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

Score: _______________ Grade: ______________

 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

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
 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

Level of Intravenous fluid
Date/ Time T PR RR BP Endorsement Remarks
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 &

Indicates date & shift Indicate date & shift Indicate date & shift
ORDERED FREQUENCY

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 Medication Nursing Diagnosis Goal Nursing Intervention Special Endorsement
Order Blood
 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______________________________________