Date Bed # Patient’s Name, Services Diet IVF Vital Signs Treatment, X-ray and Lab Specific Nursing

Treatment, X-ray and Lab Specific Nursing Care

Shift and Diagnosis Procedures
Januay Deluxe 5 Tarifa, Analiza Low Salt, PNSS Initial Latest
07, 2010 Low Fat IL x BP 120/80 M
6AM-  Hypertensive 8° PR 74 G
2PM Urgency RR 18 H
Temp 36
Extension Duque, Raquel Initial Latest
10 D5NM BP 110/90 110/90  Cholecystectomy  Encouranged
 Acute NPO 1L x PR 86 83  With Catheter Deep Breathing
Appendicitis 8° RR 22 21 Exercise
S/P Appendectomy Temp 36.9 37.2
Room 11 Manalili, Toribio Initial Latest
Bed C D5NM BP 110/80 110/80  Cystourethroscopy
 Urinary NPO x8 PR 74 78  With Catheter
Incontinence RR 24 22
Temp 36 30
Room 11 Cadelina, Jeffrey Initial Latest
Bed F BP 110/80 110/80  Wet Dressing
 Cellulitis Left Leg Soft Diet PR 80 82
RR 20 19
Temp 37.4 37.5
Room 14 Sawi, Melody Initial Latest
Low Salt, BP 90/60 90/60
 Acute Respiratory Low Fat
PR 95 91
Failure DAT
RR 20 19
Temp 36.3 36.6

Prepared By:
Pimentel, Anna Loraine B.
CLDH-EI Batch 2011
 Bed # and Medication/s Shift
Patient’s
Name
Deluxe 5 6 7 8 9 10 11 12 1 2

Tarifa,  Carvedilol 25mg 1 tab √

Analiza  Dianorm 1 tab BID √
 Analgesia 1 cap BID √
 Vitaroxima 750mg q8° √
 Reaform/l-max 500mg tab √
Room 14  Levox 750mg 1tab OD/NN √
 Peptisolv/omepron 20mg 1cap BID √
Sawi,  Kalium Durule 1 tab qid √ √
Melody  Vastarel MR 35mg 1 tab BID √
 Norgesic 1 tab TID √ √
 Terqecef 200mg 1 cap BID √ √
 Zertin 1 cap BID √
Extension  Tyoxone 1 gm q12° √
10
√
 Viprazo 1 amp IV q12°
Duque,
Raquel √
 Panazole 500mg IV q8°
Room 11  Forgram 1gm IV q12° √
Bed C
√
 Cloxacillin 1gm IVP q8°
Cadelina,
Jeffrey  Metformin 500mg 1 tab TID √ √
Room 11  Kefox 750mg IV

Manalili,
Toribio
 Central Luzon Doctors’ Hospital
Educational Institution
A.Y. 2010-2011
2nd Semester

DAILY PLAN OF ACTIVITIES

ST, Camilus-Afternoon Duty (2PM-10PM)

January 07, 2010, Friday

Time Activitiy/ies

05:45AM-06:00AM Checking of attendance, uniform and Paraphernalia

06:00-06:15AM Equal assigning of respective patient/s

06:15AM-08:00AM Joining the endorsement and nurses’ rounds

08:00AM-10AM Vital signs taking every four hours depending to patient assigned,
Preparing due medications then Initial Charting

10:00AM-10:30AM Checking then Writing of Initial Charting

10:30AM-11:30AM Dinner Break

11:30AM-12:30PM Giving due medications, and taking intake and output

12:30PM-01:00PM Plotting of vital signs, record intake and output, signing of medication/s
given then Closing of charts

1:00PM-02:00 Post Conference then Dismissal

Prepared by:

Pimentel, Anna Loraine B.

(Student Head Nurse)
Submitted to:

Mr. Marvin Rey Veloso, RN, MSN

(Clinical Instructor)