College of Nursing

USSO Building
Visca, Baybay City, Leyte, Philippines
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

FM-CON-###-### N U R S E S N O T E S
Name Mrs. E.A Reason for Admission Vaginal bleeding for 1 week
Age 41 years old Sex F Medical Impression

Date F = Focus D = Data A = Action R = Response

January 01, 2013 Deficient knowledge D= A 41 year old client who is 11 weeks pregnant was diagnosed to
related to lack of have incomplete abortion. Client consumes 10 sticks of champion
education as per day or 1,642 packs for 9 years. "Giingnan man ko nga ihunong
evidenced by ang pagpanigarilyo kay makadaot sa akong gisabak, pero lisod man
substance abuse ang naandan na" as verbalized by the client. She refrained from
smoking upon hospitalization. The client also drinks "tuba"
occasionally around 3 glasses per session. “Kaingon naku dili
makadaot ang sigarilyo sa ako gesabak karun kay dugay-dugay
naman ko nanigarilyo pero wa man naapektuhan ako unang mga
anak" as verbalized by the client.
A= Provide client health teaching in regard to substance abuse
which gives the importance of abstaining from use of substances to
maintain optimal wellness. Encourage client to reduce the
consumption of smoking from 10 to 6 sticks and so on.
R= The client was able to learn and understand the effects of
cigarette smoking to the body. "Ako suwayan day" as verbalize by
the client to reduce cigarette smoking.
January 02, 2013 Stress Overload D= The client is 11 weeks pregnant and was diagnosed as
incomplete abortion. The client verbalized, “Ge dugo ko sud a usa
ka semana.”
A= Encourage the client to do daily exercise, deep breathing, and
meditation. Be available to client for listening and talking.
R= Patient is able to demonstrate effective coping stress as
evidenced by:
- Controlled emotion
- Have enough sleep
- Able to provide proper basic needs within the family.
January 03, 2013 Acute Pain D= “Inig molihok o mo lakaw ko mo sakit ako kinatawo.” As
verbalized by the client. The patient also reported discomfort and
pain during urination due to Curettage. The patient rate the pain of 6
from the pain scale of 10 where 1 is the lowest and 10 is the highest.
A= Encouraged the patient to have a rest period to prevent fatigue.
Promote relaxation technique while also maintaining the client’s
environment clean.
R=The physical pain of the client was alleviated and was able to
relax.

VSU's Vision: A globally competitive university for science, technology, and environmental conservation.
VSU's Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and
innovative technologies for sustainable communities and environment.
FM-CON-###-### Visayas State University - College of Nursing | Page | 2
 College of Nursing
USSO Building
Visca, Baybay City, Leyte, Philippines
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

FM-CON-###-### NURSING CARE PLAN # ____1__

Name Mrs. E.A Reason for Admission Vaginal bleeding for 1 week
Age 41 years old Sex F Medical Impression

PLANNING NURSING INTEVENTIONS

NURSING OUTCOME
ASSESSMENT CUES RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION INTERVENTIONS
(with references)
Deficient knowledge Goal Independent After 8 hours of
Subjective related to lack of With 8 hours of - Observe client's ability - Education in self-care must take rendering appropriate
“Kaingon naku dili education as rendering appropriate and readiness to learn into account physical, sensory, nursing intervention the
makadaot ang sigarilyo evidenced by intervention the patient (e.g., mental acuity, mobility, sexual, and psychosocial patient was able to:
sa ako gesabak karun substance abuse will be able to ability to see or hear, no changes related to age (Bohny, -Learn and understand
kay dugay-dugay existing pain, emotional 1997). the effects of cigarette
naman ko nanigarilyo Desired Outcome readiness, absence of - The client brings to the learning smoking to the body.
pero wa man Scientific Basis -Learn and understand language or cultural situation a unique personality, -Verbalized to attempt
naapektuhan ako Role of stress does effects to body of too barriers). established social interaction reduce cigarette
unang mga anak" as play in substance much cigarette - Assess barriers to patterns, cultural norms and smoking as evidenced
verbalized by the client abuse occurs more in smoking. learning (e.g., values, and environmental by “ako suwayan day”
biologic response to -Participate in learning perceived change in influences (Bohny, 1997). as verbalized by the
Objective stress in brain, as process and verbalize lifestyle, financial -Optimizes outcomes and promote patient. Goal is partially
-black lips noted perceived by the understanding bad concerns, cultural health promotion. met.
-with dental carries individual, results in effects of smoking patterns, lack of - New information is assimilated
noted during stimulation of the during health teaching. acceptance by peers or into previous assumptions and
assessment hypothalamus-center -Provide correct self- co-workers). facts and may involve negotiating,
-stress noted of emotional responses care measures. -Identify motivating transforming, or stalling.
-smoke's 10 sticks per and houses the limbic -Reduce cigarette factors for the individual - Objectives put the content into
day of cigarette before system of the brain. smoking at least 6 of 10 like client needs to stop focus, provide a forum for
admission Medical and Surgical sticks per day and so smoking because of evaluation outcomes, and ensure
pp 920. Nicotine has on. advanced lung cancer. continuity. Client involvement
both stimulant and - Provide substitute for - Determine client's improves compliance with health
sedative properties that cigarette to prevent previous knowledge of regimen and makes teaching and

VSU's Vision: A globally competitive university for science, technology, and environmental conservation.
VSU's Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.
 affect the CNS. Daily smoking during leisure or skills related to his or learning a partnership.
ingestion of nicotine time like candies or her diagnosis and the
results in accumulation chewing gums. influence on willingness
of nicotine in the body, to learn.
lasting 24 hrs. because - Involve clients in
of cyclic properties of writing specific
nicotine, the body outcomes for the
begins to require more teaching session, such
nicotine usage to as identifying what is
maintain the stimulant most important to learn
effects of the drug. from their viewpoint and
REFERENCE: lifestyle.
Medical-Surgical by
Ignatavicius-workman. Collaborative
5th edition. Vol. l. pp Assess willingness of - Attention needs to be directed at
95-96oi family to incorporate new family adjustment factors. For
information, example, women recovering from
immunizations, alcohol abuse are at risk for relapse if
medical/dental care, and their spouse continues to drink
diet/behavior alcohol (Murphy, 1993), and
modifications in support of modification of eating patterns plus
the client. social and partnership support have
had more success than modification
Dependent alone (Keller et al, 1997).
Administer medication REFERENCE
as indication like https://nursing-nic-
Clindamycin 300 mg noc.blogspot.com/2013/10/deficient-
TID P.O knowledge.html

FM-CON-###-### Visayas State University - College of Nursing | Page | 4

 College of Nursing
USSO Building
Visca, Baybay City, Leyte, Philippines
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

FM-CON-###-### DRUG THERAPEUTIC RECORD # ______

Name Mrs. E.A Reason for Admission Vaginal bleeding for 1 week
Age 41 years old Sex F Medical Impression

MECHANISM OF CONTRA- SIDE EFFECTS/ ADVERSE NURSING

DRUG NAME DRUG CLASS INDICATIONS
ACTION INDICATIONS EFFECTS CONSIDERATION
Generic: Therapeutic: -Inhibits protein Patient’s -hypersensivity to Side Effects: Observe 15 rights of
Clindamycin Anti-infective synthesis in Indications: drug or nausea, vomiting, diarrhea, drug administration
susceptible bacteria -treatment of lincomycin stomach pain, joint pain, vaginal Before:
Brand: at the level of the serious infections itching or discharge, -check doctor’s
Cleocin 50’s ribosome, caused by Pregnancy skin rash or itching, heartburn, order
Pharmacologic: thereby inhibiting susceptible Category: sore throat, or changes in bowel -assess for allergy
Complete Lincosamide peptide bond strains of Pregnancy risk habits (especially in older adults). to clindamycin,
Prescription: formation and anaerobes category B history of asthma or
Clindamycin 300 REFERENCE: causing cell death. REFERENCE: other allergies,
mg TID McGraw-Hill Nurse’s REFERENCE: https://www.rxlist.com/clindamycin- allergy to tartrazine
Drug Handbook 7th REFERENCE: General: McGraw-Hill side-effects-drug-center.htm -assess history of
Date of Rx: Edition page: 279 McGraw-Hill -systemic Nurse’s Drug renal impairment,
January 2, 2013 Nurse’s Drug administration: Handbook 7th Adverse Reactions: lactation, regional
(11:10 am) Handbook 7th serious infections Edition page: 279 GI: nausea, vomiting, diarrhea, enteritis or
Edition page: 279 caused by abdominal pain, esophagitis, ulcerative colitis
REFERENCE: susceptible pseudomembranous colitis
McGraw-Hill strains of Hematologic: neutropenia, During:
Nurse’s Drug anaerobes, leucopenia, agranulocytosis, -verify patient’s
Handbook 7th streptococci, thrombocytopenia purpura identify
Edition page: 279 staphylococci, Hepatic: jaundice, hepatic -administer the right
penumococci dysfunction drug with the right
-parenteral: Skin: maculopapular rash, dose at the right
treatment of generalized morbilliform-like rash time
septicemia Other: bitter taste (with I.V. use), -state the
-topical phlebitis at I.V site, induration and importance and

VSU's Vision: A globally competitive university for science, technology, and environmental conservation.
VSU's Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.
 dermatologic sterile abscess (with I.M. use), purpose of the drug
solution: anaphylaxis to the patient
treatment of acne -check the patency
vulgaris REFERENCE: of the IV site and IV
-vaginal McGraw-Hill Nurse’s Drug line
preparation: Handbook 7th Edition page: 280 -if hypersensitivity
treatment of reaction occurs,
bacterial stop the
vaginosis administration
immediately
REFERENCE:
2011 Lippincott’s After:
Nursing Drug -regulate the IVF
Guide with the prescribed
flow rate
-monitor LFT’s and
renal function tests,
and blood counts
-report severe or
watery diarrhea,
abdominal pain,
inflamed mouth or
vagina, skin rash or
lesions
-take full prescribed
course of oral drug.
Do not stop talking
without notifying
your health care
provider
-document and
record
REFERENCE:
2011 Lippincott’s
Nursing Drug Guide

FM-CON-###-### Visayas State University - College of Nursing | Page | 6