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
