DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY

SOUTH LA UNION CAMPUS

College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

OPERATING ROOM WRITE UP

Name: Year/Section/Group:

Patient’s Name: Age: Gender:

Address:
Pre-op diagnosis:

Post-op Diagnosis:

Operation done: Date of

operation: Type of Anesthesia

Time Time Ended: started:

Surgeon: Anesthesiologist:
Scrub Nurse:

History of the patient:

Discussion of the disease/condition/pathophysiology:

:
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

NURSING JOURNAL
It should be 5 years or less
SUMMARY (brief and concise, research methodology and research design, recommendation)
IMPLICATIONS/IMPORTANCE TO :
1. Nsg education
2. Nsg practice
3. Nsg research
4. Society/community/ patient
Own recommendation or insights

TITLE: Effectiveness of various communication strategies for improving childhood pneumonia

Community-acquired pneumonia (CAP) continues to be a major cause of death for children in India, especially in
rural regions with inadequate access to medical care. Lack of trust in government healthcare systems and delayed
symptom detection are major contributors to this problem. The purpose of the study was to assess how well behavior
change interventions based in communities and facilities may improve the care-seeking habits of CAP patients in
rural Lucknow, India. In order to increase the number of children receiving timely and appropriate medical care from
government health facilities, the research aimed to strengthen healthcare infrastructure and develop structured
awareness sessions using validated information, education, and communication (IEC) materials. The findings
revealed a significant improvement in care-seeking behavior, underscoring the importance of community education
and healthcare system reforms in reducing pneumonia-related mortality.

Nursing education of this study emphasizes the importance of including public health education and behavior change
communication tactics into nursing programs. Nurses play an important role in promoting health and disease
prevention, especially in rural and underserved communities. To ensure that future nurses can effectively
communicate with caregivers about diseases like pneumonia, training programs should emphasize community
participation, early symptom recognition, and health education. By incorporating these ideas into nursing education,
healthcare workers will be better ready to conduct community interventions, identify barriers to care-seeking, and
build trust in public healthcare systems.

Nursing practice of this study emphasizes the importance of community health nurses in providing preventative
education and supporting early care-seeking behaviors in nursing practice. Nurses must be proactive in providing
awareness sessions, advising caregivers, and emphasizing the significance of prompt medical attention. The use of
supplied pneumonia medicine kits, which include critical medications as well as training materials, allows nurses to
standardize treatment regimens and guarantee evidence-based care is followed. Furthermore, nurses working in
government facilities must continue to establish relationships with the communities they serve, addressing concerns
and misconceptions that may discourage caregivers from obtaining professional care.
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

Nursing research of this study lay the groundwork for future nursing research on behavior modification interventions
in healthcare. Future research might look into the long-term viability of such programs, their adaptability in other
cultural or geographical settings, and the possibility of spreading similar interventions to other preventable childhood
diseases. Furthermore, nursing research could look into the efficiency of different means of communication, such as
audio, visual, and digital platforms, in raising health awareness and changing healthcare-seeking behaviors. Nursing
research can help reduce childhood mortality and build public health systems by continuing to develop new methods
for community-based healthcare interventions.

Community acquired pneumonia (CAP) is a prevalent childhood illness. During the first two years of life, the majority
of instances of CAP are caused by viruses. Society will be greatly impacted by this work, especially in terms of
enhancing child health outcomes and lowering preventable mortality rates. Reducing pneumonia-related mortality
can be achieved by raising caregivers' knowledge of and confidence in government healthcare facilities, which will
encourage them to seek prompt medical help for their kids. Pneumonia sufferers gain from improved healthcare
infrastructure and frontline staff training, which also raises the standard of public health services generally.
Furthermore, by providing caregivers with the information they need to identify early symptoms and respond quickly,
community-wide education programs promote a preventative healthcare culture. By working together, communities,
legislators, and healthcare professionals may effectively address public health issues, as this intervention's success
indicates.

REFERENCE:

Awasthi S., & Kumar D. (2019). Effectiveness of various communication strategies for improving childhood
pneumonia case management: a community based behavioral open labeled trial in rural Lucknow, Uttar
Pradesh, India. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-8050-0
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

13 AREAS OF ASSESSMENT
-------------------------------------

1. Psychosocial Status. This area deals with the person’s roles in relationship to others-family,
workgroup, and health professionals. If the nurse were attempting to diagnose the problems of a group of
persons, this area would include the social relationships within those group-patterns of leadership, methods
of resolving conflict. However, beginning practice generally deals primarily with individuals, and the outline
of data needed will focus only on that needed for an individual

A. General Social Status

1.Ethnic background
2.Occupation-status or position in that occupation
3.Economic status
4.Religious practices
a. Religion, Affiliation
b. Practices or beliefs which might affect reaction to health care(proscriptions against transfusion,
immunization or blood beliefs about the cause of disease
5.Type of housing accommodation
6.Contact or previous referrals to social agencies
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

B. Family or Peer Group Social Status

1.Position in the family (father, mother, etc.)
2.Others in family
3.With whom the person lives; that he or she considers close if he or she lives alone
4.Marital status
5.Role in family (e.g. source of support during crisis,” black sheep”,etc.) C.
Social developmental Status
1.Age
2.Sex
3.Marital Status
4.Degree of dependence and independence (prior to and during health deviation)
5.Sexuality
a. Level of sexual development
b. Attitudes toward own sexuality
c. Reproductive data (male and female)
i. Number of children, number of pregnancies, number of live births (self,
spouse, or significant sexual partner)
ii. Attitude toward contraception; contraceptive methods if used iii. Difficulties
related to menopause
d. Reproductive organs
i. Appearance of genitalia; presence or absence of lesons; abnormal
innervations ii. Unusual genital discharge
iii. Menstrual pattern, age of menarche
iv. History of disease or surgery affecting reproductive organs

2.Mental and Emotional Status. These are considered as one category since one’s intellectual growth
bears on reaction to self and others, and vice versa. There’s overlap between the psychosocial area and
the mental emotional area, but the student need not waste energy trying to fit a piece of data precisely
into one category. The important thing is to note the information somewhere.

A. Mental Status
1. Level of consciousness (response to verbal stimuli, response to noise and light, response to touch
and painful stimuli, spontaneous activity)
2. Orientation to time, place, and person
3. Intellectual development relative to age
4. Mental skills (level of education, ability to read and write, vocabulary, ability to comprehend and
follow directions, attention span, memory span, ability to understand abstraction)
5. Perception and understanding of health problems and goals of medical and nursing therapy
6. Beliefs and attitude about disease
7. Previous experiences with and reaction to illness and hospitalization

B. Emotional Status
1. Affect (general mood and emotional response)
2. Reactions to stressful situations (includes kinds of situation person considers stressful)
3. Patterns of relating to others
4. Special concerns or fears.
5. Concepts of self---self-esteem (prior to and in relation to current health problems; body image)
6. Substance taken to alter emotional response (includes prescribed medications---tranquilzers,
sedatives, mood-elevating drugs; alcohol; mind expanding drugs; amphetamines)
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

3. Environmental Status. Factors in the clients’ home, work, or institutional environment are assessed
in several other areas. However, some factors, related to safety, control of infection,
And environmental effects upon illness need to be assessed in their own right. A.
Safety Factors
1. Age
2. State of mobility
3. Arrangements of objects in physical environment; other potential safety hazards, 4. Sensory
deficits
5. OrIentation, disorientation to environment 6.
Use of restraining device.
7. Use of prosthetic and other supportive devices---crutches, artificial limbs, mechanical lifting device
B.Infection Control
1. Prescence of infectious disease or infected wounds in patients, family, or others in proximity
2. Barriers to cross infection (isolation techniques, hand-washing facilities, distance from infected
persons or infectible persons)
3. Patient and family understanding and beliefs about transfer of pathogens
4. Equipment potentially harboring Pathogens (Isolates, humidifier, pulmonary therapy equipment)
C. Environmental Effects on Illness
1. Patterns of activity, light, noise, color (varied, steady, excessive, absent)
2. Arrangement of environment in relation to functional abilities or disabilities (are pictures and
reading materials place where bedfast person can see them? are equipments placed where
handicapped person can reached them?)

4. Sensory Status. This area refers to the state of perceiving senses---vision, hearing, smell, and taste,
touch. Language perception and formation are categorized here although they are dependent upon both
sensory and motor function. A. Visual Status
1. Visual Acuity (ability to distinguish objects at a specified distance), papillary response
2. Field of vision (lateral, horizontal, vertical, extraocular movements)
3. Known deficit (myopia, presbyopia, blindness, astigmatism, etc.)
4. Corrective or prosthetic device (glasses, contact lenses, artificial eye)
5. Unusual sensation (rainbows around light, blind spots, flashing lights) B. Auditory status
1. Ability to distinguish voice (distance, loudness)
2. Known deficit
3. Corrective device
4. Unusual sensation (ringing, buzzing, dizziness)
C. Olfactory Status
1. Ability to discriminate odors
2. Unusual sensation (lack of smell, heightened sensitivity to smell, smelling odors with no stimulus
present)
D. Gustatory Status
1. Ability to discriminate sweet, sour, salty, and bitter
2. Unusual sensation (lack of taste, substance taste alike
E. Tactile Status
1. Ability to discriminate sharp and dull, light and firm touch
2. Ability to perceive heat, cold, and pain in proportion to stimulus
3. Ability to differentiate common objects by touch (stereognosis)
4. Intactness of body image
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

5. Abnormal sensation (lack of pain, touch, heat, cold sensation, increased or decreased pain in
proportion to stimulus; diffuse burning, pricking or pain)
G. Sensory Environment
1 .Intensity
2 Pattern
3 Variety
4 Appropriateness to developmental level

5 Motor Status. This area evaluate the ability of the person’s nervous system to initiate action
A. Medical restrictions on activity (Physician’s prescription for bed rest, CBR without BRP’s, etc.) B.
Musculoskeletal status
1. General movement (coordination, ease, stability)
2. Muscle strength, tone, and mass (all extremities, trunk and abdomen; symmetry; prior to and
during health problem)
3. Range of joint motion (all joints, active and passive motion)
4. Posture
5. Handedness
6. Deformities
7. Abnormal innervations to muscles (paralysis, weakness)
C. Mobility
1. Method of ambulation (assisted, with supportive aids such as cane, crutch and wheelchair)
2. Gait (mode of walking, coordination, stability)
3. Endurance (amount of activity tolerated)

6. Nutritional Status. This area deals not only with obvious data about intake of foods but also with
attitudes toward eating and toward special diets
A. Dietary Habits
1. Usual eating habits (number and time of meals, inclusion of “basic four” categories of food,
preferred foods excesses) 2. Appetite
3. Changes related to health problem (appetite changes, special diet prescribed by physician or by
patient-client)
4. Person responsible for preparing food at home
B. Adequacy of Diet
1. Height, weight; gain loss pattern
2. General appearance
C. Attitude toward eating
1. Importance of food to feeling of well being
2. Religious dietary restrictions
3. Symbolic meaning of food (reward, love, punishment)
D. Factors in Food Ingestion
1. State of teeth (dentures, partially or completely edentulous; disease of teeth and gums; oral
hygiene habits)
2. State of mouth (intactness of mucous membranes; disorders of salivary glands; moistness;
presence of debris)
3. State of consciousness
4. Ability to swallow
5. Gastrointestinal motility, bowel sounds
E. Digestion
1. Ease of digestion
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

2. Nausea, vomiting
3. Eructation (belching)
4. Medications affecting digestion and metabolism of foods
F. Non-oral Means of Feeding
1. Parenteral fluids; hyperalimentation
2. Nasogastric tube, gastrostomy

7. Elimination Status. This category includes elimination via the urinary and gastrointestinal tracts.
A. Normal Patterns (frequency, amount, color, consistency of stool)
B. Aids to Elimination Normally Used (beverages, laxatives, position)
C. Changes Due top Health Problems
1. Character of urine (color, odor, specific gravity, unusual constituents)
2. Character of stool (color, odor, consistency, presence of unusual constituents)
D. Method of Eliminating (toilet, commode, bedpan)
1. Artificial orifices (ileal conduit urine; colostomy, ileostomy – bowel)
2. Method of care of excretions from artificial orifices
E. Special Problems
1. Incontinence (urine, stool; ways of coping)
2. Urinary retention
3. Constipation
4. Diarrhea
5. Abnormal bowel sounds

8. Fluid and Electrolyte Status. Maintenance of balance of body fluids and electrolytes is essential to
homeostasis and to life. Although the physician has primary responsibility in restoring this balance
nurses observations often provide key data for the medical management. In addition, the nurse may
play an important role in helping to maintain this balance.
A. Normal Patterns of Fluid Intake and Output
1. Ingestion of food and fluids (amounts in 24 hours, types preferred)
2. Output (urine, stool, perspiration)
B. Changes Due to Health Problem (increase or in intake and
C. Measurements
1. Oral and parenteral intake (includes type of solid foods)
2. Output (urine, liquid stool, number of formed stools, drainage from wounds, occasionally
perspiration and respiratory loss)
D. Indirect Data
1. State of Fluid Balance
a. Weight
b. Thirst
c. Skin turgor, dryness
d. Condition of mouth, mucous membranes (dry, moist, coated, presence of
crust)
e. Edema
f. Blood pressure, lying and standing
2. Venous state (distended, flattened, filling time)
3. Level of consciousness
4. Depression or elevation of fontanels in infants
5. Neuromascular flaccidity or irritability
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

6. Laboratory values of electrolytes, pH

7. Medical therapy (drugs, parenteral fluids, blood)

9. Circulatory Status. These observations give indirect data about the state of the heart and blood
vessels.
A. Pulse
1. Rate
2. Quality (thready, weak, bounding, strong)
3. Rhythm (regular, irregular, paired beats)
4. Apical-radial differences
5. response to activity, emotional stress
6. medications which alter heart rate or rhythm
B. Heart Sounds
C. Blood pressure
1. systolic, diastolic
2. lying and standing
3. discrepancies between arm
4. factors altering accuracy of reading ( obesity, cuff size) D. General appearance
1. Color (skin, lips, nails)
2. evidence of volume depletion or edema
3. urine output, fluid intake
4. warmth and color of extremities
5. undue fatigue alter exertion
6. pains in legs after walking
7. chest or epigastric pain, precipitating factors
E. Special Observations. If the patient has acute cardiac disease and his or her condition is being
specially monitored, the list may also include data from monitoring devices such as the character
of the electrocardiogram, central venous pressure, arterial pressure..

10. Respiratory Status. The state of the respiratory function may be assessed both directly and
indirectly. The indirect measurements give some clues to the state of cellular respiration
A. direct measurements
1. patency of the airway
2. respirations
a. rate, rhythm, depth, ease, use of accessory muscles
b. Factors altering character (position, emotion, cough, humidity, air pollution)
c. Breath sounds
3. Cough
a. patterns (upon arising, continuous, random, after smoking)
b. Productive of sputum
c. Character of sputum (color, viscosity, odor, hemoptysis)
B. Indirect Measurements
1. Smoking History
2. Medications affecting respiratory rate, patency of bronchial tree
3. Color (skin, lips, nails)
4. Clubbing of Nails
5. Posture, skeletal defects such as kyphosis
6. Level of consciousness (increase or decrease)
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

7. Anxiety or Apprehension (diffuse or specific regarding breathing)

8. Laboratory values (PaO2, PaCO2, pH)
C. Supportive Devices
1. Nebulizers, aerosols (patterns of use, effectiveness)
2. Positive pressure breathing
3. Tracheostomy
4. Assisted or controlled ventilation with respirator

11. Temperature Status

A. Subjective feeling of warmth and cold
B. Usual measures of temperature comfort
C. Body Temperature
1. oral
2. rectal
3. axillary
D. Perspiration
1. Presence or absence
2. Pattern (night, day, intermittent)
E. Environmental Temperature and humidity
F. Methods of altering temperature
1. convection, conduction, radiation, evaporation
2. special equipment (hypo-hyperthermia blanket)

12. Integumentary Status. This area refers to the condition of the skin and underlying tissues, mails and
hair.
A. Skin Condition
1. Color, turgor
2. Intactness (presence of wounds, incisions, ulcers, pressure sores, diaper rash)
3. Character of any lesions present (dry, draining, infected)
4. Areas of ischemia
5. Factors predisposing to skin breakdown (prolonged pressure, lack of position change ,
unprotected bony prominences, incontinence, age, hyperactivity, self-destructive
tendencies)
B. Condition of Nails and Hair
C. Habits of Personal Hygiene
D. Odos and Excretions (oily, perspiration, abnormal)

13. Comfort and Rest Status

A. Sleep
1. Normal sleep pattern (number of hours, time, feeling of being rested)
2. Alterations due to health problem
3. Aids used for sleep (beverages, warm bath, medications)
B. Comfort
1. Presence of pain or discomfort (location, duration, degree, extent, character, precipitating
factors)
2. Use of aids to relieve pain or discomfort (prior to and during current health problem)
3. Changes in pain or discomfort with current health problem
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

NURSING CARE PLAN

EXPLANATION OF
ASSESSMENT OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
THE PROBLEM
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

FDAR CHARTING
DATE/ TIME FOCUS DATA ACTION RESPONSE

Name of Clinical Instructor: Signature:

Ward: Shift:

Patient: Age: Diagnosis:

 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

DRUG STUDY
DRUG NAME DRUG MODE OF ACTION SIDE EFFECTS AND CONTRAINDICATION NURSING
(Generic Name, Brand CLASSIFICATION ADVERSE MANAGEMENT/
Name, Dose, Route, REACTIONS CONSIDERATION
Dosage)
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

CASE PRESENTATION/ CASE STUDY

Case Title: 18. Area 9 of the 13 Areas of

Assessment
1. Objectives/Goals 19. Area 10 of the 13 Areas of
Assessment
2. Introduction 20. Area 11 of the 13 Areas of
Assessment
3. Patient’s Demographic Data 21. Area 12 of the 13 Areas of
Assessment
4. History of the Present Illness 22. Area 13 of the 13 Areas of
Assessment
5. Past Health History 23. Laboratory Result
Interpretation
6. Family History 24. List and Prioritization of nursing
diagnoses
7. Social History 25. Anatomy and Physiology
8. Genogram 26. Disease Entity and General Pathophysiology
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
SOUTH LA UNION CAMPUS
College of Community Health and Allied Medical Sciences
Agoo, La Union, Philippines 2504 | (072) 682-0063
www.dmmmsu.edu.ph | cchams.sluc@dmmmsu.edu.ph

9. Course of Confinement 27. Specific Pathophysiology

10. Area 1 of the 13 Areas of 28. Assessment of NCP
Assessment
11. Area 2 of the 13 Areas of 29. Explanation of the Problem of the
Assessment NCP
12. Area 3 of the 13 Areas of 30. Nursing Outcomes/Objectives of the
Assessment NCP
13. Area 4 of the 13 Areas of 31. Nursing Interventions of the NCP
Assessment
14. Area 5 of the 13 Areas of 32. Rationale of the NCP
Assessment
15. Area 6 of the 13 Areas of 33. Evaluation of the NCP
Assessment
16. Area 7 of the 13 Areas of 34. Drug Study
Assessment
17. Area 8 of the 13 Areas of 35. References
Assessment