PHILIPPINE GENERAL HOSPITAL Name: Case No.

:
The National University Hospital (Surname) (First Name) (Middle Name)
University of the Philippines Manila
Taft Avenue, Manila Age: Height: Ward/Bed No: Birthdate:
PHIC – Accredited Health Care Provider Sex: Weight: Unit/Room No.: ADVANCED DIRECTIVES:
ISO 9001: 2008 Certified
Date Hospital FULL CODE/DNR/DNI/NA
24-HOUR PEDIATRIC NURSING
Day: Signed: Y/N Date:_______
DOCUMENTATION SHEET
NURSING ASSESSMENT
OXYGENATION AND CIRCULATION SENSORIMOTOR ELIMINATION
Parenteral Access 6-2 2-10 10-6 Musculoskeletal 6-2 Urine Output
2-10 10-6 6-2 2-10 10-6
Heplock@ Full Clear

ROM
Turbidity
Peripheral Line (see Flow Sheet) Limited Cloudy
Central line Site@ Weakness R/L Pale Yellow

Deficits
AVF@ Paralysis R/L Amber

Color
Others : Paresthesia R/L Tea-Colored
Cardiovascular Traction Specify: Orange
Distinct Specify: Bloody
Cast
Sounds
Heart

Faint Stool
Murmurs Sling: Formed
Others: Others: Semi-formed
Regular Watery
Rhythm
Irregular NUTRITION/METABOLIC & FLUID/ELECTROLYTES Others:
Full NPO Drains
Pulses
Weak Fluid Limitation/Total Drip Rate: Coffee-Ground

NGT/OGT
Device: Per Orem: Bilious
Respiratory NGT/OGT Bloody
Regular PEG/Tube-G/Tube-J Others:
Pattern

Irregular: TPN (see Flow Sheet) Right/Left/Mediastinal

Chest tube thoracostomy

Dyspneic/Apneic Gastrointestinal __ way-Bottle
Abnormalities
Retractions: Soft Water Seal Level: _____ cc
Clear R/L Abdomen Flat Low Pressure Suction
Crackles R/L Distended Heimlich Valve/Jackson-Pratt
Sounds
Breath

Rhonchi R/L Normoactive Serous

Sounds

Output
Bowel

Wheezes R/L Hypoactive Serosanguinous

Decreased R/L Hyperactive Bloody
Productive Umbilical Stump: Moist/Dry Location:
Cough
Jackson-Pratt

Non-productive Stoma: Pressure: Full/Half/ 1/3 Pressed

Color: Liquid Serous
Output
Secretions

Stoma

Output

Consistency: Semi-Formed Serosanguinous

Amount: Formed Bloody
Nasal cannula @__ L per min Skin Integrity Purulent
Face Mask/ Funnel/ Hood Normal Location:
Hemovac

@ ___ L per min Mottled Serous

Oxygen Support

CPAP/NCPAP/BiPAP/NIPPV
Color

Cyanotic Serosanguinous
Trache/ET: Size__ Level__ Pale Bloody
To Mech Vent Jaundice Purulent
To Bag-valve Mask Others: Penrose Drain@
To Macronebulizer Moist T-tube
Moisture
Settings: Dry Tube Gastrostomy/Jejunostomy
Good Pigtail Catheter @
Turgor
SENSORIMOTOR Poor Tube Ventriculostomy
Neurologic Warm Pericardiostomy tube
Temp
Asleep Cold Clammy Others:
Activity

Awake Edema: SEXUALITY-REPRODUCTIVE

Calm Normal R/L
Breast

Agitated Location: Lump R/L

Lesion/ Wound/
Incision/ Burn
Hematoma/

Good Thickening R/L

Cry

Fair Description: Others:

Poor Abnormalities :
Genitalia

Eye Response Dressing/Packing:

GCS (specify

Verbal Response Grade: Discharges :

score)

Pressure
Motor Response
Sore
Total_ Location: GENETICS
Size (mm) L____ R _____ ELIMINATION Birth Defects
Brisk R/L Freely Structural
Pupils

Voiding

Sluggish R/L Foley/Straight/Condom Catheter Functional

Nonreactive R/L Nephrostomy
Others :
 24-HOUR PEDIATRIC NURSING DOCUMENTATION SHEET
Name: Date: Case No.:
(Surname) (First Name) (Middle Name)
Age/Sex: Birthdate: Ward/Bed No: Unit/Room No.:
NURSING INTERVENTIONS
Comfort, Safety and Hygiene and Privacy Measures Psychosocial Care
6-2 2-10 10-6 6-2 2-10 10-6 6-2 2-10 10-6 6-2 2-10 10-6
Observed Strict Asepsis Encouraged Deep Rendered Tepid Sponge Encouraged verbalization
& Hand Hygiene Breathing Exercises Bath of feelings
Reinforced Hygienic Rendered Chest Pulmo- Facilitated Bladder/ Recognized spiritual
Measures physiotherapy Bowel Training (q___) practice
Kept Thermoregulated Performed Applied bandages/ Engaged Patient/
Suctioning stockings Relatives in Care Plan
Minimized Sensory Provided Trache/ET Care Facilitated Explained plan of care
Disturbance Rehabilitation
Provided Patient PerformedCatheter/ Facilitated Prosthetic Provided Health
Privacy TubeCare Training Education
Given Tube Feeding Performed Wound Applied Restraints with Ensured Presence of
(q__) Care Consent Responsible Watcher
Observed Fluid Performed Stoma Observed Safety Collaborative Referrals:
Restriction Care Precautions
Ensured Fluid Ensured Bed Turning Encouraged Kangaroo Others:
Replacement (q___) Mother Care, proper
latching on and rooming-in
DIAGNOSTIC EXAMINATIONS and MEDICAL PROCEDURES
6-2 2-10 10-6

NARRATIVE NOTES (Miscellaneous Nursing Interventions and Significant Events)

6-2 2-10 10-6

Nurse-in-Charge: Nurse-in-Charge: Nurse-in-Charge:

 PHILIPPINE GENERAL HOSPITAL 24-HOUR NURSING DOCUMENTATION SHEET (Additional Sheet)
The National University Hospital Name:
University of the Philippines Manila
Taft Avenue, Manila (Surname) (First Name) (Middle Name)
PHIC – Accredited Health Care Provider Age/Sex: Birthdate: Case No.:
ISO 9001: 2008 Certified
Date: Ward/Unit: Room/Bed No.:
NARRATIVE NOTES (Additional Notes)
6-2 2-10 10-6

Nurse-in-Charge: Nurse-in-Charge: Nurse-in-Charge: