This is a general checklist of what the unit/ ward nurse is supposed to accomp

Directions: The system will write " YES" if DONE and "X" i

DAILY CHEC
Date: 02/03/20
AM PM NIGHT PRN
VS YES X
I/Os YES X
MAR
NCP
Monitoring
Fall Assessment
Skin Assessment
Health Teachings
Laboratory Results Checking
Health Assessment

Date: (MM/DD/YYYY)
AM PM NIGHT PRN
VS
I/Os
MAR
NCP
Monitoring
Fall Assessment
Skin Assessment
Health Teachings
Laboratory Results Checking
 posed to accomplish within the EMR within the shift.
f DONE and "X" if NOT DONE

DAILY CHECKLIST
Date: Date:
AM PM NIGHT PRN AM PM NIGHT PRN

Date: Date:
AM PM NIGHT PRN AM PM NIGHT PRN
 REGISTRATION SHEET
Patient's Name: Ika, Dusug Mona
Birthday: March 15, 1984
Hospital Registration #: 1984
Religion: Roman Catholic
Address: 154 Maginhawa, Diliman, Lungsod Quezon, Kala
Date of Admission: 02/03/20
Chief Complaint: N/V
Admitting DiagnosisVomiting x4-6 approx 1ooml in amt

Other Diagnoses:
Allergies: (Food, Meds, Scents, Particles, Others)
Reaction to Allergies:

Contact in Case of Emergency : 09399648177

Name: Leonardo Da Vinci
Address: 154 Maginhawa, Diliman, Lungsod Quez
CellPhone # / Landline #: 87000
ON SHEET PICTURE
 Column1 Column2
HEALTH ASSESSMENT

Head-to-toe Assessment Date: 02/03/20

Assessment conducted by: MonicaL. Borja Time: 12.04 PM

LOC
Drow
✘
Alert sy
Orientation
Person
Place
Time
Situation
Vitals
Temp 36.8 R: 102 cpm
BP 124/84 mmHg PulseOx: 92%
Head
Hair
PERLA
Nose
Ears
Mouth
Midline tongue
Moist
Lesions
Dentitions
Neck
Carotid Pulse JVD+
Chest
Muf
ApicalPulse ed
Breath Sounds Anterior
Chest Symmetry
Skin Turgor(clavicle)
Abdomen
Inspection: globular
□Auscultation ✘ hyperactive BS
□ LUQ (active / hyper / absent) Active ✘

□ RUQ (active / hyper / absent) Active ✘

✘
□ LLQ (active / hyper / absent) Active ✘

□ RLQ (active / hyper / absent) Active ✘

□Palpation: soft, non-tender

Upper Extremities
□Radial Pulse
◦ other:
□ Temp vsTrunk (warm / cool)
□Grip equal and strong_______________
□Capillary refill <2 sec
□ Vein Filling________________________

Lower Extremities
□Hair present
□Edema
□Foot strength
□Homan's sign (+ / - ) (-) (+)
□Temp vs Trunk ( warm / cool ) warm cool
Yellow
□Nails ed
□Pedal pulse
ROM Strength
□ Upper R □ Upper R
□ Upper L □ Upper L
□ Lower R □ Lower R
□ Lower L □ Lower L
□ Sensation

General Assessment
□ Weight: 156 lbs Height: 4'11 (149.86 cm)
□ BM: last BM 01/31/20 to medium soft well formed stool. Brown

Pain Assessment
□ Acute/Chronic □ Intensity ( 0-10)
□ Location
□ Duration
□ Characteristic
□ Precipitation
□ Frequency
□ Non-Verbals
□ Relief Factors
□ Sleep
Skin Assessment
□ Description _______________________
Column3 Column4

Lethargic Straporous Com

a

Trachea midline

Arrythmia
Posterior Lateral

✘
Hyper ✘
Absent
✘
Hyper ✘
Absent
✘ ✘
 ✘
Hyper ✘
Absent
✘
Hyper ✘
Absent

(+)
cool
Thicke Ingro
ned wn

well formed stool. Brown in color

Date: 02/03/20 Time: 12 pm
Notes: Risk for fluid volume deficit related to vomiting
D- 4-6 vomiting, UO= 720 cc
A- Monitored V
Encouraged small frequent meals, Instructed to monitor intake and
biscuits to include in the diet, Continuity of care
interventions and health teachings, (-) vomiting, intake = 290cc

Date: Time:
Notes:
 Nurses' Notes
m
vomiting
O= 720 cc
A- Monitored VS Regulated IVF as ordered, Reinforced diet as prescribed by the physician,
to monitor intake and output, Encouraged upright position when eating, Recommended ice chips and
are R - verbalized response to
ing, intake = 290cc
 physician,
d ice chips and
balized response to
Date: Date: 01/31/2020
SHIFT: AM PM
TIME TAKEN: 1210
BP 128/83
TEMP (Degrees Celsius) 36.8
TEMP ROUTE (Oral, Axillary, PR, Forehead Scan) AX
PR 102
RR 23
O2 SAT 98%
Pain Scale: 0/10
 VITAL SHEET
1/2020 Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)
NIGHT PRN AM PM NIGHT PRN AM PM
DD/ YY) Date: (MM/ DD/ YY)
NIGHT PRN AM PM NIGHT PRN
Date: 02/03/20
AM SHIFT
INPUT in ML OUTPUT in ML
ROUTE AMOUNT ROUTE
PO URINE
IVF BM
PEG TUBE DRAINAGE TUBES
JT VOMITUS
NGT
TPN
MEDS
Others Others
Total INPUT Total OUTPUT

Others
Total OUTPUT 0
 I and O SHEET
PM SHIFT
PUT in ML INPUT in ML OUTPUT in ML
AMOUNT ROUTE AMOUNT ROUTE AMOUNT
720 PO URINE
IVF BM
PEG TUBE DRAINAGE TUBES
600 JT VOMITUS
NGT
TPN
MEDS
Others Others
al OUTPUT 1320 Total INPUT 0 Total OUTPUT
 NIGHT SHIFT
INPUT in ML OUTPUT in ML
ROUTE AMOUNT ROUTE AMOUNT
PO URINE
IVF BM
PEG TUBE DRAINAGE TUBES
JT VOMITUS
NGT
TPN
MEDS
Others Others
0 Total INPUT 0 Total OUTPUT 0
Nursing Care Plan #1
Date Started: 2/3/2020 Target Date:
Cues/ Clues Nursing Diagnosis Nursing Objectives
3 wks AOG Intake will be approx.
VS 1500 cc
T:36.8 Risk for deficient fluid volume
related to vomiting as evidenced
PR:102
by patient vomiting 4-6 times 100 Clear liquids will be
RR:23 mL tolerated w/o vomiting
BP:128/83 within 24 hrs
O2:98% Equal intake and output
within 24 hrs
UO upon
admission: x4 Electrolyte levels will
approx 180 ml remain within normal
range throughout
total pt OP: hospital stay
1320
hyperactive BS
 Nursing Care Plan #2
2/4/2020 Date Started:
Nursing Interventions Evaluations Cues/ Clues
Monitor UO q2˚
Monitor intake and output q12˚ tolerated clear
Assess for clinicl signs for DHN liquids w/o
Administer IVF as prescribed vomiting within
24 hrs
Introduce cold water, ice chips, ginger
products, and room temperature broth Intake: 1600cc
or bouillon if tolerated and appropriate
to the patient’s diet.
Instruct client/SO to monitor color of
urine

Encourage client to increase fluid intake

Encourage limit intake of alcohol and

caffeinated beverages

Assess client's mentation and behavior

g Care Plan #2
2/3/2020 2/4/2020
Nursing Diagnosis Nursing Objectives Nursing Interventions Evaluations
Nursing Care Plan #3
Date Started: (MM, DD, YYYY) Target Date: (MM/ DD/ YYYY)
Cues/ Clues Nursing Diagnosis Nursing Objectives
e: (MM/ DD/ YYYY)
Nursing InterventionsEvaluations
 HEA
#1 Nursing Diagnosis: Risk for deficient fluid vloume related to ex
Start Date: 2/3/20
End Date: 2/4/20
Health Teachings: 1) Encouraged increased fluid intake 2) introduc
output 4) Encouraged small frequent meals throughout the day 5)
to avoid sudden change in postion or excessive motion

#2 Nursing Diagnosis:
Start Date:
End Date:
Health Teachings: 1)
 HEALTH TEACHINGS
vloume related to excessive vomiting

uid intake 2) introduce clear liquids such as ice chips and popsicles. 3) Instructed to monitor unrinary
hroughout the day 5) Intruct client to eat slowly 6)Recommend upright position when eating. 7) Instructed
ve motion
onitor unrinary
eating. 7) Instructed
Directions: Change the administration box (yellow) to actions taken (see lege

LEGEND: GIVEN DELAYED

NOT GIVEN DISCONTINUED

MEDICATION ADM

MEDICATIONS
Cipro (ciprofloxacin) 500mg PO one tab every 12 hrs for 10 days
Start Date : Jan. 31, 2020 End Date: Feb. 10, 2020

Multivitamin one tab PO daily

Start Date: Feb. 01,2020 End Date: NONE

Losargard (losartan) 50mg PO every bedtime

Start Date: Feb. 01, 2020 End Date: May 31, 2020
ns taken (see legend colors)

CATION ADMINISTRATION RECORD (MAR)

Feb. 01, 2020 Feb. 02, 2020 Feb. 03, 2020
TIME ADM TIME ADM TIME ADM
1000 1000 1000
2200 2200 2200

1200 1200 1200

2100 2100 2100

Date: 02/01/220
Blood Exam Test: CBC with differential count
Date: 01/31/2020
Procedure: Chest Xray

Results: Normal Chest Xray

MD NAME & ID: Dr. Farokh Contractor ID # 4321

Date: 02/01/2020
Procedure: MRI ABD
Results :MRI scan of the pelvis demonstrating the fibrous dysplasia of the righ
MD Name & ID #: Dr. Jose Santos ID # 1254
Date: 01/31/2020
Procedure: CT of ABD

Results: Normal findings

MD NAME & ID: Dr. Farokh Contrac
s dysplasia of the right proximal femur with the femoral neck fracture
ormal findings
ID: Dr. Farokh Contractor ID # 4321
 Do
Date: Time:
Notes:

Date: Time:
Notes:
Doctor's Progress Notes