DIGITAL LEARNER'S WORKSHEET

STUDENT NAME RAPHAEL CHINO ARAGON

DATE: INSTITUTION:

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Conceptualized by Jefferson Galanza (Faculty, SLU-SON)

Spreadsheet Layout: Nonette Laini Miranda (BSN Batch 2022)
 Before you begin your duty, write a personal prayer for your
groupmates, clinical instructor, and the healthcar

WORKSHEET

SECTION/GROUP: A-2

AREA:
a personal prayer for your assigned patient/s,
structor, and the healthcare team.
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FILL-UP data completely (Put N/A if not applicable)
PATIENT'S PROFILE
In compliance with the Data Privacy Act, Patient Name and other personal Data are NOT ALLOWED in this worksheet.

REVIEW OF SYSTEM Patient’s Case: Age: Sex:

IVF AND I&O Doctor/s:

MEDICATIONS Diagnosis: Activity Restriction:

VITAL SIGNS Chief complaint: Diet:

Special
Endorsemment
Contraptions
LABORATORY DATA
Brief History

CONCEPT MAP
Present Illness

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING & Past Medical-Surgical

HEALTH TEACHING
CRITICAL THINKING & Past Medical-Surgical
HEALTH TEACHING

COMMUNICATION

COLLABORATION

Family
ETHICO-LEGAL

REFLECTIONS

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OB-Gyne

Personal / Social
WED in this worksheet.

Room/BED #:

Activity Restriction:

Diet:

Contraptions
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ASSESS THE PATIENT (Initial/Focus/General): Use RED color for ABNORMAL FINDINGS
PATIENT'S PROFILE
REVIEW OF SYSTEMS
REVIEW OF SYSTEM
BASELINE VS: T: PR: RR:
IVF AND I&O
General
MEDICATIONS
Skin
VITAL SIGNS

Head, Eyes, Ears, Nose,

LABORATORY DATA Throat (HEENT)

Neck
CONCEPT MAP
Breast
NURSING CARE PLAN

Respiratory
 Respiratory
F-D-A-R CHARTING

Cardiovascular

CRITICAL THINKING &

HEALTH TEACHING
Gastrointestinal

COMMUNICATION Urinary

COLLABORATION Genital

ETHICO-LEGAL Peripherial/Vascular

REFLECTIONS Muskuloskeletal

Neurologic
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 Neurologic
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Hematologic

Endrocrine

Psychiatric
NDINGS

YSTEMS

BP: SPO2:
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COMPUTE FOR IVF
PATIENT'S PROFILE
TIME
IVF: #: TYPE:
HOOKED
REVIEW OF SYSTEM
8-HOUR SHIFT:
DATE HOOKED Change as MAIN LINE
IVF AND I&O appropriate

IV MAIN LINE 8AM

MEDICATIONS
IV SIDE DRIP 9AM
VITAL SIGNS
IV LEVEL RECEIVED 10AM
LABORATORY DATA
IV REGULATION 11AM
CONCEPT MAP
IV RATE PER HOUR 12NN
NURSING CARE PLAN
IV TO CONSUME IN 8 HOURS 1PM
F-D-A-R CHARTING
IV LEVEL TO ENDORSE 2PM
CRITICAL THINKING &
HEALTH TEACHING 3PM
COMMUNICATION
DATE INTAKE: ORAL IVF GAVAGE TOTAL OUTPUT URINE
AM AM
COLLABORATION
PM PM
NIGHT NIGHT
ETHICO-LEGAL
TOTAL TOTAL

REFLECTIONS

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 DUE:

MAIN LINE SIDE DRIP

 DRAINAGE
BOWEL TUBES VOMITUS TOTAL
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PATIENT'S PROFILE DRUG RECITATION

REVIEW OF SYSTEM
DOSAGE Frequenc
Generic Name Brand Name & Route
Indication
y
IVF AND I&O
Hydrocortisone Hydrocort,
Alphosyl,
Aquacort, Cortef,
MEDICATIONS Cortenema,
SoluCortef

VITAL SIGNS
 LABORATORY
DATA

CONCEPT MAP

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING
& HEALTH TEACHING

COMMUNICATION
COMMUNICATION
TREATMENT (Nebulizaton, Hot water bag, etc)
COLLABORATION Type Dosage if any Frequency SIGNIFICANCE

ETHICO-LEGAL

REFLECTIONS

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 MECHANISM OF ACTION SIDE EFFECTS
Hydrocortisone injection belongs to a class of drugs called
glucocorticoids, or steroid hormones. A class of drugs is a group of
medications that work in a similar way. These drugs are often used to
treat similar conditions. Hydrocortisone injection works by reducing
inflammation (irritation and swelling) in the body.
c)
SIGNIFICANCE
NURSING RESPONSIBILITY
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VITAL SIGNS
PATIENT'S PROFILE DATE
VITAL SIGNS 1ST 2ND 3RD 4TH

REVIEW OF SYSTEM TIME: (Change as

8AM 9AM 10AM 11AM
appropriate)

IVF AND I&O TEMPERATURE

MEDICATIONS PULSE RATE

VITAL SIGNS RESPIRATORY RATE

LABORATORY DATA BLOOD PRESSURE

CONCEPT MAP OXYGEN SATURATION

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING

COMMUNICATION
COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

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5TH 6TH 7TH 8TH

12NN 1PM 2PM 3PM

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LABORATORY AND IMAGING DATA
PATIENT'S PROFILE
Relevant laboratory / Imaging data Date Done Results
REVIEW OF SYSTEM

IVF AND I&O

MEDICATIONS

VITAL SIGNS

LABORATORY DATA

CONCEPT MAP

NURSING CARE PLAN

F-D-A-R CHARTING
CRITICAL THINKING &
HEALTH TEACHING

COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

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Normal Values SIGNIFICANCE OF THE TEST/DIAGNOSTICS
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Create CONCEPT MAP (Insert Jpeg file of concept map)
PATIENT'S PROFILE

REVIEW OF SYSTEM

IVF AND I&O

MEDICATIONS

VITAL SIGNS

LABORATORY DATA

CONCEPT MAP

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING

COMMUNICATION
COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

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NURSING CARE PLAN: Identify @ least 3 nursing concerns/diagnosis & select priority nursing diagnosis
PATIENT'S PROFILE

REVIEW OF SYSTEM FOCUS /Nursing Diagnosis PLAN: Nursing Interventions

IVF AND I&O

MEDICATIONS

VITAL SIGNS

PRIORITY:
LABORATORY DATA
LABORATORY DATA

CONCEPT MAP
EXPECTED OUTCOMES of PRIORITY diagnosis only

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING

COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

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Reference/s
ority nursing diagnosis

sing Interventions Rationale

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SAMPLE F-D-A-R Charting
PATIENT'S PROFILE
FOCUS /Nursing Diagnosis DATA
REVIEW OF SYSTEM
> Impaired physical mobility > Received patient awake flat on the bed
related to neuromuscular on spine board with straps and rigid
IVF AND I&O impairment as evidenced by cervical collar for now. With on-going
diminished senses of lower IVF of PLNSS 1L X 8 hours. On NPO.
extremities and loss of motor Intact and patent IFC Fr16 inserted
MEDICATIONS function on the lower extremities. aseptically and attached to a urine bag.
With diminished senses of lower
VITAL SIGNS extremities, poor bladder/bowel control,
with loss of motor function on the lower
extremity. Diagnostic tests done. GCS 15
LABORATORY DATA (E:4, M:5, V:6). With hyperactive bowel
sounds. Muscle strength: 5/5 on both
CONCEPT MAP upper extremities and 0/5 on both lower
extremities.
NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING

COMMUNICATION

COLLABORATION

ETHICO-LEGAL
REFLECTIONS

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ATA ACTION RESPONSE

wake flat on the bed >Monitored vital signs and neurological > Muscle strength is still 5/5 on both
straps and rigid vital signs. Determined the level of upper extremities and increased strength
w. With on-going sensory and motor functions by requesting rated as 1/5 on both lower extremities.
8 hours. On NPO. client to perform certain actions. Assessed Vital signs: T=36.5, PR=80, RR=20,
C Fr16 inserted reflexes. Assisted with full passive ROM BP=120/80.
hed to a urine bag. exercises on all extremities and joints,
ses of lower using slow smooth movements. Raised
dder/bowel control, siderails. Provided means to summon help
unction on the lower (special sensitive call light). Elevated
ic tests done. GCS 15 lower extremities at intervals or raise foot
th hyperactive bowel of bed when permitted in individual
ngth: 5/5 on both situation. Assessed skin daily and
d 0/5 on both lower observed for pressure areas and provided
meticulous skin care. Applied appropriate
embolic stockings Administered
medications as ordered by the physician.
Encouraged use of relaxation techniques.
Consulted with physical and occupational
therapists and rehabilitation team.
EVALUATION

JUSTIFICATION
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CRITICAL THINKING & HEA
PATIENT'S PROFILE

REVIEW OF SYSTEM What possible complications do you

anticipate from the current patient's
condition?
IVF AND I&O

MEDICATIONS
What assessment do you need to
identify and respond to if this
VITAL SIGNS complication develops?

LABORATORY DATA

CONCEPT MAP
What educational opportunities can
NURSING CARE PLAN you possibly identify for your client?

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING
Post (via insert photo-jpeg) your infographic here

COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

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AL THINKING & HEALTH TEACHING

here
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COMMU
PATIENT'S PROFILE
REVIEW OF SYSTEM
IVF AND I&O

MEDICATIONS

VITAL SIGNS

LABORATORY DATA

CONCEPT MAP

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING

COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

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COMMUNICATION
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COLLABORATIO
PATIENT'S PROFILE

REVIEW OF SYSTEM

IVF AND I&O

Answer:

MEDICATIONS

VITAL SIGNS

LABORATORY DATA

CONCEPT MAP

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING

COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

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COLLABORATION & TEAM WORK
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ETHICO-MORAL-LE
PATIENT'S PROFILE

REVIEW OF SYSTEM

IVF AND I&O

Answer:

MEDICATIONS

VITAL SIGNS

LABORATORY DATA

CONCEPT MAP

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING

COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

JOURNAL
ETHICO-MORAL-LEGAL IMPLICATIONS
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JOURNAL
PATIENT'S PROFILE
TITLE
REVIEW OF SYSTEM
YEAR PUBLISHED
IVF AND I&O
AUTHORS
MEDICATIONS
PUBLICATION
VITAL SIGNS
AIM/PURPOSE
LABORATORY DATA
DESIGN
CONCEPT MAP
LOCALE
NURSING CARE PLAN

POPULATION
F-D-A-R CHARTING

TOOL

CRITICAL THINKING &

HEALTH TEACHING
CRITICAL THINKING &
HEALTH TEACHING

COMMUNICATION

FINDINGS/RESULTS
COLLABORATION

ETHICO-LEGAL

REFLECTIONS

CONCLUSION
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RECOMMENDATIONS

REFLECTION
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REFLECTION: Write a thoughtful reflection about this virtual c
values of a future Filipino
PATIENT'S PROFILE

REVIEW OF SYSTEM

INTRAVENOUS FLUID

MEDICATIONS

VITAL SIGNS

LABORATORY DATA

CONCEPT MAP

NURSING CARE PLAN

F-D-A-R CHARTING

CRITICAL THINKING &

HEALTH TEACHING

COMMUNICATION

COLLABORATION

ETHICO-LEGAL

REFLECTIONS

JOURNAL
lection about this virtual clinical experience and link them to your values as a person, and the
alues of a future Filipino Louisian professional nurse.