San Lorenzo Ruiz College College of Nursing

Name of Patient: Diagnosis:

Hospital No.: Room No.: Physician:

PHYSIOLOGIC BODY PARTS Head and Neck Head

INSPECTION

PALPATION

PERCUSSION

AUSCULTATION

Normocephalic and symmetrical

Hair

Scalp

Forehead

White and gray, no scars noted, lighter skin color than complexion Lighter in color than skin complexion, moist from perspiration, no scars, free from dandruff No wounds/ scars, color is even which is light brown, lentigens (brown age

Normal skull which looks smooth, no masses nontender, and depressions, no pain felt Flat shaft, brittle, moist from perspiration/ oily, thin Without masses, no pain felt, no lumps

No pain felt, without lesions and depressions, no masses, no pain felt, , temporal pulse=

spots) noted

Face

Eyes

Eyebrows

slightly 61 bpm synchronized on both sides with normal strength, warm to touch Oval, , No masses, no symmetrical pain felt, no facial features, swelling dry skin, poor skin turgor, facial grimace and facial wrinkles noted In line with each other/ symmetrical, non-protruding Bilateral, No masses, no grayish and lumps, no white in color, nodules evenly distributed, symmetrically aligned, parallel

PHYSIOLOGIC BODY PARTS Eyelashes

INSPECTION Evenly distributed, slightly curved outward, black, blink reflex= 15 times per minute UPPER LIDS: Symmetrical, Intact, able to open and close, pale pink in color, dry, drooping

PALPATION Active blink reflex, thin

PERCUSSION

AUSCULTATION

Eyelids

Involuntary when blinking

eyelids LOWER LIDS: Involuntary Symmetrical, when blinking intact, able to open and close, pale pink in color, dry white, absence of lesions, small veins are visible Not inflamed; pale pink in color, moist Transparent and glossy, teary looking, clear Equal in size of both eyes and brownish in color, appears flat with a regular shape Black, Equally round, reactive to light and accommodatio n Both eyes are well coordinated, it moves smoothly and symmetrically and follows the 6 fields of gaze. Constricting during light reflex and simultaneously

Sclera

Conjunctivae

Cornea

Iris

Pupil

Muscle Function

Muscle Balance

Visual Acuity

Peripheral Vision

Nose

Frontal Sinus

Maxillary Sinus

during consensual light reflex 20/20 (Normal Vision); Upon admission,, patient experienced blurring of vision and gradually returns to normal Able to see the stimulus at about 90 degrees temporally, 50 degrees superiorly, 70 degrees inferiorly, and 60 degrees nasally Found in the midline of the face with no lesions and no presence of discharges Evidence of swelling around the eyes and nose, gray during transilluminati on Evidence of swelling around the eyes and nose, grayish color during

No masses, no lumps, no pain felt

Slightly tender Dull sound upon palpation

Slightly tender

Dull sound

transilluminati on Mouth Lips Pallor, pale pink in color, cracked and dry Pale pink in color, no bleeding, smooth Yellowish, 27 teeth, 2 extracted, and dentures for molars noted, presence of dental plaques also noted Pink in color and is in the midline of the mouth. It moves freely and the dorsal and ventral surface is moist. Attached to the tongue, pink in color Pink in color, absence of lesions, blood vessels visible Slightly whitish in color and dome-shaped with ridges, no lesions, dry Light pink in color, concave, Non-tender, no pain felt, soft, no lumps No pain felt

Gums

Teeth

Tongue

Frenulum

Sublingual

Hard Palate

Hard

Soft Palate

Soft

Uvula

Tonsils

no lesions, moist Hanging in the midline of soft palate, pink in color, slightly dry Pink, moist, No pain felt not inflamed Slightly slurred Bilaterally equal, without swelling, light brown in color consistent with the patients facial skin, no discharges, laterally aligned with the outer canthus of the eye, symmetrical, and pendulous Able to perceived the words and sounds equally in both ears Able to move the head in full range of motion without complaints or discomforts, able to move neck with full ROM: flexion= 45, hyperextension

Speech EARS

Firm, absence of lumps, no pain felt

Auditory Acuity

Neck

Smooth, absence of lesions, no pain felt, carotid pulse= 61 bpm synchronized and strong pulse

Lymph Nodes Trachea

Thyroid Gland

= 60, lateral abduction= 40, rotation=10 Not inflamed No pain felt during palpation Appears in Placed centrally midline in midline, spaces are equal on both sides, not deviated Moves up No enlargement, when masses and swallowing, no tenderness visible masses

Thorax Chest Anterior Lighter in color, equal rise and fall, breathing route is 18 cycles per minute, moist with perspiration Equal chest Resonance on Clear sounds on expansion, full lung area, flat both lobes of the symmetric on ribs lungs excursion, warm skin, axillary temperature= 37.8C Respiratory rate= 18 cycles per minute, bilateral symmetry Nonpalpable, heartbeats=61 bpm Warm to touch, no pain felt, full and symmetric expansion No pain felt no lumps, absence of masses, and lesions Resonant Clear sounds on sound on both lobes of the intercostals lungs spaces, flat on ribs Dull Sound Apical pulse= 61 bpm Resonant sound heard Clear sounds on both lobes of the lungs

Lungs

Heart

Chest Posterior

Spine vertically align, symmetrical Color is the same with the body, flat, umbilicus in the midline and non-

Abdomen

Tympanic High pitched sound over the sound/ gurgles: 8 stomach, times/minute dullness over the liver and spleen

protruding Liver Spleen Kidney Extremities Upper Even in color, hairy, slight age spots noted, numbness and difficulty moving left hand, with ongoing IVF #4 of PNSS 1L @ 20 gtts/min at the level of 150 cc infusing well @ right hand; unable to perform gross and fine motor skills at left hand Color is even, poor skin turgor, wrinkles, and unable to resist the force exerted on his left hand and was able to resist force exerted on the right hand No pain felt, capillary refill less than 3 seconds, brachial and radial/ulnar pulse palpable, T= 37.8 degrees Celsius PR= 61 bpm BP= 120/80 mmhg No pain felt, Dull sound lightly palpable Non palpable Dull sound Non palpable, no Dull sound pain

Muscle tone

Muscle strength

no pain felt, no lumps, nontender, warm and moist from perspiration. Patient has weak resistance to force exerted to him

Reflexes

Biceps= flexion of the forearm Triceps=

extension of the elbow Brachioradialis= supination and flexion of forearm Lower Equal in size, brown in complexion, even skin tone, hairy legs No pain felt, popliteal/dorsalis pedis and tibal pulse palpable

Muscle Strength

Muscle tone

Weak resistance to force exerted on him Color is even, No pain felt, unable to non-tender, no move left leg, lumps, warm to symmetrical, touch age spots and wrinkles noted Patellar= extension of the knee Achilles= planter flexion of the feet Plantar= toes curved/plantar flexion of the toes Patient is confined to bed (nonambulatory) due to leftsided weakness. Gait was not assessed. Patient is confined to bed (n0n-

Reflexes

Gait

Balance

Coordination

ambulatory) due to leftsided weakness. Balance was not assessed. Patient is confined to bed. Coordination was not assessed.

San Lorenzo Ruiz College of Ormoc College of Nursing Ormoc City

Name of Patient: Serenio, Olympio Lota Diagnosis: Post-gliotic seizure secondary to CVA Diabetes Mellitus, type 2 Essential Hypertension, stage I Hypokalemia

Hospital No.: 39096- 2011 Room No.: MM8 Physician: Dr. Honey Alcantara/ Dr. Dennis Daniel Roa

DRUG THERAPEUTIC RECORD Drug/ Dose/ Classification/ Frequency/ Mechanism of Route Cction Indications/ Contraindications/Side Effects Principles of Care Treatment Evaluation

Metformin HCl

Classification: Antidiabetic

Indications:

1. Do

not Monitor urine serum glucose levels

Medications or taken at

-Adjunct to diet to discontinue lower blood this

ordered dose, date and time. Desired

Dose: 500mg Route: Oral Frequency: BID Timing: 10 am 10 pm

Mechanism of glucose with type 2 medication Action: Exact mechanism DM -As part without of consulting healthcare with provider. wherein 2.

frequently to effects determine effectiveness of drug and dosage. obtained.

is combination

not understood therapy which possibly insulin increases peripheral utilization

either drug alone Monitor cannot control blood

of glucose levels in glucose and Arrange for

glucose, decreases.

patients with type 2 ketone DM

as transfer insulin therapy

to

prescribed.

Contraindications:

Swallow

during periods of

-Hypersensitivity to extendedthe drug, CHF; release tablets by whole;

high stress.

diabetes complicated fever, infections, surgery

do Use

IV if

severe not crush or glucose major chew. severe

hypoglycemi Do not use a occurs as a

Side Effects: Gastrointestinal:

this during

drug result overdose.

of

Nausea, vomiting, pregnancy. anorexia, heartburn, diarrhea Avoid and flatulence Hypersensitivity: -allergic using alcohol Increased risk of

hypoglycemi a occurs as a result the overdose. . of

skin while

reactions, eczema, taking pruritus, erythema, drug. urticaria

Report your fever, sore throat, unusual rash bruising, dark-urine, lightcolored stools, hypoor or

hyperglyce mic reactions.

Amlodipine desylate (Norvasc)

Classification: CalciumChannel Blocker

Indications: -Hpertension

-Monitor patient carefully.

-Caution patient continue

Medications to taken at

ordered dose,

Contraindications: -Hypersensitivity -Monitor

taking drug, date and time. even feeling better. when Desired effects obtained.

Dose: 500 mg Route: Oral

Mechanism of -used cautiously to blood Action: Inhibits patients other receiving pressure peripheral frequently

Frequency: TID Timing: 6 am 2 pm 10 pm

calcium influx cardiac

ion vasodilators across and Side effects:

during

-Tell

the SL

initiation of patient therapy.

Nitroglycrei n may be as

smooth muscle CNS: cells, decreasing myocardial contractility and thus -headache, fatigue, -Notify dizziness, headedness, paresthesia light- prescriber

taken

needed when

if signs of angina heart failure symptoms occur, such are acute. IF

oxygen CV: also -edema,

demand; dilated coronary arteries arterioles.

flushing, as swelling patient of hands continues

palpitations Gastrointestinal:

and feet or nitrate

and -nausea, abdominal shortness of therapy pain Genitourinary: -sexual difficulties Musculoskeletal: -muscle pain -Alert: Dont confuse with Amiloride. breathing. during adjustment of amlodipine dosage, urge continued compliance.

Citicoline

Classification:

Indications:

-May

be Administer

Medications

Dose: 500 mg Route: Oral Frequency: TID Timing: 6 am 2 pm 10 pm

-Neurotonics -Nootropics

-Parkinsons disease -Head

taken without

this medication

taken

at

ordered dose, date and time. to Desired effects obtained.

acute food. With without or without regard meals.

Mechanism of cerebral injury Action: Increases blood flow and oxygen Contraindications: -Cerebrovascular disease

meals.

-Should not -Observe be taken in closely the late monitor patients it neurologic or

consumption in -Parasympathetic the brain. It is hypertonia also involved

afternoon because can

in the synthesis Side Effects: of lecithin. -diarrhea the -hypertension/ hypotension

cause status.

difficulty in sleeping. -Report physician for -Should be unusualities started within such 24 rashes as and

Increases

neurotransmiss ion because favors synthesis production speed

levels -blurred vision it -chest pain the -tachycardia and -restlessness

hours of a chest tightness occurs.

-body temperature stroke. of elevation -Monitor neurostatus while

dopaminergic antagonist

-Slowly

through inhibition tyrosine

the of

taking drug.

the injexct over 3- 5 minutes into a vein

hydroxylase.

-Contact physician immediatel y if allergic reaction such hives, rashes and chest tightness occurs. as

or into a Yport.

Phenytoin (Dilantin)

Classification: Anticonvulsant / Antiepileptic

Indications:

-Tell patient

the Medications to taken at

-to control tonic- REquireme clonic

(grandmal) nts usually notify

ordered dose,

Dose: 100 mg Route: Oral Frequency:

and complex partial increase Mechanism of (temporal Action: Unknown. hydantoin seizures A -for patient lobe) during pregnancy.

prescriber if date and time. skin rash Desired effects obtained.

develops.

requiring a loading -Use

only -Advise

TID Timing: 6 am 2 pm 10 pm

derivative that dose probably stabilizes neuronal membranes and -to treat during neurosurgery prevent

clear

patient

to

and solution for avoid driving and other -Dont give potentially IM unless hazardous activities that require mental alertness until drugs

seizures injection.

limits -status epilepticus

seizure activity by either Contraindications:

dosage adjustments

increasing influx sodium across

-Hypersensitivity to are made. of the drug ions -Sinus bradycardia, -Divided

cell SA block, 2nd- and doses given CNS effects degree AV with or are known.

membranes in 3rdthe cortex

motor block, or Adam- after meals during Stokes syndrome may -Advise patient not to

nerve impulses -Used cautiously to decrease generation.

those with hepatic adverse GI change dysfunction, hypotension -Elderly reactions. brands dosage -Stop drug forms if Side Effects: CNS: rash hes stabilized on therapy. once or

appears.

-ataxia, speech, mental

slurred -Dont stop dizziness, drug confusion, suddenly -Tell patient not to use

twitching, nervousness, headache CV:

because this capsules that may worsen are seizures. discolored.

-periateritis, nodosa -Monitor EENT: -nystagmus, diplopia, vision Metabolic: -osteomalacia Hepatic: -toxic hepatitis blurred -Monitor CBC calcium drug

-Advise to

level patient control alcohol.

in blood.

and -Warn patient and not

level every parents 6 and periodically onitor hepatic function. . -Stress

months to stop drugs abruptly.

the

importance of good oral hygiene and regular

dental examination.

Glimepiride

Classification: -Medium

Indications: to

-May diet used to together

be -Tell patient Medications to take the taken drug at

to -Adjunct and lowerglucose

Dose: 3 mg Route: Oral Frequency: OD Timing: 8 am

long-acting sulfonylurea Antidiabetic drug

exercise

first ordered dose,

blood with insulin meal of the date and time. level in for patients day. lose -Make patient first understands that therapy relieves symptoms but does not cure disease. the the Desired effects sure obtained.

patients with tpe 2 who DM whose glucose control

Mechanism of hyperglycemia Action: Unknown. Lowers glucose possibly stimulating release insulin

cant be managed after

by diet and exercise responding alone level -Adjunct by and to diet in -Monitor with fasting or glucose to therapy.

exercise

conjunction of insulin

from metformin therapy level in patients with periodically

functioning

pancreatic beta type 2 DM whose to cells and may hyperglycemia lead increased sensitivity peripheral tissues insulin. to Contraindications: determine

-Stress

the

importance of adhering to weight diet,

to cannot be managed therapeutic by of alone dosage. glimepiride- response. maximum

-Use of oral reduction hypoglyce mics exercise and

may personal

-hypersensitivity to carry higher hygiene the drug -Pregnant elderly clients -breastfeeding patients -debilitated malnourished patients -When Side Effects: CNS: -dizziness, asthenia,, headache EENT: changing patient -Advise woman to risk of CV programs. or mortality than use of -Advise diet alone patient to carry

or diet and wear/ or insulin therapy.

identificatio n at all

times.

from other consult sulfonylure ases prescriber

to before

-changes accommodation, Gastrointestinal: -nausea Hematologic: -leukopenia, hemolytic anemia Skin:

in glimepiride, planning transition period is pregnancy.

not needed.

-pruritus, erythema, urticaria, photosensitivity reactions Hepatic: -cholestatic jaundice

Dexamethas one

Classification: Corticosteroid

Indications: -crebral edema -inflammatory

-Determine

-Tell patient Medications at

whether the not to stop taken patient is drug

ordered dose, or date and time. Desired effects obtained.

Dose: 4 mg tab 1 tab Route:

Mechanism of conditions Action: Not defined. -shock clearly -adrenocortical insufficiency

sensitive to abruptly other corticostero ids. without

prescribers consent.

Oral Frequency: BID Timing: 8 am 6 pm

Decreases inflammation, mainly stabilizing leukocyte lysomal membranes; suppresses immune response; stimulates Contraindications: -For better -Instruct to drug

by -Hypersensitivity to results and patient the drug -recent MI less toxicity, take

with food or

-patients with GI give once- milk. ulcer, renal disease, daily hypertension, in dose the -Teach patient signs -Give dose the and

osteoporosis, DM, morning. hypothyroidism, cirrhosis,

oral symptoms of with early adrenal

bone marrow; diverticulitis, & influences seizures, fat failure

heart food when insufficiency possible. , fatigue,

protein, ,and

muscle Side Effects: CNS: -euphoria, -Give injection IM weakness, joint pain,

carbohydrate metabolism.

deeply into fever, anorexia, nausea, shortness of breath, to dizziness,

insomnia, vertigo, gluteal headache, paresthesia, seizures CV: muscle. Route injection sites

-heart

failure, prevent muscle

and fainting.

hypertension,

edema, arrthymias, atrophy. thrombophlebitis, thromboembolism EENT: -cataracts, glaucoma -Always adjust lowest effective dose.

-Warn patient about easy to bruising.

-Advise patient avoid to

-Watch for exposure in depression pr psychotic episodes especially in dose therapy. infections (such as

measles and chicken pox) and to notify

high- the prescriber if such exposure

-Diabetic patient may need

occurs.

increased insulin; monitor glucose levels.