulocytopenia,
aplastic anemia,
decreased Hgb or After:
Hct, bone marrow - Tell patient to
depression, immediately
menorrhagia report signs
RESPIRATORY: and symptoms
- Dyspnea, of allergic
hemoptysis, reactions
pharyngitis, (such as rash,
bronchospasm, itching, hives,
rhinitis chest

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 OTHER: tightness, and
- Peripheral edema, trouble
anaphylactoid breathing)
reactions to - Evaluate the
anaphylactic effectiveness
shock. of drug given.
- Rechecked the
vital signs and
symptoms
occur.
- Documentation

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