University of San Carlos

College of Nursing
Cebu City
Discharge Plan and Instruction Format
Name: Marilou Alcover
Age: 5months old Sex: F Religion: Roman Catholic
Diagnosis: Pneumonia
Surgery Undergone, if any NONE
Hospital: Jesus Paras Memorial Hospital
Rm/Ward-bed No. Physician: Pedia Ward; Dr. Pozon
A. Objectives (SMART/ KVSA Format)
1. The patient SO will verbalized the need of their child to take medication on time.
2. The patient will demonstrate the proper breathing pattern.
3. The patient will continue to be breastfeed as prescribed by his doctor.
4. The patient SO will develop a sense of optimism.
I. Medication
Name of
Drugs
Sabutamol

Dosage
Taken 3-4x a
day

Route
Inhalation/
nebulizer

Curative
Effects
relaxes
bronchial and
uterine smooth
muscles by
acting on beta
2-adrenergic
blocker

Major Side
Effects
CNS:
weakness,
headache
CV:
tachycardia,
palpitation,
hypertension
GI:
Nausea and
vomiting

II. Exercise/ Activity

Type of activity allowed/ to be continued: continue bed rest
Procedure or Step: none
Use of Equipments: (if any) none
Restriction: none
III. Treatment
(Prescribed treatment to be continued at home or to a referred health institution)
1. Continue taking medication for the prescribed number of days
2. Adhere to the prescribed diet ( breastfeeding) to regain strength and energy
IV. Health Teaching
[] clinic appointment schedules
[ ] uses of alternative medication
[] follow-up laboratory examinations

[ ] Relapse prevention measures

[] understanding and knowing what to do with side effects and medications
[] others: Medication should be taken on the time and for the prescribed period of time
even if the patient feels better.

V.
A. Observation signs and symptoms that need reporting:
Extreme palpitations and difficulty in breathing
The baby is always crying
Fever of 38c
B. Intervention/ homes remedies that may be done immediately prior to seeking
consultation:
None
VI. Diet (prescribed by the doctor/ dietians)
1. prescribed diet: Breastfeeding
2. restriction: none

VII. Spiritual and Psychological Needs

[] spiritual counseling
[ ] confession
[] supportive counseling
[ ] grief work
[] family therapy
[ ] join organizations/ church activities
[ ] anger management
[ ] reconciliation of conflicted relationship
B. Discharge Details
a. Date of Discharge:
b. Time of Discharge:
c. Accompanied by:
d. Mode of transportation:
e. General condition upon discharge:

Simeon Alcover
Patient /Relative
(Signature over Printed Name)

Validated:

Mekko Mae Villamor and Guada Vergara

STUDENT NURSE
(Signature over Printed Name)

__________________________
CLINICAL INSTRUCTOR
(Signature over printed Name)