Patient Profile: de La Salle-Lipa College of Nursing

De La Salle
College of N
Pres. J.P. Highway, Lipa
Patient Pr
Patient Registration
Name: B.P
Age: 66 years old 5 months and 6 days
Sex: Female
Birthdate: N/A
Address: N/A
Phone: N/A
Religion: Roman Catholic
Occupation: N/A
Email Address: N/A
Chief Complaint: sudden dizziness, elevated blood pressure
of 200/150 mmHg
History of Present Illness: Few hours prior to consultation, while patient B.P. is having his schedule hemodialysis, patie
experienced sudden dizziness, headache, and loss of coordination. No cardiac pain noted but accompanied by elevation
blood pressure of 200/150 mmHg. Patient prompted consultation and admission for further observation about his cond
Admitting Diagnosis: Hospital Community Acquired Pneumonia, Chronic Kidney Disease stage 5, secondary to hypertens
De La Salle-Lipa
College of Nursing
Pres. J.P. Highway, Lipa City, Batangas
Patient Profile
Vital Signs
Vital signs
BP: 130/80 mmHg
RR: 82 bpm
PR: 20 bpm
Temp: 36.3°C
Ht: 5'2"
Wt: 63 kg
Oxygen Saturation:
Pain scale: N/A
GCS: N/A E: N/A M: N/A V: N/A
Allergies: N/A
Immunization: N/A
nsultation, while patient B.P. is having his schedule hemodialysis, patient

s of coordination. No cardiac pain noted but accompanied by elevation of
pted consultation and admission for further observation about his condition.
ed Pneumonia, Chronic Kidney Disease stage 5, secondary to hypertension

lle-Lipa
f Nursing
ipa City, Batangas
Profile
Past Medical History Medications

( - ) Asthma: Clopidogrel ( Plogrel ) , 75mg/tablet
( - ) CVA:
( - ) Cancer:
( + ) Diabetes:
( + ) Heart Disease:
( - ) Hypertension:
( + ) OTHERS: Kidney diseases from father side
( - ) Previous Surgery:
P/S History Laboraties:

( - ) Tobacco Use : Packs
Quits: Yes: or No: ✓
( - ) Alcohol Use : Bottles/Glass
( - ) Subtance Use :
OB History
G P ( N/A ) Philhealth ( - )
LMP: N/A EDC: N/A HMO: N/A
De La Salle-Lipa
College of Nursing
VS Monitoring Sheet
Patient Name: B.P. Attending Physician: Not Specified
Date Time Blood Pressure Temperature Pulse Rate Respiratory Rate
02/15/2019 130/80 mmHg 36°C 82 bpm 20 bpm

pa
sing
Batangas
Sheet
Physician: Not Specified Room No.
O2 Saturations Pain Scale Remarks Signature
N/A N/A N/A

De La Salle - Lipa
College of Nursing
Pres. J.P Laurel Highway, Lipa City, Batangas
VS Graphing Sheet
Patient Name: Evelyn Borromeo Attending Physician: Not Specified
Date
Number of Days
RR CR T
12
12
12
12
12
12
12
12
4
8
4
8
4
8
4
8
4
8
4
8
4
8
4
180
41
170
40
160
39
150
38
140
37
130
36
120
35
110
100
70
70
90
60
80
50
70
40
60
30
50
20
40
10
BLOOD PRESSURE
6-2pm
Urine times 2-10pm
10-6am
6-2pm
Stool No. 2-10pm
10-6am
hysician: Not Specified Room No.
12
12
12
12
12
12
8
4
8
4
8
4
8
4
8
4
8
4
8
De La Salle - Lipa
College of Nursing
I & O Monitoring Sheet

Patient Name: Evelyn Borromeo Attending Physician: Noy Room No.
INTAKE OUTPUT
DATE
NGT/
Oral IV Fluid NGT Others Total Urine Stool Others
Vomitus
6-2pm
2-10pm
10-6am
Total
Date
NGT/
Vomitus
6-2pm
2-10pm
10-6am
Total
Date
NGT/
Vomitus
6-2pm
2-10pm
10-6am
Total
Date
NGT/
Vomitus
6-2pm
2-10pm
10-6am
Total
Date
NGT/
Vomitus
6-2pm
2-10pm
10-6am
Total
Room No.
TPUT
Total Sign
Total Sign
Total Sign
Total Sign
Total Sign
Total Sign
De La Salle - Lipa
College of Nursing
Neurological Evaluation
Patient Name: Attending Physician:
Date
Time
Best To Verbal Command Obey 6
Motor Localizes Pain 5
Response Flexion Withdrawal 4
Flexion Abnormal 3
Extension 2
No Response 1
Best Oriented and Converses 5

Verbal Disoriented and Converses 4
Reponse Inappropriate Words 3
Incomprehensives Words 2
No Response 1
Eye Spontaneously 4
Opening To Verbal Command 3
To Pain 2
No Response 1
Pupil 10
Size 9
and 8
Rection 7
6
5
4
3
2
1
Brisk
Sluggish
Non Reactive
Room No.
De La Salle - Lipa
College of Nursing
KARDEX
Date Diagnostic Exam Request Specimen Result In Date No. IVF/ Blood Trans
OR Slip Received by
Date Operation to be Preformed / Radiological Procedure Consent Slip Signed NOD Surgeon/OB
Date Medications Dose Route Frequency Date Treat

02/15/2019 Clopidogrel ( Plogrel ) 75 mg / tablet Per Orem q.d
Date PRN Med

Diet: Not Specfied Allergies: No known allergies.
Age: 66 years old Sex: Female Status: Married
Date and Time of Admission: Adm Dx: Hospital Community Acquired Pneumonia, Chronic Kidney Disease stage 5, secondary Procedure Performed (if any): Bioph
February 09, 2019 , 1300H to hypertension Pain Assessment , Activities of Daily
Assessment .
Room No: Not Specified Name of the Patient: B.P Attending Physician: Not Specified
Page 1
STAT DOSE
Date Stat Medication Time Given Given By
Diagnotic/Radiologic Procedure
Date Procedure Preparation Instruments
Contraptions (if any)
Contraptions Date and Time Inserted Date and Time Removed
Other/Special Orders
Date and Time Endorsement Date and Time
Page 2
IVF/ Blood Transfusion/Side Drip Remarks
Anesth Pedia Remarks
Treatment Frequency
PRN Medications Frequency

Nationality: Not Specified Wt: 63 kg Ht: 5'2
Status: Married Religion: Roman PhilHealth ⃝

Catholic
HMO: N/A
e Performed (if any): Biophysical, Psychosocial & Functional Assessment,
essment , Activities of Daily Living Assessment and Cultural Spiritual
ent .
n: Not Specified Referrals: None
Given By Remarks
Instruments Remarks
and Time Removed Remarks
Endorsement
De La Salle - Lipa
College of Nursing
Medication Chart
Patient Name: B.P. Attending Physician: Not Specified Room No:
Date and Time Given Stat Medication Signature
Standing Order Time Dates:

Medications: Clopidogrel ( Plogrel ) 12mn
4am
6am
8am
12nn
Date and time of Order: 4pm
Signature 8pm
Medications: 12mn
4am
6am
8am
12nn
Signature 8pm
Medications: 12mn
4am
6am
8am
12nn
Signature 8pm
Medications: 12mn
4am
6am
8am
12nn
Signature 8pm
PRN Medication
Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given
Medications:
Date and time of Order: Signature Signature Signature Signature Signature Signature Signature Signature
Signature
PRN Medication
Medications:
Signature
PRN Medication
Medications:
Signature
IV FLUIDS
Date No. Time Started Time to be IVF Signature
Consumed
Side Drips
Date No. Time Started Time to be IV Side Drip Signature

Consumed
Blood Products
Time to be
Date No. Time Started Blood Products Signature
Consumed
De La Salle - Lipa
College of Nursing
Pres. J.P. Laurel Highway, Lipa City, Batangas
NURSES NOTES
Patient Name: Admitting Diagnosis:
Date and Shift

Salle - Lipa
e of Nursing
ghway, Lipa City, Batangas
SES NOTES
Admitting Diagnosis: Room Number
Date and Shift

De La Salle-L
College of Nu
Pres. J.P. Highway, Lipa City
Discharge Instr
Patient Name: B.P.
Medication Names
Clopidogrel ( Plogrel )
Special Instructio
De La Salle-Lipa
College of Nursing
Discharge Instruction
Age: 66 Sex: Female
Dosage Frequency
75 mg 1 tablet Per Orem, Once a Day
Special Instructions
a
ng
ngas
tion
Room Number: Not Specified
Discharge Instructions
Take medicine as prescribed and report any adverse reactions.

Patient Profile: de La Salle-Lipa College of Nursing

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De La Salle

nsultation, while patient B.P. is having his schedule hemodialysis, patient

ed Pneumonia, Chronic Kidney Disease stage 5, secondary to hypertension

Past Medical History Medications

P/S History Laboraties:

Date Time Blood Pressure Temperature Pulse Rate Respiratory Rate

02/15/2019 130/80 mmHg 36°C 82 bpm 20 bpm

O2 Saturations Pain Scale Remarks Signature

N/A N/A N/A

I & O Monitoring Sheet

Best Oriented and Converses 5

Date Medications Dose Route Frequency Date Treat

Date PRN Med

Age: 66 years old Sex: Female Status: Married

Anesth Pedia Remarks

PRN Medications Frequency

Status: Married Religion: Roman PhilHealth ⃝

n: Not Specified Referrals: None

Date and Time Given Stat Medication Signature

Standing Order Time Dates:

Date No. Time Started Time to be IV Side Drip Signature

Date and Shift

Date and Shift

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