Liceo de Cagayan University

Cagayan de Oro City

DATA BASE HISTORY

Name of Patient: Sex: Age: Religion:

Civil Status: Educ. Level:
Income: Occupation:

Nationality: Date Admitted: Time: Attending Physician:

Informant: Admitting Dx.:
Temp.: Pulse Rate: Resp. Rate: BP: SpO₂:
Ward/Room: Height: Weight:
Home Address:

Chief Complaint and History of present Illness:

(Reasons for hospitalization; outset, character, methods used to resolve problem)

Date Type of Previous Illness/ Pregnancy/ Delivery

Has received blood in the past: Yes No If yes, indicate the dates
Reaction: Yes No

Allergies:
Medication Name Route, Dose &Frequency Date & Time of Last Dose Reaction
 NURSING SYSTEM REVIEW CHART
Name: Date:
Vital Signs:
Pulse: BP: Temp.: RR: SpO₂: Height: Weight:

INSTRUCTION: Place an (X) in the area of abnormalities. Write comment on the space provided. Indicate the location of the problem
in the figure using (X).

EENT
[] impaired vision [] blind [] Pain
[] reddened [] drainage [] lesion seen
[] gums [] hard of hearing [] deaf
[] burning [] edema
Assess eyes, ears, and nose throat for abnormality
[] no problem

RESPIRATORY
[] asymmetric [] tachypnea [] apnea
[] rales [] cough [] barrel chest
[] bradypnea [] shallow [] rhonchi
[] sputum [] diminished [] dyspnea
[] orthopnea [] labored [] wheezing
[] pain [] cyanotic
Assess respiration, rate, rhythm, depth, pattern,
breathe sounds, comfort
[] no problem

CARDIO VASCULAR
[] arrhythmias [] tachypnea [] numbness
[] diminished pulses [] edema [] fatigue
[] irregular [] bradycardia [] murmur
[] tingling [] absent pulses [] pain
Assess heart sounds, rate rhythm, pulse, blood pressure, circulation,
fluid retention, comfort
[] no problem

GASTROINTESTINAL TRACT
[] obese [] distention [] mass
[] dysphagia [] rigidity [] pain
Assess abdomen, bowel habits, swallowing, bowel sounds,
comfort [] no problem

GENITO- URINARY TRACT and GYNE

[] pain [] urine color [] vaginal bleeding
[] hematuria [] discharges [] nocturia
Assess urine freq., control, color, odor, comfort,
gyne- bleeding, discharge
[] no problem

NEURO
[] paralysis [] stuporous [] unsteady
[] seizures [] lethargic [] comatose
[] vertigo [] tremors [] confuse
[] vision [] grip
Assess motor function, sensation, LOC, strength, grip, gait,
Coordination, orientation, speech.
[] no problem

MUSCULOSKELETAL and SKIN

[] appliance [] flushed [] cool [] drainage
[] Petechiae [] ecchymosis [] rash [] lesion
[] prosthesis [] stiffness [] atrophy [] deformity
[] poor turgor [] hot [] diaphoretic [] skin color [] moist
[] wound [] swelling [] itching [] pain
Assess mobility, motion, galt, alignment, joint function, skin color, texture, turgor, integrity
[] no problem
 NURSING ASSESSMENT
SUBJECTIVE OBJECTIVE
COMMUNICATION: [] glasses [] languages
[] hearing loss Comments: []contact lens [] hearing aide
[] visual change [] speech difficulties
[] denied R L
Pupil size:
Reaction:

OXYGENATION: Resp.: [] regular [] irregular

[] dyspnea Comments: Describe:
[] smoking history

[] cough
[] sputum R:
[] denied L:

CIRCULATION: Heart Rhythm [] regular []irregular

[] chest pain Comments: Ankle edema:
Pulse Car. Rad. DP Fem*
[] leg pain R:
[] numbness of L:
Extremities Comment:
[] denied
* if applicable
NUTRITION:
Diet: [] dentures [] none
[] N [] V Comments:
Character Full Partial With Patient
[] recent change in
Weight, appetite Upper [] [] []
[] swallowing
Difficulty Lower [] [] []
[] denied
ELIMINATION: Comment: Bowel sounds:
Usual bowel pattern [] urination frequency
Abdominal distention
[] constipation [] urgency Present [] Yes [] No
Remedy [] dysuria Urine * (color, consistency,
[] hematuria odor)
Date of last BM [] incontinence
[] polyuria
[] diarrhea [] foley in place
Character [] denied
* if they are in place?
MGT. OF HEALTH & ILLNESS:
[] alcohol [] denied Briefly describe the patient’s ability to follow treatments
(amount, frequency) (diet, meds, etc.) for chronic health problems (if present).

[] SBE last Pap Smear:

LBM:
 SUBJECTIVE OBJECTIVE

SKIN INTEGRETY: [] dry [] cold [] pale

[] dry Comments: [] flushed [] warm
[] moist [] cyanotic
[] Itchy *rashes, ulcers, decubitus ( describe size, location,
[] other drainage)
[] denied

ACTIVITY/SAFETY: [] LOC and orientation

[] convulsion Comments:
[]limited motion of joint [] gait [] walker [] cane [] other

Limitation in ability to [] steady [] unsteady

[] ambulate [] sensory and motor losses in face or extremities:
[] bathe self
[] other
[] denied [] ROM limitation:

COMFORT/SLEEP/AWAKE: [] Facial grimaces

[] pain Comments: [] guarding
(location [] other signs of pain:
frequency
remedies)
[] nocturia [] side rails release form signed (60 + years)
[] sleep difficulties
[] denied

COPING: Observed non-verbal behaviour:

Occupation:
Members of household:

Most supportive person: The person and his phone number that can be reached
any time:
 DOCTOR’S ORDER SHEET
Patient: Attending Physician:
Diagnosis: Date Admitted:

Date/ Time Doctor’s Order Rationale of Order

DOCTOR’S ORDER SHEET

Patient: Attending Physician:
Diagnosis: Date Admitted:

Date/ Time Doctor’s Order Rationale of Order

Name of Patient:

Diagnosis:

LABORATORY RESULTS
Dx. Exam Results Normal Values Significant of the Result
Date Ordered Diagnostic/ Laboratory Clinical Significance
Exams
Date Ordered I.V. Fluids/ Blood Clinical Significance

NURSING CARE PLANS

 DATE/
NURSING STANDARDS FOCUS DAR
TIME
 FLUID INTAKE and OUTPUT CHART
INTAKE OUTPUT
DATE SHIFT ORAL I.V. OTHERS TOTAL URINE VOMITUS DRAINAGE OTHERS TOTAL

TOTAL
FOR 24
HRS

TOTAL
FOR 24
HRS

TOTAL
FOR 24
HRS

TOTAL
FOR 24
HRS

TOTAL
FOR 24
HRS

Note: Entries will start during Duty proper.

 VITAL SIGNS MONITORING SHEET

IVF Level per

Date/ Level of Intravenous fluid
T PR RR BP Endorsement Remarks
Time consciousness (vol. & drops/ min.)
 ROOSTER LIST
DATE
SHIFT NOC AM PM NOC AM PM NOC AM PM
LAST CENSUS
NO. OF ADMISSION
NO. OF DISCHARGE
CURRENT CENSUS

STATUS RM NAME OF PATIENT C.C/ DIAGNOSIS ATTENDING PHYSICIAN

STATUS LEGEND: New Admission: Discharge: Expired: (RED) Transferred: *

MEDICATION WORKSHEET
 DATE
DRUG, DOSE, ROUTE &
ORDERE Indicates date & shift Indicate date & shift Indicate date & shift
FREQUENCY
D

Note: Entries will start during

Assessment

HEALTH TEACHINGS
Name of the Patient
MEDICATION RATIONALE

EXERCISE

TREATMENT

OUT PATIENT
(CHECK-UP)

DIET
 KARDEX
Name: Chief Complaints:
Address: Diagnosis:
Age: Sex: Civil Status: Attending Physician:
Ward: Room: Date & Time Admitted:

Doctor’s IVF/
Date Observation Blood Medication Nursing Diagnosis Goal Nursing Intervention Special Endorsement
Order
 DRUG STUDY
Name of Drug Special Indication Nursing Responsibility
Mechanism of Action (Relate it to
(Generic Name / (Based on patients (Based on drug’s
patient’s problem)
Brand Name) Problem) physiologic effects)
 DRUG STUDY
Name of Drug Special Indication Nursing Responsibility
Mechanism of Action (Relate it to
(Generic Name / (Based on patients (Based on drug’s
patient’s problem)
Brand Name) Problem) physiologic effects)
 PATHOPHYSIOLOGY
Name of Patients:

Diagnosis:

REFERENCES:

Score: Grade:
 PONR
(Problem-Oriented Nursing Records)

INTENSIVE NURSING PRACTICUM

Student Name: NOC
AM
PM
Area of Assessment:
Inclusive Date:
Clinical Instructor: NOC
AM
PM