Head to Toe Assessment Date :

Conducted By: Jestian Ryll B. Delacruz Time:

LOC Lower extremities

ALERT Drowsy lethargic stuporous Coma Hair Present
Orientation Edema
Person Foot strength
Place Homain
Time
Situation Temp vs trunk

Vitals Nail
Temp 36.8 c
BP 90/60 mmHg
Rr 19 bpm Pedal Pulse
PR 50 BPbpm
Pulse Ox 97%

Head Normocephalic R.O.M

Hair no mass scars lessions Upper R
PERLA 3 mm Upper L
nose midline, symmetrical, no discharges Lower R
ears NO LESIONS, DEFORMITIES, NO DISCHARGES NOTED Lower L
Mouth NO INFLAMMATION, SWELLING, EXUDATE
Midline Tongue Yes Sensation
Moist Yes
Lesions none General Assessment
Definition none
Neck Weight
Carotid Pulse Yes JVD trachea midline BM
Chest
Apical Pulse Yes muffled Arrthythmia Pain Assessment
Breath sounds
Anterior normal Intensity
Posterior normal Location
Lateral normal Duration
Chest symmtery symmetrical Characteristics
Skin turgor ( clavicle) 20 sec return to normal Precipitation
Abdomen Frequency
* Inspection no masses, scars,lesions noted Non-Verbal
* Auscultation Relief Factors
 LUQ active hyper absent Sleep
RUQ active hyper absent
LLQ active hyper absent Skin Assessment
RLQ active hyper absent Description
* Palpation no abdominal masses and tenderness are noted.

Upper Extremities
Radial Pulses equal 2+
Other

Temp. VS trunk Warm Cool

Grip equal and strong pool
Capillary refill 1.8 seconds
Vein Filling rapid 28 seconds
 ###
8:30 AM

Lower extremities
Hair Present
X
Foot strength POOR
Homain POS NEG

Temp vs trunk warm cool

yellow thickened Ingrown

shiny and firm

Pedal Pulse
R palp doppler
L palp doppler

Strength
active Upper R G+
active Upper L G+
active Lower R G+
active Lower L G+

Sensation Normal

General Assessment

50 kg Heigth 5'2 ft
20.1

Pain Assessment
Acute Chronic
Intensity 6 out of 10
Location head
Duration 10 minutes
Characteristics Sharp
Precipitation
Frequency Intermittent
Non-Verbal guarding behavior
Relief Factors n/a
Skin Assessment
Description
* Fill in BOX
DATE: Sept 21, 2021 TIME: 9:00AM
Doctor Order
Nov. 10, 2021 9:00
Notes:
Start 3% NS i Lit @125 ml hr., Mannitol 500 ml q4 hrs 30 gtts/ min. (Adjust
Dexamethasone IV 4 mg BID, monitor BP, q hr, watch for any sign of seizure
monitoring,
Date : SEPT. For serum
21, 2021 Time 12:AMElectrolytes, CT scan, ECG, pulse oximeter monito

Date: Sept 21, 2021 Time: 3:00 PM

Date: Time:
Notes:
ctor Order
Nov. 10, 2021 9:00 am
Notes:
30 gtts/ min. (Adjust the IV rate when giving mannitol),Nifedipine 30mg.PO q6hr.
or any sign of seizure( note frequency and time), monitor Neuro status (LOC). I&0
ulse oximeter monitoring, glucose monitoring OD. O2 /nasal Cath @3 lits/ min
This is a general checklist of what the unit/ ward nurse is supposed to accomplish within the EMR within the s
Directions: The system will write " YES" if DONE and "X" if NOT DONE
DAILY CHECKLIST
Date:
1st 2nd 3rd PRN
VS (BP) 168/88
Temp. 37.9
Pulse Rate 128
Respiratory Rate 24
I/Os (Intake) 550.38mL
(Output) 150mL

MAR YES
1 Metropolol YES
2 Clopidogrel YES
3 Morphine Sulfate YES
4 Aspirin YES
5 Heparin YES
6. Nitroglycerin YES
7. Oxygen Therapy YES
NCP YES
Monitoring YES
Fall Assessment YES
Skin Assessment YES
Health Teachings YES
Laboratory Results Checking YES
Health Assessment YES
lish within the EMR within the shift.
d "X" if NOT DONE
ILY CHECKLIST
Date: Date:
1st 2nd 3rd PRN 1st 2nd 3rd PRN
Name: Nora Harake
Date Admitted: 11-Oct-21
Address: Malued Dagupan City
Attending Physician:

IVF MONITORING SHEET

DATE IVF INCORPORATION
3 % NS 1L @125ml/hr
IVF MONITORING SHEET
TIME STARTED FLOW RATE AMOUNT INFUSED AMOUNT ENDORSED
9:00 AM 31 gtts/min 250 ml 750ml
NURSING CARE PLAN SEPTEMBER 9, 2021

FOCUS DATA/ACTION/RESPONSE
shortness of breath D- patient present with shortnes of breathing with increase a

A- encourage patient to sit upright as tolerated

teach and encourage diaphragmatic breathing
encourage sleeping in relaxed position
identify complications and encourage patient to report su
monitor vital signs

R- patient was able to breath adequately during activities aft

NURSING CARE PLAN SEPTEMBER 9, 2021

FOCUS DATA/ACTION/RESPONSE
Acute pain D- Left arm pain 20-30 over 3days intermittently
pain worsen and radiate to the neck
facial grimace

A- using pain scale measure patient pain

encourage patient to assume a comfortable position
administer analgesic as prescribed by the physician
monitor vital signs

R- patient was free from pain, maintenance stable vital signs

 f breathing with increase activities.

t as tolerated
matic breathing

ourage patient to report such accordingly

quately during activities after nursing intervention

intermittently

comfortable position
bed by the physician

ntenance stable vital signs and relaxed posture

Date: Date:
SHIFT: 8-Apr
TIME TAKEN: 8 12 4 8
BP 168/88
TEMP (Degrees Celsius) 37.9
TEMP ROUTE (Oral, Axillary, PR, Forehead Scan)
PR 128
RR 24
O2 SAT 9900%
Pain Scale: 5-Oct
 VITAL SHEET
Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)

12 4 8 12 4 8 12 4 8 12
M/ DD/ YY) Date: (MM/ DD/ YY)

4 8 12 4 8 12 4 8 12 4
Date: April 29, 2021
1st SHIFT
INPUT in ML OUTPUT in ML
ROUTE AMOUNT ROUTE AMOUNT
PO 150 ML URINE 150
IVF 250 ML BM
PEG TUBE DRAINAGE TUBES
JT VOMITUS
NGT
TPN
MEDS 0.3854 ML
Others Others
Total INPUT 400 ML Total OUTPUT

Others
Total OUTPUT 0
 I and O SHEET
2nd SHIFT 3rd SHI
INPUT in ML OUTPUT in ML INPUT in ML
ROUTE AMOUNT ROUTE AMOUNT ROUTE AMOUNT
PO URINE PO
IVF BM IVF
PEG TUBE DRAINAGE TUBES PEG TUBE
JT VOMITUS JT
NGT NGT
TPN TPN
MEDS MEDS
Others Others Others
250 Total INPUT 0 Total OUTPUT 0 Total INPUT
 3rd SHIFT
OUTPUT in ML
ROUTE AMOUNT
URINE
BM
DRAINAGE TUBES
VOMITUS

Others
0 Total OUTPUT 0
Nursing Care Plan #1
Date Started: (MM, DD, YYYY) Target Date:
ASSESSMENT Nursing Diagnosis PLANNING
(MM, DD, YYYY)
Nursing Interventions Rationale Evaluations
Nursing Care Plan #2
Date Started: (MM, DD, YYYY) Target Date: (MM/ DD/ YYYY)
ASSESSMENT Nursing Diagnosis PLANNING
: (MM/ DD/ YYYY)
Nursing Interventions Rationale Evaluations
Nursing Care Plan #3
Date Started: (MM, DD, YYYY) Target Date: (MM/ DD/ YYYY)
ASSESSMENT Nursing Diagnosis PLANNING
MM/ DD/ YYYY)
Nursing Interventions Rationale Evaluations
Directions: Change the administration box (yellow) to actions taken (see legend colors)

LEGEND: GIVEN DELAYED

NOT GIVEN DISCONTINUED
MEDICATION ADMINISTRATIO
DATE
MEDICATIONS TIME

1 METROPOLOL 5mg IV over 1 min. q5 min for 3 doses. 9:00am.

2 Clopidogrel 75 mg PO OD 10:30 AM

4 Morphine Sulfate 5 mg IV PRN 10:00 AM

5 Aspirin 300 mg PO OD 10:30 AM

6. Nitrogylcerine .4 mg sublingually PRN 9:00 AM

7. Heparin IV OD (keep protamine sulfate inj available) 9:30 AM

8. Oxygen Inhalation/ nasal cath @4 lit/min 9:00 AM

ON ADMINISTRATION RECORD (MAR)
DATE
ADM TIME ADM TIME ADM
Smith Nora
Last name Given Name Middle name Date
Age
Malued Dagupan City Pangasinan Sex
Address Birthday
Time submitted
9/11/2021 Room #
Diagnosis Requested By:

LABORATORY REQUEST

HEMATOLOGY BLOOD CHEMISTRY

CBC GLUCOSE
WBC, DIFF COUNT ONLY BUN
HGB, HCT ONLY CREATININE
ESR LIPID PROFILE
PLT COUNT CHOLESTEROL
CLOTTING TIME/BLEEDING TIME TRIGLYCERIDES
PTT HDL/LDL
APTT BUA
PERIPHERAL SMEAR SERUM ELECTROLYTES (Na, K, Cl, Ca)
AMYLASE
CLINICAL MICROSCOPY BILIRUBIN STUDIES
ROUTINE URINALYSIS SGOT
URINE ALBUMIN SGPT
SPERM ANALYSIS TOTAL PROTEIN
PREGNANCY TEST ALBUMIN
GLOBULIN
SEROLOGY/BLOOD BANKING A/G RATION
C RECATIVE PROTEIN HBA1C
HBSAG TROPONIN I
HIV QUANTITATIVE
HCV QUALITATIVE
ANTI-HAV CREATININE CLEARANCE
RPR 24 HOURS URINE PROTEIN
TYPHIDOT ALKALINE PHOSPHATASE
WIDAL TEST CK-MB
ABO/RH TYPING D-DIMER
CROSS MATCHING/SCREENING
H. PYLORI MICROBIOLOGY
DENGUE TEST GRAM STAIN
PSA AFB STAIN
THYROID FUNCTIONS TES CULTURE AND SENSITIVITY
TSH KOH
FT3
 FT4 OTHERS
CT SCAN, ECG,
PARASITOLOGY
FECALYSIS
OCCULT BLOOD
 SEPT. 21, 2021
68
FEMALE
AUGUST 5, 1962
9;00 AM
3
DR. Divina Gracia Corrigan

FASTING RANDOM

ELECTROLYTES (Na, K, Cl, Ca)

QUANTITATIVE
QUALITATIVE
INE CLEARANCE
RS URINE PROTEIN
E PHOSPHATASE

E AND SENSITIVITY