Nursing data base:

* Patient's name : * Hospital record No : * Room No : * Bed No : * Age : * Sex : * Accompanied to hospital by : * Admitted from : home, emergency room, clinic, other *

Previous hospitalization and illness: Allergies : YES NO: * Type of allergy : * Immunization received :

* If any family member has health problem

 Feeding pattern : breast feeding / bottle feeding / gavages' feeding Activity pattern : Normal bed rest restricted

Name

Dose

Frequency Route

Action

NAME

MY CHILD

NORMAL VALUE

Finding Length / height - Weight - Head Circumference (HC) - Chest Circumference - Arm circumference - Skin Fold thickness
1/11/2011
2/11/2011

1/11/2011

Finding
1/11/2011
2/11/2011

1/11/2011

-Temperature - Pulse - Respiration - Blood pressure

Finding - Facial expression (happiness, frightened,)

1/11/2011
2/11/2011

- Posture (position, type of body movement.) NAD - Hygiene (cleanliness, body odor, nails, teeth, feet, and clothing condition). - Nutritional status (Normal body wt., overweight, underweight). - Behavior (child personality, level of activity, - State of awareness (conscious, semi conscious, unconscious).

 NAD ( NO ABNORMAILTY DETECTED )

Nursing Data base :

* Infant's name : * Birth Date : * Gestational age of birth : * Apgars : * Birth weight :
- Present gestational age : - Present length : - Head circumference : - Chest circumference :

Temperature : Respiration : Diagnosis : Heart rate : B1ood Pressure

Nursing Database:
Students Name: Group: Section:

Patients Name: Sex Age Weight

Admission Date

Diet

Diagnosis:
ASK
Diarrhea
Vomiting Fever Urine Out put

Habits
Amount

Frequency
Odor

Duration
Color

Medication Received:
Name Dose Frequency Route Action

 Immunization Received:

FEEL
Anterior Fontanel Normal
Slight Depressed

Very Depressed

Mouth, Tongue Tear Capillary Refill

Moist Normal Less than 2 Seconds

Dry May present or NOT 2 3 Seconds

Very Dry No Tear More Than 2-3 Sec.

A
SIGNS

C Severe Dehydration (loss > 10% Lethargic, floppy unconscious Very sunken, dry Drinks poorly, or unable to drink Goes back very slowly (> 2 seconds) Plan C

No signs of Some dehyd. (loss < Dehydration 5%) (loss 5 10%)

Well, Alert Restless, Irritable

General Condition

E
M

Eyes
Thirst

Normal
Drinks Normally Goes back quickly

Sunken
Thirsty, Drinks eagerly Goes back Slowly

Skin Pinch

Select Treatment Plan

Plan A

Plan B

Treatment Where What Type

How Much How Given

Feeding

Thank you