DATA BASE AND HISTORY

Name of Patient: C.C.B Sex: Male Age: 56 Religion: Roman Catholic

Civil Status: Married Income: N/A Nationality: Filipino
Date Admission: ________________Time: ___________ Informant: ______________________
Temperature: 37.8 Pulse Rate: 89 Resp. Rate: 27 BP: 120/70
Height: ____________ Weight: _____________

Chief Complaint and History of Present Illness

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Type of Previous Illness Type of Previous Illness

Date Date
Pregnancy/Delivery Pregnancy/Delivery

Has received blood in the past: ___ Yes _/ No; If yes, list dates _____ Reaction ___ Yes ___
No
Medication Dose / Time of Name of Dose / Time of Last
Name Frequency Last Dose Medication Frequency Dose
Acetylcystein 600mg/OD
e
Paracetamol 500mg/tab
Ascozin 1tab/PO
Azithromycin 500mg PO 9/25/21
Ceftriaxone 450mg TIV 9/25/21
Remdesivir 9/25/21

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Admitting diagnosis: ____________________________________________________________
Attending Physician: ____________________________________________________________
Score: __________
Grade: __________
NURSING SYSTEM REVIEW CHART
Name: C.C.B Date: 10/11/21
Vital Signs:
Pulse: 89bpm BP: 120/70mmHg Temp: 37.8°C Height: __________ Weight: __________
INSTRUCTIONS: Place an (X) in the area of abnormality. Write comment on the space
provided. Indicate the location of the problem in the figure using (X).
EENT:
[ ] impaired vision [ ] blind ________________
[ ] pain reddened [ ] drainage ________________
[ ] burning [ ] edema [ ] lesion teeth ________________
[ ] assess eyes, ears, and nose ________________
[ ] throat for abnormality [ X ] no problem ________________
RESPIRATION ________________
[ ] asymmetric [ X ] tachypnea [ ] barrel chest ________________
[ ] apnea [ ] rales [ X ] cough ________________
[ ] bradypnea [ ] shallow [ ] rhonchi ________________
[ ] sputum [ ] diminished [ ] dyspnea ________________
[ ] orthopnea [ ] labored [ ] wheezing ________________
[ ] pain [ ] cyanotic ________________
[ ] assess resp. rate, rhythm, depth, pattern ________________
[ ] breathe sounds, comfort [ ] no problem ________________
GASTRO INTESTINAL TRACT ________________
[ ] obese [ ] distention [ ] mass ________________
[ ] dysphagia [ ] rigidly [ ] pain ________________
[ ] assess abdomen, bowel habits, swallowing ________________
[ ] bowel sounds, comfort [ ] no problem ________________
GENITO-URINARY and GYNE ________________
[ ] pain [ ] urine color [ ] vaginal bleeding ________________
[ ] hematuria [ ] discharge [ ] nocturia ________________
[ ] assess urine freq., control, color, odor, comfort ________________
[ ] gyn-bleeding [ ] discharge [ ] no problem ________________
NEURO ________________
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures ________________
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors ________________
[ ] confused [ ] vision [ ] grip ________________
[ ] assess motor function, sensation, LOC, strength ________________
[ ] grip, gait, coordination, speech [ ] no problem ________________
MUSCULOSKELETAL and SKIN ________________
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae ________________
[ X ] hot [ ] drainage [ ] prosthesis [ ] swelling ________________
[ ] lesion [ ] poor turgor [ ] cool [ ] deformity ________________
[ ] atrophy [ X ] pain [ ] ecchymosis [ ] diaphoretic moist ________________

2
 [ ] assess mobility, motion, gait, alignment, joint function ________________
[ ] skin color, texture, turgor, integrity [ ] no problem ________________
NURSING ASSESSMENT 2
SUBJECTIVE OBJECTIVE
COMMUNICATION:
 HHearing loss Comments: __________  Glasses  Languages
 VVisual changes ____________________  Contact lens  Hearing aide
 D[X]Denied ____________________ R L
____________________ Pupil Size: 3mm  Speech difficulties
____________________ Reaction: PERRLA
OXYGENATION:
 DDyspnea Comments: “medjo gi hangos Resp.  Regular [X] Irregular
 SSmoking history ko”as verbalized by the Describe: Fast respiratory rate
 C[X]Cough patient___________________
 SSputum ________________________ R: ____________________________________________
 DDenied L: ____________________________________________

CIRCULATION:
 CChest pain Comments: ___________ Heart Rhythm [X]Regular  Irregular
 LLeg pain _____________________ Ankle Edema: ___________________________________
 NNumbness of _____________________ Carotid Radial Dorsalis Pedis Femoral
extremities _____________________ R: _____________________________________________
 DDenied _____________________ L: _____________________________________________
_____________________ Comments: ______________________________________
_____________________ ________________________________________________
_____________________ *If applicable ____________________________________

NUTRITION:
Diet Comments: ____________  Dentures [X] None
 N  V _____________________
 RRecent change in _____________________ Full Partial With Patient
weight an appetite _____________________ Upper   
 DDifficulty in _____________________
swallowing _____________________ Lower   
 D[X]Denied _____________________
ELIMINATION: Comments: _____________ Bowel Sounds: __________
Usual bowel pattern  Urinary frequency _______________________ _______________________
_______________________________________________ _______________________ Abdominal Distention
 Constipation  Urgency _______________________ Present  Yes  No
remedies  Dysuria _______________________ Urine* (color,
_______________________  Hematuria _______________________ consistency, odor)
Date of last BM  Incontinence _______________________
_____________________
_______________________  Polyuria _______________________
_______________________
 Diarrhea character  Foley in place _______________________
*if foley bag catheter is in
_______________________
 Denied place
MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to follow treatments
 Alcohol  Denied (diet, meds, etc.) for chronic health problems (if present).
(amount, frequency)
__________________________________________________ ________________________________________________
__________________________________________________ ________________________________________________
________________________________________________

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  SBE Last Pap Smear: _______________________
LMP:

SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:  dry  cold  pale
 DDry Comments:  flushed [X] warm
 IItching ______________  moist  cyanotic
 OOther ______________ *rashed, ulcers, decubitus (describe size, location,
 DDenied ______________ drainage) ____________________________________
______________ ____________________________________________
______________ ____________________________________________
ACTIVITY / SAFETY:  LOC and orientation: _____________________
 CConvulsion Comments: - ________________________________________
 DDizziness ______________ Gait:  walker  care  other
 LLimited motion of joints ______________ [X] steady  unsteady
Limitation in ability to ______________ Sensory and motor losses in face or extremities
 AAmbulate ______________ ____________________________________________
 BBathe self ______________ ____________________________________________
 OOther ______________ ____________________________________________
______________ ROM limitations: _____________________________
 D[X]Denied
______________ ____________________________________________
______________ ____________________________________________
COMFORT / SLEEP / AWAKE  facial grimaces
 P[X]Pain Comments:  guarding
(location, frequency, “sakit lang akong
 other signs of pain _______________________
remedies) likod” “lisod
tulog tungod sige
________________________________________
 NNocturia
ug ubo” ________________________________________
 S[X]Sleep difficulties
 DDenied
 side rail release form signed (60+ years) ______
________________________________________
COPING: Observed non-verbal behavior: ___________________
Occupation ____________________________________________
Members of household: 4 ____________________________________________
Most supportive person: Mother ____________________________________________
_____________________________________________Person (Phone Number) ________________________
____________________________________________
SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)
________________ Daily Weight ________________ PT / OT
________________ BP Shift ________________ Irradiation
________________ Neuro VS ________________ Urine Test
________________ CVP / SG Reading ________________ 24 hour Urine Collection

Date Ordered Diagnostic / Laboratory Date Done Date I.V. Fluids / Blood Date Disc.
Exams Ordered

4
 PATHOPHYSIOLOGY
Name of the patient: C.C.B
Diagnosis:

5
 HEALTH TEACHINGS

Name of Patient: C.C.B

Ascorbic acid-to increase requirement of
vitamin C
MEDICATION

Instruct patient to do at home breathing

exercises. To improve breathing
EXERCISE

Rest and stay hydrated

TREATMENT Proper hand hygiene

6
 Monitor symptoms and encourage patients
check in if symptoms get worse
Follow up check up after 5 days (depending on
the instructions given)
OUT-PATIENT
(Check-up)

Fresh seasonal fruits and vegetables, properly

washed, along with protein-rich dals, pulses or
lean meats, and whole grains are the best foods
to be consumed during the pandemic. Along
with these probiotic-rich curds, good fats from
nuts, seeds & herbs, and spices like turmeric,
ginger, garlic which have antiviral and anti-
DIET inflammatory properties should also be
included. Avoiding Highly processed and
packaged foods, refined sugars, high-fat foods,
foods rich in saturated and trans fat, can not
only lower immunity but also interfere with the
body’s ability to fight the infection. Also, red
meats should be avoided as they increase
inflammation in the body

Score: ___________ Grade: _____________

7
 DRUG STUDY
Name of Patient: C.C.B
Name of Drug Date Dose / Mechanis Specific
Classificati Contra- Side Effects / Nursing
Generic Ordere Frequency m of Indication (why
on indication Toxic Effects Precaution
(Brand) d Route Action drug is ordered)
Acetylcystei 9/5/2 belongs 600mg/ Decrease Treatment of Known Hypersensitiv Patients
ne 1 to the OD s respiratory hypersensitiv ity reactions suffering
class of Viscosit affections ity to have been from
organic y of characterized acetylcystein reported in bronchial
compoun respirato by thick and e. As patients asthma
ds known ry tract viscous Acetylcystein receiving must be
as n-acyl- secretion hypersecretio e (Fluimucil) acetylcysteine strictly
l-alpha- s and ns: acute granules and , including monitored
amino promote bronchitis, tablets bronchospas during the
acids their chronic contain m, therapy.
removal bronchitis aspartame, it angioedema, Should
by and its is rashes and bronchospa
breaking exacerbations contraindicat pruritus. sm occur,
disulfide ; pulmonary ed in patients Other adverse the
bond emphysema, suffering effects treatment
mucoviscidos from reported with must be
is and phenylketonu acetylcysteine suspended
bronchiectasi ria include immediatel
s nausea and y. It should
vomiting, be used
fever, with caution
syncope, in asthmatic
sweating, patients and
8
 arthralgia, patients
blurred with a
vision, history of
disturbances peptic
of liver ulceration
function.
Score: __________ Grade: __________

Name of Patient: C.C.B

Name of Drug Date Dose / Mechanis Specific
Classificati Contra- Side Effects / Nursing
Generic Ordere Frequency m of Indication (why
on indication Toxic Effects Precaution
(Brand) d Route Action drug is ordered)
Paracetamol 9/3/2 Analgesi 500mg/ Antipyre Temporary Contraindicat CNS: Do not
1 c(nonopi tab tic:Redu Reduction of ed With headache exceed the
oid)Antip ces fever fever,tempor allergy to   recommend
yretic by acting ary relief of acetaminophe CV: chest ed dosage.
directly minor aches n. pain,dyspnea,  
on the and pains   myocardial Reduce
hypothal caused by Use damage when dosage with
amic common cold cautiously doses of 5- hepatic
heat- and with 8g/day are impairment.
regulatin influenza,hea impairedhepa ingested daily  
g center dache,sore tic for several Avoid using
to cause throat,toothac function,chro weeks or multiple
vasodilat he, nic whendoses of preparations
ion and backache,me alcoholism, 4g/day containing
sweating, nstrual pregnancy,lac areingested acetaminop
which cramps tation for 1yr hen. 
9
 helps   Carefully
dissipate GI: hepatic checkall
heat toxicity and OTC
failure, products.
jaundice  
  Give drugs
GU: acute with food if
renal failure, GI upset
renal tubular occurs.
necrosis  
Discontinue
drug of
hypersensiti
vity
reactions
occur

Score: __________ Grade: __________

0
1
 Name of Patient: C.C.B
Name of Drug Date Dose / Mechanis Specific
Classificati Contra- Side Effects / Nursing
Generic Ordere Frequency m of Indication (why
on indication Toxic Effects Precaution
(Brand) d Route Action drug is ordered)
Ascozin 9/3/2 Ascorbic 1 tab/PO increases Deficiency Hypersensitiv GIT: Increased
1 acid P.C adaptive and increased ity to ascorbic nausea, intake of
(vitamin capacity requirement acid. vomiting, ascorbic
C), of an of vitamin C. Hyperoxaluri heartburn, acid over a
combinat organism Deficiency a. diarrhea. prolonged
ions , and increased Thrombophle period may
enhances requirement bitis, CNS: result in an
its of Zinc. inclination to increase in
hyperexcitabi
resistanc Decreased thrombosis, renal
lity of CNS,
e to immunity pancreatic clearance
headache.
infection diabetes. and
s. It Children age Urinary deficiency
maintain less than 18 system: may result
s years old. formation of if it is
colloidal urinary, withdrawn
condition cystine and too rapidly.
of oxalate
intercellu concernments
Vitamin C
lar .
long-term
substanc administrati
e and Skin and on in high
normal subcutaneous dose during
1
1
 capillary tissue: pregnancy
penetrati allergic can cause a
on(it reactions. negative
inhibits influence on
hyaluron fetus
idase). developmen
t
Score: __________ Grade: __________

Name of Patient: C.C.B

Name of Drug Dose / Mechanis Specific
Date Classificati Contra- Side Effects / Nursing
Generic Frequen m of Indication (why
Ordered on indication Toxic Effects Precaution
(Brand) cy Route Action drug is ordered)
Azithromyci 9/12/21 class of 500mg Bacterios Treatment of Contraindicat CNS: Instruct
n drugs PO tatic or lower ed with dizziness, patient to
known as bacterici respiratory hypersensitivi headache, take the
macrolide dal in infections ty to vertigo, drug as
antibiotic susceptib such as azithromycin, somnolence, prescribed
s le community- erythromycin, fatigue even after
bacteria acquired or any feeling
pneumonia macrolide GI: diarrhea, better
antibiotic abdominal
pain, nausea, Advise the
dyspepsia, patient to
flatulence, avoid
vomiting, excessive
2
1
 melena, sunlight and
pseudomembr to wear
anous colitis protective
OTHER: clothing
superinection and use
s, sunscreen
angioedema, when
rash, outside
photosensitivi
ty Instruct
patient to
take at least
1 hour
before or 2
hours after
a meal

Teach the
patient to
reconstitute
medication
and to
shake well
before use
Score: __________ Grade: __________
3
1
 Name of Patient: C.C.B
Name of Drug Dose / Mechanis Specific
Date Classific Contra- Side Effects / Nursing
Generic Frequency m of Indication (why
Ordered ation indication Toxic Effects Precaution
(Brand) Route Action drug is ordered)
Ceftriaxone 9/12/21 3rd 450mg Works Indicated Hypersensitiv Pain Assess
generati TIV by inpatients ity To patient’s
on inhibitin with Cephalospori Induration previous
cephalo g the neurologic ns, penicillins sensitivity
sporin mucopep complication and related reaction to
Phlebitis
tide s, antibiotics penicillin or
synthesis myocarditis other
in the and arthritis. Rash cephalospor
bacterial It is also ins.
cell wall. effective in Diarrhea
The beta- Gram Assess
lactam Negative Thrombocyto patient for
moiety Infections;M sis signs and
of eningitis,Gon symptoms
Ceftriaxo orrhea. It's of infection
Leucopenia
ne Binds also for Bone before and
to and joint during the
carboxyp infections,Lo Glossitis
treatment
4
1
 eptidases wer
,endopep respiratory Respiratory Report
tidases,a tract Superinfectio signs such
nd infections,mi ns as
transpept ddle ear petechial,ec
idase in infection, chymotic
the PID,Septice areas,epista
bacterial mia and xis or other
cytoplas Urinary Tract forms of
mic Infections unexplained
membran bleeding.
e
Monitorhe
matologic,e
lectrolytes,
renal and
hepatic
function.

Assess for
possible
supper
infection:itc
hing fever

Score: __________ Grade: __________

5
1
 Name of Patient: C.C.B
Name of Drug Dose / Mechanis Specific
Date Classific Contra- Side Effects / Nursing
Generic Frequency m of Indication (why
Ordered ation indication Toxic Effects Precaution
(Brand) Route Action drug is ordered)
Remdesivir 9/12/21 Direct- Loading To to treat Hypersensitiv can cause Liver
acting dose inhibit people with ity. Baseline gastrointestin function
antiviral (Day 1): the coronavirus ALT ≥5 times al symptoms tests and
agent 200 mg SARS- disease 2019 the upper (e.g., nausea), prothrombi
that IV as a CoV-2 (COVID-19) limit of elevated n time
works single RNA- normal transaminase should be
as a dose depende (ULN). levels, an obtained in
delayed nt RNA Severe renal increase in all patients
chain Maintena polymera impairment prothrombin before
terminat nce dose se (eGFR <30 time (without remdesivir
or. (from (RdRp), mL/min) a change in is
Broad- Day 2): which is including the administere
spectru 100 mg essential patients international d and
m IV once a for viral receiving normalized during
antiviral day replicatio renal ratio), and treatment as
medicat n—and replacement hypersensitivi clinically
ion thus therapies ty reactions. indicated.
creation Remdesivir
of Safety and may need to
virions efficacy have be
that not been discontinue
circulate established in d if alanine
6
1
 in the patients transaminas
body younger than e (ALT)
12 years or levels
weighing less increase to
than 40 kg. >10 times
the upper
limit of
normal and
should be
discontinue
d if an
increase in
ALT level
and signs or
symptoms
of liver
inflammatio
n are
observed
Score: __________ Grade: __________
7
1
 NURSING CARE PLAN
Name of Patient: ___________________________
NURSING RATIONA EVALUATI
CUES OBJECTIVES INTERVENTIONS
DIAGNOSIS LE ON
Subjectiv Hyperthermia Short term: within 1 hour Monitor condition To After all the
e: related to of nursing intervention the determine nursing
“init positive patient’s elevated the intervention
japon bacterial temperature to lessen necessity the client's
ko”as infection as for body temp
Long term:
verbalize manifested by interventio subsided
The patient's body
d by the warm to touch n and the within the
patient skin and RR of temperature will return to effectivene normal
27 normal within three days ss of range
● Monitor vital signs
of receiving nursing care. treatment,
Objective
or by a
:
tepid
Skin sponge
warm to ● Administer bath.
touch Replacement Fluids and
Restlessn electrolytes
ess
To assist
Temp: ● Administer antipyretic with
38℃
measures
PR:89 to reduce
RR:27 body
temperatur
e
8
1
 To support
circulating
volume
and tissue
perfusion.

To
facilitate
recovery
Score: __________ Grade: __________
9
1
 HEALTH TEACHINGS

Name of Patient: _______________________________

MEDICATION

EXERCISE

TREATMENT

OUT-PATIENT
(Check-up)

DIET

Score: ___________ Grade: _____________

0
2