Liceo de Cagayan University

Cagayan de Oro City

DATA BASE HISTORY
Name of Patient: ____________________________________ Sex: _________ Age: ________
Civil Status: ____ Educ. Level: _________________________

Religion: ___________________

Income: ______________ Occupation: _____________________

Nationality: ______________ Date Admitted: _____________ Time: __________ Attending Physician:_____________________

Informant: _________________________ Admitting Dx.: ____________________________________________________________
Temp.: ___________ Pulse Rate: ____________ Resp. Rate: _____________ BP: ______________ Ward/Room: ____________
Height: _____________ Weight: _______________ Home Address: __________________________________________________
Chief Complaint and History of present Illness:
(Reasons for hospitalization; outset, character, methods used to resolve problem)

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Date

Type of Previous Illness/ Pregnancy/ Delivery

Has received blood in the past: _______ Yes _______ No

Reaction: _______ Yes _______ No
Allergies:
Medication Name

If yes, indicate the dates _______________________________________

Route, Dose &Frequency

Date & Time of Last Dose

Reaction

Score: _______________ Grade: _______________

NURSING SYSTEM REVIEW CHART

Name: ____________________________________________________________________ Date: ___________________
Vital Signs:
Pulse: ______________ BP: ______________ Temp.: _____________ 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

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NURSING ASSESSMENT
SUBJECTIVE
COMMUNICATION:
[] hearing loss
[] visual change
[] denied

OXYGENATION:
[] dyspnea
[] smoking history
________________
[] cough
[] sputum
[] denied
CIRCULATION:
[] chest pain
[] leg pain
[] numbness of
Extremities
[] denied

Comments: _______________
_________________________
_________________________
_________________________
_________________________
Comments: _______________
________________________
_________________________
_________________________
_________________________
_________________________
Comments: _______________
_________________________
_________________________
_________________________
_________________________
_________________________

NUTRITION:
Diet: ___________________________________________
[] N
[] V
Comments: _______________
Character
_________________________
[] recent change in
_________________________
Weight, appetite
_________________________
[] swallowing
_________________________
Difficulty
_________________________
[] denied
_________________________
ELIMINATION:
Usual bowel pattern
[] urination frequency
_________________
___________________
[] constipation
[] urgency
Remedy
[] dysuria
_________________
[] hematuria
Date of last BM
[] incontinence
_________________
[] polyuria
[] diarrhea
[] foley in place
Character
[] denied
_________________
MGT. OF HEALTH & ILLNESS:
[] alcohol
[] denied
(amount, frequency)
_____________________________________________
_____________________________________________
[] SBE last Pap Smear: ______________________________
LBM: _________________________________________

OBJECTIVE
[] languages
[] hearing aide
[] speech difficulties
R
L
Pupil size: ____________________________
Reaction: ____________________________
[] glasses
[]contact lens

Resp.:
[] regular
[] irregular
Describe: ________________________________________
________________________________________________
________________________________________________
R: ______________________________________________
L: ______________________________________________
Heart Rhythm
[] regular
[]irregular
Ankle edema: ____________________________________
Pulse
Car.
Rad.
DP
Fem*
R:______________________________________________
L:______________________________________________
Comment: _______________________________________
________________________________________________
* if applicable
[] dentures

[] none
Full

Partial

With Patient

Upper

[]

[]

[]

Lower

[]

[]

[]

Comment:______________ Bowel sounds: ___________

_______________________ _______________________
_______________________
Abdominal distention
_______________________ Present [] Yes [] No
_______________________ Urine * (color, consistency,
_______________________
odor)
_______________________ ______________________
_______________________ ______________________
_______________________ ______________________
_______________________ ______________________
_______________________
* if they are in place?
Briefly describe the patients ability to follow treatments
(diet, meds, etc.) for chronic health problems (if present).
________________________________________________
________________________________________________
________________________________________________
________________________________________________

SUBJECTIVE
SKIN INTEGRETY:
[] dry
[] Itchy
[] other
[] denied

ACTIVITY/SAFETY:
[] convulsion
[]limited motion of joint
Limitation in ability to
[] ambulate
[] bathe self
[] other
[] denied

Comments: _______________
_________________________
_________________________
_________________________
_________________________
_________________________

Comments: _______________
________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________

OBJECTIVE
[] dry
[] cold
[] pale
[] flushed
[] warm
[] moist
[] cyanotic
*rashes, ulcers, decubitus ( describe size, location,
drainage) ________________________________________
________________________________________________
________________________________________________

[] LOC and orientation _____________________________

________________________________________________
[] gait
[] walker
[] cane
[] other
[] steady
[] unsteady __________
[] sensory and motor losses in face or extremities: _______
________________________________________________
________________________________________________
[] ROM limitation: _________________________________
________________________________________________

COMFORT/SLEEP/AWAKE:
[] pain
Comments: _______________
(location
_________________________
frequency
_________________________
remedies)
_________________________
[] nocturia
_________________________
[] sleep difficulties
_________________________
[] denied
_________________________

[] Facial grimaces
[] guarding
[] other signs of pain: ______________________________
________________________________________________
________________________________________________
[] side rails release form signed (60 + years)
________________________________________________

COPING:
Occupation: _____________________________________
Members of household: ____________________________
________________________________________________
________________________________________________
Most supportive person: ___________________________
________________________________________________
________________________________________________

Observed non-verbal behaviour:

______________________
________________________________________________
________________________________________________
________________________________________________
The person and his phone number that can be reached any
time: ___________________________________________
________________________________________________
________________________________________________

DOCTORS ORDER SHEET

Patient: _____________________________________
Attending Physician: ________________________________
Diagnosis: ______________________________________________________ Date Admitted: __________________

Date/ Time

Doctors Order

Rationale of Order

DOCTORS ORDER SHEET

Patient: _____________________________________
Attending Physician: ________________________________
Diagnosis: ______________________________________________________ Date Admitted: __________________

Date/ Time

Doctors Order

Rationale of Order

Name of Patient: ___________________________________________________________________________

Diagnosis: _________________________________________________________________________________

LABORATORY RESULTS
Dx. Exam

Results

Normal Values

Significant of the Result

Name of Patient: ___________________________________________________________________________

Diagnosis: _________________________________________________________________________________

LABORATORY RESULTS
Dx. Exam

Results

Normal Values

Significant of the Result

Date Ordered

Diagnostic/ Laboratory Exams

Clinical Significance

Date Ordered

I.V. Fluids/ Blood

Clinical Significance

NURSING CARE PLANS

NURSING STANDARDS

DATE/
TIME

FOCUS

DAR

NURSING CARE PLANS

NURSING STANDARDS

DATE/
TIME

FOCUS

DAR

FLUID INTAKE and OUTPUT CHART

INTAKE
DATE

SHIFT

ORAL

I.V.

OUTPUT
OTHERS

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.

TOTAL

URINE

VOMITUS

DRAINAGE

OTHERS

TOTAL

VITAL SIGNS MONITORING SHEET

Date/ Time

PR

RR

BP

Level of
consciousness

Intravenous fluid
(vol. & drops/ min.)

IVF Level
per
Endorsement

Remarks

ROOSTER LIST
DATE
SHIFT
LAST CENSUS
NO. OF ADMISSION
NO. OF DISCHARGE
CURRENT CENSUS
STATUS

RM

STATUS LEGEND:

NOC

AM

PM

NAME OF PATIENT

New Admission:

NOC

AM

PM

C.C/ DIAGNOSIS

Discharge:

Expired:

NOC

AM

PM

ATTENDING PHYSICIAN

(RED) Transferred:

MEDICATION WORKSHEET
DATE
ORDERED

DRUG, DOSE, ROUTE &

FREQUENCY

Note: Entries will start during

Assessment

Indicates date & shift

Indicate date & shift

Indicate date & shift

HEALTH TEACHINGS
Name of the Patient
MEDICATION

EXERCISE

TREATMENT

OUT PATIENT
(CHECK-UP)

DIET

RATIONALE

KARDEX

Name: ____________________________________________________

Chief Complaints: ___________________________________________

Address: __________________________________________________

Diagnosis: _________________________________________________

Age:

Civil Status:_____________

Attending Physician:_________________________________________

Room:______________________

Date & Time Admitted:_______________________________________

Sex:

Ward:

Date

Observation

Doctors
Order

IVF/
Blood

Medication

Nursing Diagnosis

Goal

Nursing Intervention

Special Endorsement

DRUG STUDY
Name of Drug
(Generic Name / Brand
Name)

Special Indication
(Based on patients
Problem)

Mechanism of Action (Relate it to

patients problem)

Nursing Responsibility
(Based on drugs
physiologic effects)

DRUG STUDY
Name of Drug
(Generic Name / Brand
Name)

Special Indication
(Based on patients
Problem)

Mechanism of Action (Relate it to

patients problem)

Nursing Responsibility
(Based on drugs
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 ______________________________________