CARDIAC DRUG STUDY

Drug Data Mechanism of Action Indication Contraindication

Generic Name: Digoxin increases the Used to treat heart failure, Contraindicated in patients
Digoxin force of myocardial atrial fibrillation and certain with ventricular
contraction and decreases in pedatric patients fibrillation,ventricular
Brand Name:
conduction veloctiy throught tachcardia, and known
Moexipril. Perindopril. Quinapr the atrioventricular(AV) hypersensitivity to digoxin
Classification: node. It acheives this by
cardiac glycoside inhibiting the sodium-
potassium ATPase
pump,leading to increased
intracellular sodium and
calcium
concentrations,which
enhaces cardiac contractility
DRUG STUDY
Drug Data Mechanism of Action Indication Contraindication
Generic name: Furosemide is an anthranilic Furosemide is indicated for furosemide should not be
Furosemide acid derivative and a potent the treatment of edema given to children who have
diuretic. It mainly inhibits associated with congestive shown hypersensitivity
Brand Name:
the reabsorption of Na and heart failure, cirrhosis of the reactions to the medication
Lasix chloride in the ascending liver, and renal disease, or its components.
Classifications: loop of Henle and in both including the nephrotic Additionally, furosemide is
loop diuretics the proximal and the distal syndrome, in adults and contraindicated in pediatric
renal tubules, interfering pediatric patients patients with anuria, as it
with the chloride-binding relies on renal function for
cotransport system, thereby its diuretic effect.
causing its natriuretic effect.
Drug Study
Drug Data Mechanism of Action Indication Contraindication
Generic Name: Blocks beta-1 and beta-2 Hypertension, certain Bradycardia, heart block,
Propanolol adrenergic receptors, arrhythmias, hypertrophic cardiogenic shock, asthma
decreasing heart rate and cardiomyopathy
Brand
InnoPran Name:
XL, and contractitlity
Hemangeol.
Classifications:
Beta blockers

Drug Study
Drug Data Mechanism of Action Indication Contraindication
Generic Name: Blocks the conversion of Hypertension, congestive patients who are
angiotensin I to angiotensin II, heart failure, and certain hypersensitive to this
Enalapril
leading to vasodilation and types of chronic kidney product or any other
Brand Name: reduced blood pressure. angiotensin converting
disease.
Vasotec enzyme inhibitor. Avoid in
Classifications: neonates, in volume
ACE inhibitor depletion and renovascular
disease. Not recommended
 angiotensin I to angiotensin II, heart failure, and certain
leading to vasodilation and types of chronic kidney
reduced blood pressure. disease.

disease. Not recommended

in neonates and in pediatric
pateints with glomerular
filtration<30ml/min/1.73m2.
Drug Study
Drug Data Mechanism of Action Indication Contraindication
Generic Name: Selectively blocks beta-1 Severe bradycardia, heart
Esmolol adrenergic receptors, For the rapid control of block greater than first
leading to decreased heart ventricular rate in patients degree, cardiogenic shock,
Brand Name:
rate and contractility, with atrial fibrillation or atrial and overt cardiac failure.
Brevivloc thereby reducing blood flutter in perioperative,
Classifications: pressure.Similar to other postoperative, or other
Beta-blocker beta-blockers, esmolol emergent circumstances
blocks the agonistic effect where short term control of
of the sympathetic ventricular rate with a short-
neurotransmitters by acting agent is desirable.
competing for receptor Also used in
binding sites. Because it noncompensatory sinus
predominantly blocks the tachycardia where the rapid
beta-1 receptors in cardiac heart rate requires specific
G STUDY
Contraindication Adverse Effect Nursing Considerations
ontraindicated in patients Nausea Monitor for signs of
with ventricular Vomiting toxicity,especially in
fibrillation,ventricular pediatric patients, and
loss of appetite
tachcardia, and known educate caregivers about
ypersensitivity to digoxin Bradycardia the importance of regular
Arrhytmias monitoring.Monitoring
Blurred Vision serum digozin levels and
electrolytes

UDY
Contraindication Adverse Effect Nursing Consideration
osemide should not be Diarrhea monitoring fluid and electrolyte
en to children who have balance, as furosemide can lead
Dizziness to electrolyte imbalances,
own hypersensitivity Headache particularly hypokalemia. Regular
actions to the medication assessment of serum electrolyte
its components. Cramps levels, especially potassium, is
ditionally, furosemide is Jaundice essential. monitoring renal
function is paramount, as
ntraindicated in pediatric Blurred Vision furosemide is primarily excreted
ients with anuria, as it Vertigo by the kidneys. Regular
es on renal function for assessment of urine output and
Constipation renal function tests helps ensure
diuretic effect.
Blurred Vision adequate renal function for
optimal drug clearance and
udy
Contraindication Adverse Effect Nursing Considerations
Bradycardia, heart block, heat fialure Monitor HR, BP, educate on
ardiogenic shock, asthma exacerbation the side effects
bronchopasm
tiredness
bloody stools
cough
constipation
nausea
chills
udy
Contraindication Adverse Effect Nursing Considerations
ients who are cough Nursing Considerations:
persensitive to this Monitor blood pressure and
renal dysfunction,
oduct or any other potassium levels regularly.
giotensin converting angioedema.
Assess for signs of
zyme inhibitor. Avoid in Hypotension angioedema, especially in
onates, in volume rashes patients with a history of
pletion and renovascular fever allergic reactions. Educate
ease. Not recommended the patient to report any
 ease. Not recommended the patient to report any
neonates and in pediatric anemia
persistent cough or swelling
eints with glomerular pruritus of the face, lips, tongue, or
ation<30ml/min/1.73m2. throat immediately.
udy
Contraindication Adverse Effect Nursing Considerations
vere bradycardia, heart Bradycardia Monitor heart rate and
ck greater than first hypotension, blood pressure closely,
gree, cardiogenic shock, especially during initiation
heart failure exacerbation.
d overt cardiac failure. and titration. Use with
nausea caution in patients with
weakness respiratory conditions.
dizziness Assess for signs of
headache worsening heart failure,
such as dyspnea or edema.
Educate patients about the
risk of bradycardia and the
importance of seeking
medical attention if
experiencing symptoms
such as dizziness or
fainting.
 NEUROLOGY DRUG STUDY
Drug Data Mechanism of Action Indication Contraindication
Generic Name: Blocks voltage-gated Blocks voltage-gated Hypersensitivity to
Carbamazepine sodium channels, sodium channels, carbamazepine, history of
Brand Name: stabilizing neuronal stabilizing neuronal bone marrow depression,
Tegretol membranes and reducing membranes and reducing concomitant use of
Classification : synaptic transmission of synaptic transmission of monoamine oxidase
impulses. impulses. inhibitors (MAOIs).
Anticonvulsant, Mood Stab

Generic Name: Stimulates alpha-2 Treatment of attention Hypersensitivity to

Clonidine adrenergic receptors in deficit hyperactivity clonidine, bradycardia,
Brand Name: the brainstem, reducing disorder (ADHD), hypotension, recent
Catapre sympathetic outflow and hypertension, and myocardial infarction.
Classifications : lowering blood pressure. Tourette syndrome.
Alpha-2 Adrenergic Agonis

Generic Name: Increases brain levels of Treatment of epilepsy, Hepatic disease,

Valproic Acid gamma-aminobutyric acid bipolar disorder, and hypersensitivity to
Brand Name: (GABA), an inhibitory migraine prophylaxis. valproic acid, urea cycle
Depakote neurotransmitter, and disorders.
Classfications: blocks voltage-gated
sodium channels.
Anticonvulsant, Mood
Stabilizer

Generic Name: Binds to synaptic vesicle Adjunctive treatment of Hypersensitivity to

Levetiracetam protein SV2A, modulating epilepsy, particularly levetiracetam, renal
Brand Name: neurotransmitter release partial-onset seizures. impairment.
Keppra and reducing neuronal
Classifications : excitability.
Anticonvulsant

Generic Name: Blocks voltage-gated Treatment of epilepsy, Hypersensitivity to

Lamotrigine sodium channels, bipolar disorder, and lamotrigine, history of
Brand Name: inhibiting the release of maintenance therapy for Stevens-Johnson
Lamictal glutamate and reducing mood stabilization. syndrome or toxic
Classifications: neuronal excitability. epidermal necrolysis.
Anticonvulsant, Mood Stab
 sodium channels, bipolar disorder, and lamotrigine, history of
inhibiting the release of maintenance therapy for Stevens-Johnson
glutamate and reducing mood stabilization. syndrome or toxic
neuronal excitability. epidermal necrolysis.

Generic Name: Blocks voltage-gated Treatment of epilepsy, Hypersensitivity to

Topiramate sodium channels, migraine prophylaxis, and topiramate, metabolic
Brand Name: enhances GABAergic off-label use for weight acidosis,
Topamax inhibition, and loss. hyperammonemia.
Classification: antagonizes glutamate
receptors.
Anticonvulsant,
Antimigraine

Generic Name: Stimulates alpha-2 Treatment of attention Hypersensitivity to

Guanfacine adrenergic receptors in deficit hyperactivity guanfacine, severe
Brand Name: the brainstem, reducing disorder (ADHD). bradycardia, hypotension.
Intuniv sympathetic outflow and
Classficaitons: lowering blood pressure.
Alpha-2 Adrenergic Agonis
Generic Name: Acts on GABA-B Treatment of spasticity Hypersensitivity to
Baclofen receptors in the spinal associated with spinal baclofen, history of
Brand Name: cord, inhibiting reflex cord injury, multiple seizures, renal
Lioresal transmission and sclerosis, and cerebral impairment.
Classification: reducing muscle palsy.
spasticity.
Muscle Relaxant, GABA Ag
RUG STUDY
Contraindication Adverse Effect Nursing Considerations
Hypersensitivity to Nausea, dizziness, Monitor for signs of bone
rbamazepine, history of drowsiness, ataxia, rash, marrow suppression, liver
ne marrow depression, hematologic function tests, and
concomitant use of abnormalities (e.g., therapeutic drug levels.
monoamine oxidase leukopenia, Advise patients to report
inhibitors (MAOIs). thrombocytopenia). any rash or unusual
bleeding.
Clonidine

Hypersensitivity to Sedation, dry mouth, Monitor blood pressure

lonidine, bradycardia, constipation, and heart rate regularly.
hypotension, recent hypotension, rebound Advise patients to avoid
myocardial infarction. hypertension upon sudden discontinuation to
discontinuation. prevent rebound
hypertension.
Valproic Acid

Hepatic disease, GI upset, weight gain, Monitor liver function

hypersensitivity to tremor, hair loss, tests regularly. Advise
alproic acid, urea cycle hepatotoxicity (rare), patients to report signs of
disorders. pancreatitis (rare). hepatotoxicity or
pancreatitis, such as
abdominal pain or
jaundice.
Levetiracetam

Hypersensitivity to Fatigue, dizziness, Assess renal function

levetiracetam, renal irritability, behavior regularly. Monitor for
impairment. changes, decreased behavioral changes and
appetite. suicidality, especially in
pediatric patients.
Lamotrigine

Hypersensitivity to Rash (including serious Initiate treatment with low

amotrigine, history of skin reactions), doses to reduce the risk
Stevens-Johnson headache, dizziness, of rash. Advise patients to
syndrome or toxic diplopia, nausea. report any rash or signs
epidermal necrolysis. of hypersensitivity
immediately.
amotrigine, history of skin reactions), doses to reduce the risk
Stevens-Johnson headache, dizziness, of rash. Advise patients to
syndrome or toxic diplopia, nausea. report any rash or signs
epidermal necrolysis. of hypersensitivity
immediately.

Hypersensitivity to Cognitive impairment, Monitor for signs of

opiramate, metabolic weight loss, paresthesia, metabolic acidosis, such
acidosis, metabolic acidosis, risk of as hyperventilation or
hyperammonemia. kidney stones. anorexia. Advise patients
to maintain adequate
hydration to reduce the
risk of kidney stones.

Hypersensitivity to Sedation, hypotension, Monitor blood pressure

guanfacine, severe dry mouth, constipation, and heart rate regularly.
adycardia, hypotension. fatigue. Advise patients to avoid
sudden discontinuation to
prevent rebound
hypertension.
Hypersensitivity to Sedation, weakness, Monitor for signs of
baclofen, history of dizziness, nausea, sedation or overdose,
seizures, renal hypotonia. especially in pediatric
impairment. patients. Advise patients
to avoid alcohol and other
CNS depressants.
 DRUG STUDY
DRUG NAME MECHANISM OF ACTION INDICATION CONTRAINDICATION
GENERIC NAME : Blocks dopamine Treatment of History of gastrointestinal
Metoclopramide receptors in the gastroesophageal reflux hemorrhage, mechanical
BRAND NAME : gastrointestinal tract, disease (GERD), diabetic obstruction or perforation,
Reglan leading to increased gastroparesis, and pheochromocytoma.
CLASSIFICATION: gastrointestinal motility nausea/vomiting.
Dopamine Receptor and accelerated gastric
Antagonist, Prokinetic emptying.
Agent

GENERIC NAME : Blocks dopamine Treatment of Prolactin-secreting

Domperidone receptors in the gastroparesis, pituitary tumor,
BRAND NAME : gastrointestinal tract, nausea/vomiting, and gastrointestinal
Motilium enhancing gastroesophageal reflux hemorrhage, mechanical
CLASSIFICATION: gastrointestinal motility in pediatric patients. obstruction.
Dopamine Receptor and accelerating gastric
Antagonist, Prokinetic emptying
Agent

GENERIC NAME : Binds to opioid receptors Symptomatic treatment of Known hypersensitivity to

Loperamide in the intestinal wall, acute and chronic loperamide, acute
BRAND NAME : reducing peristalsis and diarrhea in pediatric dysentery, bacterial
Imodium increasing intestinal patients enterocolitis.
CLASSIFICATION: transit time.
Antidiarrheal Agent

GENERIC NAME : Osmotic action draws Treatment of Galactosemia, intestinal

Lactulose water into the colon, constipation, hepatic obstruction, abdominal
BRAND NAME : softening stool and encephalopathy in pain of unknown origin.
stimulating peristalsis. pediatric patients.
CLASSIFICATION:
Osmotic Laxative

GENERIC NAME : Stimulates peristalsis by Short-term treatment of Intestinal obstruction,

Bisacodyl directly irritating the constipation, bowel abdominal pain, acute
BRAND NAME : intestinal mucosa and preparation for diagnostic inflammatory bowel
Dulcolax increasing fluid secretion. procedures in pediatric disease.
CLASSIFICATION: patients.
Stimulant Laxative

GENERIC NAME : Disrupts DNA synthesis Treatment of anaerobic Hypersensitivity to

Metronidazole and inhibits nucleic acid infections, including metronidazole, first
BRAND NAME : synthesis in anaerobic bacterial and protozoal trimester of pregnancy,
Flagyl bacteria and protozoa. infections, in pediatric alcohol consumption.
patients.
 Disrupts DNA synthesis Treatment of anaerobic Hypersensitivity to
and inhibits nucleic acid infections, including metronidazole, first
synthesis in anaerobic bacterial and protozoal trimester of pregnancy,
bacteria and protozoa. infections, in pediatric alcohol consumption.
CLASSIFICATION: patients.
Antibiotic, Antiprotozoal

GENERIC NAME : Inhibits bacterial DNA Treatment of bacterial Hypersensitivity to

Ciprofloxacin gyrase and infections, including ciprofloxacin, pregnancy,
BRAND NAME : topoisomerase IV, urinary tract infections, breastfeeding, tendon
Cipro leading to impaired DNA respiratory infections, and disorders.
CLASSIFICATION: replication and cell death. skin infections, in
pediatric patients.
Antibiotic, Fluoroquinolone

GENERIC NAME : Suppresses inflammatory Treatment of Treatment of

Mesalamine cytokines and inhibits inflammatory bowel inflammatory bowel
BRAND NAME : prostaglandin synthesis, disease, including disease, including
Asacol, Pentasa reducing inflammation in Crohn's disease and Crohn's disease and
CLASSIFICATION: the colon. ulcerative colitis, in ulcerative colitis, in
pediatric patients. pediatric patients.
Aminosalicylate, Anti-
inflammatory
UDY
CONTRAINDICATION ADVERSE EFFECT NURSING CONTRAINDICATIONS
story of gastrointestinal sedation Monitor for signs of
morrhage, mechanical diarrhea extrapyramidal
struction or perforation, hyperprolactinemia symptoms, especially in
eochromocytoma. pediatric patients. Use
caution in patients with a
history of seizures.
Extrapyramidal symptoms

olactin-secreting ventricular arrhythmias Use with caution in

uitary tumor, headache patients at risk of QT
strointestinal dizziness prolongation or
morrhage, mechanical dry mouth ventricular arrhythmias.
struction. QT interval prolongation Monitor cardiac function
during treatment.

own hypersensitivity to Constipation Advise patients to stay

peramide, acute abdominal pain hydrated. Use caution in
sentery, bacterial nausea patients with liver
terocolitis. dizziness dysfunction.
drowsiness

alactosemia, intestinal Flatulence Monitor electrolyte levels,

struction, abdominal abdominal cramp especially potassium.
in of unknown origin. diarrhea Educate patients on
electrolyte imbalances dietary modifications to
prevent electrolyte
disturbances.

estinal obstruction, Abdominal cramps Administer with plenty of

dominal pain, acute diarrhea water to prevent
lammatory bowel electrolyte disturbances dehydration. Use caution
sease. rectal irritation in patients with
inflammatory bowel
disease.

persensitivity to Nausea Educate patients to avoid

etronidazole, first vomiting alcohol consumption
mester of pregnancy, metallic taste during treatment and for
cohol consumption. peripheral neuropathy 48 hours after completing
therapy.
 persensitivity to Educate patients to avoid
etronidazole, first alcohol consumption
mester of pregnancy, during treatment and for
cohol consumption. 48 hours after completing
neutropenia therapy.

persensitivity to Nausea Use caution in pediatric

profloxacin, pregnancy, diarrhea patients due to risk of
eastfeeding, tendon headache musculoskeletal adverse
sorders. dizziness effects. Encourage
tendon rupture adequate hydration.

eatment of Nausea Monitor renal function

lammatory bowel diarrhea regularly. Educate
sease, including headache patients on the
ohn's disease and abdominal pain importance of adherence
cerative colitis, in pancreatitis to treatment for
diatric patients. maintaining remission.
 Drug Study
Drug Data Mechanism of Action Indication Contraindication
Generic Name Stimulates beta-2 Treatment of asthma, Hypersensitivity to
Albutero adrenergic receptors in exercise-induced albuterol,
Brand Name the airway smooth bronchoconstriction, and tachyarrhythmias, and
ProAir HFA, Ventolin muscle, leading to bronchospasm in severe cardiovascular
Classification bronchodilation. pediatric patients. disease.
Beta-2 Adrenergic
Agonist, Bronchodilator
Generic Name Selective stimulation of Treatment of asthma and Hypersensitivity to
Levalbuterol beta-2 adrenergic reversible bronchospasm levalbuterol,
Brand Name receptors, leading to in pediatric patients. tachyarrhythmias, and
Xopenex bronchodilation. severe cardiovascular
Classifications disease.
Beta-2 Adrenergic
Agonist, Bronchodilator

Generic Name Long-acting stimulation Maintenance treatment Hypersensitivity to

Salmeterol of beta-2 adrenergic of asthma and chronic salmeterol, severe
Brand Name receptors, leading to obstructive pulmonary asthma exacerbations.
Serevent Diskus sustained disease (COPD) in
Classifications bronchodilation. pediatric patients.
Bronchodilator

Generic Name Anti-inflammatory action Maintenance treatment of Hypersensitivity to

Fluticasone by suppressing the asthma and allergic fluticasone, acute
Brand Name production of rhinitis in pediatric bronchospasm.
Flovent inflammatory cytokines patients.
Classification and reducing airway
inflammation.
Inhaled Corticosteroid

Generic Name Anti-inflammatory action Maintenance treatment of Hypersensitivity to

Budesonide by inhibiting the release asthma and inflammatory budesonide, acute
Brand Name
Pulmicort of inflammatory bowel disease in pediatric bronchospasm.
mediators and reducing patients.
Classification airway
hyperresponsiveness.
Inhaled Corticosteroid
Generic Name Breaks disulfide bonds in Treatment of acute and Hypersensitivity to
Acetylcysteine mucoproteins, reducing chronic respiratory acetylcysteine, severe
Brand Name mucus viscosity and conditions associated bronchospasm.
Mucomyst promoting expectoration. with thickened mucus,
Classifications such as cystic fibrosis
and COPD
Mucolytic, Antidote exacerbations.

Generic Name Induces active immunity Prevention of influenza Hypersensitivity to

Influenza Vaccine against influenza viruses infection and its vaccine components,
by stimulating the complications in pediatric history of Guillain-Barré
production of antibodies. patients. syndrome within 6 weeks
Contraindications: of previous influenza
Hypersensitivity to vaccination.
vaccine components,
history of Guillain-Barré
 Induces active immunity Prevention of influenza Hypersensitivity to
against influenza viruses infection and its vaccine components,
Brand
Various Name
brands (e.g., by stimulating the complications in pediatric history of Guillain-Barré
Fluzone, FluMist) production of antibodies. patients. syndrome within 6 weeks
Classification Contraindications: of previous influenza
Hypersensitivity to vaccination.
Vaccine, Immunization vaccine components,
history of Guillain-Barré
syndrome within 6 weeks
of previous influenza
vaccination.

Generic Name Anti-inflammatory action Treatment of allergic Hypersensitivity to

Mometasone by inhibiting the release rhinitis and nasal polyps mometasone, untreated
Brand Name of inflammatory in pediatric patients. nasal infections.
Nasonex mediators and reducing
Classifications nasal mucosal swelling.
Intranasal Corticosteroid
udy
Contraindication Adverse Effects Nursing Considerations
Hypersensitivity to Tachycardia, tremor, Monitor heart rate and
albuterol, palpitations, headache, blood pressure. Educate
achyarrhythmias, and paradoxical patients and caregivers
severe cardiovascular bronchospasm. on proper inhaler
disease. technique.

Hypersensitivity to Similar to albuterol but Assess lung function

levalbuterol, may have fewer before and after
achyarrhythmias, and cardiovascular effects. administration. Monitor
severe cardiovascular for signs of
disease. bronchospasm or
paradoxical reactions.

Hypersensitivity to Tachycardia, tremor, Not indicated for acute

salmeterol, severe palpitations, headache, asthma attacks. Monitor
asthma exacerbations. risk of paradoxical lung function and
bronchospasm. symptoms regularly.

Hypersensitivity to Oral candidiasis, Educate patients on

fluticasone, acute dysphonia, cough, proper inhaler technique
bronchospasm. adrenal suppression and the importance of
(rare). rinsing the mouth after
use to prevent oral
candidiasis.
Budesonide

Hypersensitivity to Similar to fluticasone, Monitor growth velocity

budesonide, acute with a lower risk of in pediatric patients.
bronchospasm. systemic side effects. Encourage proper use of
inhaler devices.

Hypersensitivity to Nausea, vomiting, Administer via

acetylcysteine, severe bronchospasm (rare). nebulization or oral route
bronchospasm. as directed. Monitor
respiratory status during
administration.

Hypersensitivity to Local reactions at the Follow recommended

vaccine components, injection site, mild immunization schedules.
istory of Guillain-Barré systemic symptoms (e.g., Educate caregivers about
ndrome within 6 weeks fever, malaise), common vaccine
of previous influenza anaphylaxis (rare). reactions and when to
vaccination. seek medical attention.
Mometasone
 Hypersensitivity to Local reactions at the Follow recommended
vaccine components, injection site, mild immunization schedules.
istory of Guillain-Barré systemic symptoms (e.g., Educate caregivers about
ndrome within 6 weeks fever, malaise), common vaccine
of previous influenza anaphylaxis (rare). reactions and when to
vaccination. seek medical attention.
Mometasone

Hypersensitivity to Nasal irritation, epistaxis, Instruct patients to prime

mometasone, untreated headache, dry mouth, the nasal spray before
nasal infections. pharyngitis. first use. Monitor for signs
of nasal mucosal
damage.
This is a general checklist of what the unit/ ward nurse is supposed to accomplish within the EMR within the shift.
Directions: The system will write " YES" if DONE and "NO" if NOT DONE
DAILY CHECKLIST
Date: (02/25/2020)
AM PM NIGHT PRN AM
VS
I/Os
MAR
NCP
Monitoring
Q Shift Head to Toe Assessment
Fall Assessment
Skin Assessment
Health Teachings
Laboratory Results Checking
Discharge Planning

Date:
AM PM NIGHT PRN
VS
I/Os
MAR
NCP
Monitoring
Q SHIFT Head to Toe Assessment
Fall Assessment
Skin Assessment
Health Teachings
Laboratory Results Checking
Yes
X
Yes
X
ft.

AILY CHECKLIST
Date:(02/26/2020) Date:
PM NIGHT PRN AM PM NIGHT PRN

Date: Date:
PM NIGHT PRN AM PM NIGHT PRN
Head to toe Assessment Date: Feb. 25, 2020
Assessment conducted by Raul De Pedro, RN Time 11:00 AM
LEVEL OF CONSCIOUSNESS
1 Alert
0 Drowsy
0 Lethargic
0 Stuporous
0 Coma
Orientation
1 Person
1 Place
1 Time
1 Situation

Vital Signs
Temp: RR:
Blood Pressure
PHYSICAL ASSESSMENT
Head
Hair:
PERLA
Nose
Ears
Mouth

Neck
0 Carotid Pulse 0 JVD+ 0 Trachea Midline

Chest
 0 Apical Pulse 0 Muffled 0 Arrhythmia
0 Breath Sounds- Anterior
Posterior Lateral
0 Chest Symmetry
0 Skin Turgor (Clavicle)
LUQ Absent
RUQ Active
LLQ Hyper
RLQ Absent
0 Palpation

Upper Extremities
0 Radial Pulses equal, +2
Others
0 Temp vs. trunk
0 Grip equal and strong
0 Capillary Refill <3 sec
0 Vein Filling Rapid
 REGISTRATION SHEET
Patient's Name:
Sex:
Birthday:
Age:
Occupation
Religion:

Address: House # Barangay Municipality/City Province Country

Date of Admission:

Chief Complaints:
Admitting Diagnosis
Other Diagnoses:

Height / Body Weight/ BMI:

Allergies:
Reaction to Allergies:

Contact in Case of Emergency :

Name:
Address:
CellPhone # / Landline #:

Release of Information Signed : Yes/NO

Advance Directive/ Type:
Code Status:
Female
Male
Country
Date: Date:
SHIFT: 6:00 AM NIGHT PRN
TIME TAKEN:
BP
TEMP:
TEMP ROUTE (Oral, Axillary, PR, Forehead Scan)
PR
RR
O2 SAT
Pain Scale:
Pain Scale Used:
 VITAL SHEET
Date: Date:
AM PM NIGHT PRN AM PM NIGHT PRN
Date:
AM PM NIGHT PRN
Name:
Age:
Sex:

INPU
Date:
AM SHIFT
INPUT OUTPUT INPUT
ROUTE AMOUNT ROUTE AMOUNT ROUTE
PO URINE PO
IVF STOOL IVF
PEG TUBE DRAINAGE TUBES PEG TUBE
JT VOMITUS JT
NGT NGT
TPN TPN
MEDS MEDS
Others Others Others
Total INPUT 0 Total OUTPUT 0 Total INPUT

Others
Total OUTPUT 0
 INPUT AND OUPUT SHEET
PM SHIFT NIGHT SHIFT
INPUT OUTPUT INPUT
AMOUNT ROUTE AMOUNT ROUTE AMOUNT
URINE PO
STOOL IVF
DRAINAGE TUBES PEG TUBE
VOMITUS JT
NGT
TPN
MEDS
Others Others
Total INPUT 0 Total OUTPUT 0 Total INPUT 0
NIGHT SHIFT
OUTPUT in ML
ROUTE AMOUNT
URINE
BM
DRAINAGE TUBES
VOMITUS

Others
Total OUTPUT 0
 NURSING CAREPLAN
Nursing Care Plan
Date Started:
Assessment Nursing Diagnosis Planning Nursing Interventions Evaluations
Administer Paracetamol 500mg PO every 6hrs PRN for fever
DAT
Weigh daily
EPLAN
Nursing Care Plan Nursing Care Plan
Date Started: Date Started:
Assessment Nursing Diagnosis Nursing Objectives Nursing Interventions Evaluations Assessment
ng Care Plan

Nursing DiagnosisNursing ObjectiveNursing InterventEvaluations

Date/Time:

Date/Time:
Nurses' Notes
 HEALTH TEACHINGS
Nursing Diagnosis:
Start Date:
End Date:

Nursing Diagnosis:
Start Date:
End Date:
ALTH TEACHINGS
 Monitoring
AM SHIFT PM SHIFT NIGHT SHIFT
DATE/ TIME:

YES
NO
nitoring
AM SHIFT PM SHIFT NIGHT SHIFT
Date:
Procedure:

Results:
MD NAME & ID:

Date:
Procedure:
Results :MRI scan of the pelvis demonstrating the fibrous dysplasia of the right proximal femur with the femoral neck fracture
MD Name & ID #: Dr. Jose Santos ID # 1254
Date:
Procedure:
Results:
MD NAME & ID:
neck fracture
 Directions: Change the administration box (yellow) to actions taken (see legend colors)

LEGEND: GIVEN DELAYED

NOT GIVEN DISCONTINUED
MEDICATION ADMINI
Feb. 24, 2020
MEDICATIONS TIME
8:00

8:00

8:00
1:00
6:00
MEDICATION ADMINISTRATION RECORD (MAR)
Feb. 24, 2020 Feb. 25, 2020 Feb. 26, 2020
ADM TIME ADM TIME ADM
8:00 8:00

8:00 8:00
Date:
Blood Exam Test: CBC with differential count

Component Reference Value Interpretation

WBC 4.0-11.0 HIGH
RBC 4.406.00
HEMOGLOBIN 13.5-18.0
HEMATOCRIT 40.0-52.0
MCV 80-100
MCH 27.0-33.0
MCHC 31.0-36.0
RDW <16.4
PLATELET 150-400

NUETROPHIL% 49.0-74.0
LYMPHOCYTES% 26.0-46.0
MONOCYTES% 2.0-12.0
EOSONOPHILS % 0.0-5.0
BASOPHILS % 0.0-2.0

HIGH
LOW

SPUTUM CULTURE
ANTIMICROBIAL MIC S. PNEUMONIAE H. INFLUENZAE S. AUREUS
AMPICILLIN >32
AMPICILLIN/CLAVULANIC ACID 16
PIPERACILLIN 16
PIPERACILLIN/ TAXOBACTAM <4
CEFALOTIN >64
CEFOXITIN >64
CEFOTAXIM 16
CEFTAZIDIME 4
CE FEPIME 2
IMIPENEM 1
Name:

DIAGNOSIS
0 I had to stay in the hospital because: _________________________
0 The medical word for this condition is: _________________________
0 I also have these medical conditions _____________________________

TESTS
While I was in the hospital, I had these tests: which showed:
______________________________________________ _________________________________________

TREATMENT
While I was in the hospital, I was treated with: The purpose of this treatment was:
______________________________________________ ________________________________________

FOLLOW-UP APPOINTMENTS:

_______ After leaving the hospital, I will follow up with my doctors.

(initials)
TESTS LOCATIONS DATE TIME

Call your Primary Care Doctor for the following:

Doctor Referral Form

Referral To:

Date: 02/24/2020

Family Name:
First Name:
Middle Name:
DAte of Birth:
Gender
Age: 16
Religion:
Reason For Referral

Latest Vital signs:

Lab Result:
Date: 02/01/2020
Blood Exam Test: CBC with differential count

Component Reference Value

WBC 4.0-11.0
RBC 4.406.00
HEMOGLOBIN 13.5-18.0
HEMATOCRIT 40.0-52.0
MCV 80-100
MCH 27.0-33.0
MCHC 31.0-36.0
RDW <16.4
PLATELET 150-400

NUETROPHIL% 49.0-74.0
LYMPHOCYTES% 26.0-46.0
MONOCYTES% 2.0-12.0
EOSONOPHILS % 0.0-5.0
BASOPHILS % 0.0-2.0

HIGH
LOW

SPUTUM CULTURE & SENSITIVITY

ANTIMICROBIAL MIC INTERPRETATION
AMPICILLIN >32
AMPICILLIN/CLAVULANIC 16
PIPERACILLIN 16
PIPERACILLIN/ TAXOBAC <4
CEFALOTIN >64
CEFOXITIN >64
CEFOTAXIM 16
CEFTAZIDIME 4
CE FEPIME 2
IMIPENEM 1
Pulmonologist
Pediatrician
Hematologist
Neurologist
Nephrologist
Ob/ Gynecologist
Interpretation
HIGH
RPRETATION