OBJECTIVES

Name:
Year and Section:
Dates of Exposure:
Area of Exposure:
Clinical Instructor:

General Objective:

Specific Objectives

KNOWLEDGE:
1.
2.
3.
4.
5.
SKILLS:
1.
2.
3.
4.
5.
ATTITUDE
1.
2.
3.
4.
5.
 DAILY PLAN OF ACTIVITIES

TIME ACTIVITIES
5:45 Arrival at the Area/ Preconference
5:50 Checking of paraphernalia
6:00 Receiving endorsement from previous shift
7:00 Nurses Rounds/Taking of Vitals signs
8:00 Recording of vitals signs/ Documentation
9:00 Morning care/Bedside care
10:00 Assist the Doctor during his rounds
12:00 Give medications/ taking of vitals signs
1:00 Charting
2:00 Endorsement to the next shift
2:30 Post-Conference
 Problem List

Name: Chief Complaint:

Age: Diagnosis: T/C Pneumonia
CUES PROBLEM RANK PHYSIOLOGIC BEHAVIORAL
ACTUAL POTENTIAL ACTUAL POTENTIAL
SUBJECTIVE: Ineffective airway Risk for ineffective Disturbed sleep pattern Risk for powerlessness
COUGH clearance related to breathing pattern related to frequent related to lack of sleep
“Katig-a sang akon ubo” presence of mucus related to presence of coughing at nighttime
“Indi ko mayo katulog 1 secretion in the airway mucus secretion in the
kay gaubo ko kun gabi” as evidence by coughing airway as evidence by
secondary to coughing secondary to
Pneumonia Pneumonia

OBJECTIVE: Ineffective Risk for deficient fluid

Thermoregulation: volume related to
List down all objective Hyperthermia related to compromised
cues increase metabolic regulatory mechanism
demands Risk for imbalance
Rales upon auscultation 2 Nutrition
Shortness of breath FEVER
Productive cough with
thick yellowish-greenish
mucus secretion
Vital Signs:
 Temp: 39C
BP-90/60mmHg
RR- 25cpm
PR- 110bpm

BODY WEAKNESS 3
 NURSING CARE PLAN

Name: Diagnosis:
Age: Ward:
Chief Complaint: Physician:
General Objective:
ASSESSMENT NURSING DIAGNOSIS PATHOPHYSIOLOGY EXPECTED OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: INDEPENDENT:

OBJECTIVE:

DEPENDENT:

COLLABORATIVE:

References:
 Laboratory Result

Name: Chief Complaint:

Age: Diagnosis:
LABORATORY TEST NORMAL VALUE RESULT IMPLICATION NURSING CONSIDERATION
CBC

HEMOGLOBIN 10-12 g/dL 6 g/dL May indicate anemia Encourage to increase iron in the
diet
Administer Iron Supplements as
ordered
 DICHARGE PLAN

PROBLEM HEALTH TEACHING RATIONALE

HYGIENE Recurrence of PROMOTIVE
1. Daily Bath Pneumonia 1. Instruct patient to practice proper 2. To deter the spread of
2. Proper Handwashing handwashing and regular daily bath. microorganisms and to avoid cross-
3. Oral Care contamination.
4. Proper food sanitation 2. Instruct patient to eat nutritious 3. To boost the immune system.
foods especially foods rich in
Vitamin C.
ACTIVITY
1. Regular exercise (walking)
2. Breathing exercises
PREVENTIVE
1. Instruct patient to avoid smoking, or 1. Smoking irritates the respiratory
second-hand smoking. tracts and may aggravate symptoms
of infection.
DIET 2. Instruct patient to avoid dairy 2. Dairy products may increase mucus
1. High Protein Diet products. secretion.

CURATIVE
1. Take going home meds as ordered:
a. Cefuroxime axetil 500mg BID 1. Cefuroxime is an anti-infective
INSTRUCTION
1. Come back 1 weeks after discharge
for check-up REHABILITATIVE
2. Take going home medicines as 1. Instruct to come back for follow-up 1. To check on the progress of the
prescribed check-up 1 week after discharge. patient’s condition.
 DRUG STUDY

Patient: Diagnosis:
Age: Physician:
Ward:
NAME OF DRUG CLASSIFICATION MECHANISM OF ACTION INDICATION ADVERSE EFFECTS NURSING PATIENT TEACHING
CONSIDERATION
Thought to produce fever Hematologic: hemolytic
analgesia by inhibiting anemia, leukopenia,
Generic acetaminophen prostaglandin and other neutropenia,
paracetamol substances that sensitize pancytopenia.
pain receptors. Drug Hepatic: jaundice.
may relieve fever Metabolic:
Brand through central action in hypoglycemia.
Biogesic the hypothalamic Skin: rash, urticaria.
heat-regulating center.

Dosage
500mg

Route of Administration
Per Orem
PO

Frequency
Q4hours as needed

Timing
8am-12pm-4pm-8pm

References: