Catanduanes State Colleges, College of Health Sciences KARDEX Integrated Provincial Health Office (EBMC)

Name:_______________________________________________ Department:_____________________
Age:______ Sex: M __F__ Civil Status:__________ Occupation:____________ Religion:_____________
Admitted on______________at__________am/pm Admission #:_________ Rm:________________
Tentative Diagnosis:____________________________________ Attending Physician:______________
Final Diagnosis:________________________________________________________________________
Health History:
Present Health History: _________________________________________________________________
_____________________________________________________________________________________

DOCTOR’S ORDERS: [ ] ACTIVITY: Ambulatory from __________

Key: [ ] to _____________
[/] carried out [ ] [ ] CBR [ ] CBR w/o BRP
[x] not carried out [ ] [ ] Others: _________________
__________________________
[ ]
[ ]
REFERRAL: [ ] DIET: [ ] DAT [ ] Soft [ ] Liquid
Key: [ ] Others: ___________________
[/] carried out [ ] __________________________
[x] not carried out
LABORATORY / [ ] Urinalysis NEUROVITAL A. Level of Consciousness
DIAGNOSTICS: [ ] Fecalysis SIGNS: [ ] Coherent [ ] Conscious
Key: [ ] Sputum 3x [ ] Lethargic [ ] Stuporous
[/] done, with result [ ] Hematology ___________ [ ] Coma [ ] Obstunded
[+] done, w/o result _____________________ B. Orientation
[x] request made, not yet [ ] Blood Chemistry _______ [ ] Time [ ] Place [ ] Person
done _____________________ C. Speech Language
[ ] Lipid Profile [ ] Clear [ ] Garbled
[ ] Blood Sugar [ ] Expressive [ ] Receptive
[ ] Crossmatching D. Abnormal Posturing
[ ] X-ray [ ] Decorticate
[ ] ECG [ ] Decerebrate
[ ] Ultrasound E. Pupillary Reactions
[ ] Thoracentesis [ ] BRTL [ ] SRTL
[ ] Paracentesis [ ] NRTL Size: R__L__
[ ] Others ________________ F. Reflexes
[ ] Babinski [ ] Gag
PARENTERAL FLUIDS: Amt. Received:__________mL [ ] Corneal [ ] DTR
Endorsed: _____________mL G. Motor Function
Site: [ ] R [ ] L ____________ [ ] R. [ ] L. arm weakness
[ ] Main Line _____________ [ ] R. [ ] L. leg weakness
[ ] Side Drip ______________ H. Cranial Nerve Function
[ ] Others ________________ _______________________
Blood Transfusion: I. Glasgow Coma Scale
[ ] FWB ______________units _____ Eye Opening
[ ] PRBC______________units _____ Verbal Response
[ ] Others ________________ _____ Motor Response
Clysis / Drainage: _____ TOTAL GGCS SCORE
[ ] Peritoneal [ ] T-Tube
[ ] Cystolysis [ ] Penrose Drain
[ ] Others ________________
NURSING [ ] Tepid Sponge Bath MEDICATIONS
INTERVENTIONS: [ ] Cold Compress Freq. Time Last Time of Nursing Resp.
Key: [ ] Deep Breathing Exercises GENERIC (Brand) Dose Given Admin
Class’n
[/] carried out [ ] Suctioning
[x] not carried out [ ] Turn to Side q2°
[ ] Bladder Training
[ ] I&O Monitoring:
______________________
Range of Motion Exercises
[ ] Passive [ ] Active
Enema
[ ] Fleet [ ] Cleansing
Ultrasonic Nebulization
[ ] Salbutamol [ ] NSS

Name: _________________________________ Unit: _________________________ Bed #: __________

TUBINGS: [ ] Endotracheal tube SPECIAL [ ] Allergy __________________
Key: [ ] Tracheostomy tube PRECAUTION [ ] No BP taking _____________
[/] Intact/Patent/ Attached to: [ ] No blood extraction
Draining [ ] Mechanical Ventilator [ ] Blood Precaution _________
[x] Closed/ MV ______ TV ______mL
Discontinued Fi02 _____% RR _____cpm
SV ___________________
[ ] Ambu Bag [ ] T-piece
02 inhalation at _______Lpm
Via: [ ] Nasal Cannula
[ ] Nasal Catheter
[ ] Venturi Mask
BP:__________ __________ NURSING [ ] Dyspnea [ ] Dizziness
T: __________ __________ PROBLEMS [ ] Abdominal Pain [ ] Vertigo
P: __________ __________ ENCOUNTERED [ ] Chest Pain [ ] Epigastric
R: __________ __________ [ ] Lumbar R/L [ ] Iliac R/L
Others: _________________ [ ] Umbilical [ ] Hypochondriac
[ ] LBM [ ] Anorexia
[ ] Dysuria [ ] Cough
[ ] Vomiting [ ] Insomnia
[ ] Loss of Appetite [ ] Edema
[ ] Weakness [ ] Fatigue
[ ] Headache [ ] Frontal
[ ] Temporal [ ] Parietal
[ ] Occipital [ ] Fever
[ ] Wound [ ] Others _________

NURSING CARE PLAN

EXPECTED
NURSING NURSING NURSING
DATE CUES RATIONALE OUTCOME /
DIAGNOSIS OBJECTIVE INTERVENTION
EVALUATION

Team Leader Charge Nurse Clinical Instructor

Remarks: ________________________________________________ Date Checked: ________________