Instructional Nursing Sheet

Obverse
Cy MEXICAN INSTITUTE OF SOCIAL SECURITY

Í8)) DIRECTORATE OF MEDICAL BENEFITS
Aie HEALTH CARE UNIT
-M” COORDINATION OF MEDICAL AREAS
CLINICAL RECORDS, THERAPEUTIC SCHEME AND NURSING INTERVENTIONS
NAME: (1) SOCIAL SECURITY NUMBER: (2)

MEDICAL UNIT :( 6) SERVICE 0 AREA: (7) |BED/STRETCH/CRIB/INCUBATOR (8)
Date(9)——-----------(10) --------------------------------------------------------------------------- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------
—Hosp Days . ______
_____—------------------' _ ----------- --------------------
F.C. IT TC EVA 8 12 16 20 24 4 8 12 16 20 24 4
170 36 41
160 36 10 111)
150 34 40 9 (12) I II III II II II
¡
140 33 8
130 32 39 7
120 31 6
110 30 38 5
100 29 4
90 28 37 3
80 27 2
70 26 36 1
60 25 0
50 24 35
Blood pressure (13)—
PVC 714)
Free. Respiratory (15)
Temperature code (16)
Size (17) Weight. 718]----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Perimeter (19)
Formula (20)
Diet (21)
Oral liquids (22)
TOTAL (¿3)
Parenteral fluids and(24)_____________________________________________________________________________________________________________________________________________

electrolytes_________________________________________________________________________________________________________________________________________
Sangrey______________________________________________________________________________________________________________________________________________________________
Blood derivatives (25)___________________
TOTAL (26)
LIQUID CONTROL
INCOME
Orally (27)
Probe (28)
Sun. parenteral and elect. (29)
Blood derivatives (39)
Total parenteral nutrition (31)
Medicines (32)
Others (33)
TOTAL (34) |
Yo _____________________________Yo
EXPENSES
Uresis Evacuations
Bleeding
Threw up
(35)
Drain Suction
(36)
Insensible losses (37)
Total revenues (38)
(39)
Total Expenditures Liquid
(40)
Balance Laboratory Studies (41)
(42)
Office studies Biological (43)
products Scheduled (44)
(45)
surgeries (46)
Surgeries performed (47)
(48)
(49)
Check list (50)
Reagents (51)
Code 2660-021-002
2660-021-002
Page2 of 22 Password: 2660-003-056
Reverse
2660-021-002
K' i MEXICAN SOCIAL SECURITY INSTITUTE
SECURITY AND SOCIAL SOLIDARITY
Filling Instructions
No Fact Annotate
1 Name The full name of the patient, starting with the paternal and maternal
surnames and first name. This information must be transcribed from:
clinical record, health record and medical appointments or other document
with which the patient is received.
Example: Fuentes Cienfuegos Marcelo.
2 NSS and
Aggregate The social security number and the digits (number and letters) that make
up the addition to the patient's social security number. This information
must be transcribed from: clinical record, health record and medical
appointments or other document with which the patient is received.
Example : 1210-55-1670-1M59OR.
3 Sex “F” if it is female, “M” if it is male and newborn complete Man or Woman as
the case may be.
4 Age The years of age in the case of adults, adolescents, schoolchildren and
preschoolers; the years and months completed in infants and days in
newborns.
Example 1: 38 years old (Adult)

Example 2: 11/12 months (Infants)
Example 3: 18/30 days (RN)
5 Dx. Doctor
The main presumptive or definitive diagnosis, recorded by the Non-Family
Physician responsible for the patient and recorded in the admission note.
Update it according to the medical notes of its evolution, in the “Medical
notes and prescription” formats 4-30 128/72.
Example: Prob. Fat Embolism
6 Medical unit The type and number of the corresponding hospital unit.
Example: General Hospital of Zone No. 1 “Dr. Luis Ernesto

“Miramontes Cardenas”
2660-021-002

EK 1 MEXICAN SOCIAL SECURITY INSTITUTE
N Fact Annotate
o7 Service or Area The name of the service or area where the patient is located, in case of
transfer to another service, enclose the name of the previous service or
area in parentheses and write down the new one immediately.
Example 1: Emergency Observation.

Example 2: (Emergency Observation) Internal Medicine.
8 Bed, stretcher,
crib or incubator The number of the bed, stretcher, crib or incubator in which the patient is
bedridden in the service or area; If it changes, put the previous number in
parentheses and record the new number.
All header data must be recorded in blue ink.
Example 1: 5
Example 2: (5) 12
9 Date
The day, month and year corresponding to the date on which the filling of
the form begins, with Arabic numerals, in the case of being made up of
only one unit, a zero “0” will be added to the left.
Example: 01/04/09.
10 Hospitalization
days The number of days that the patient has been in the service or area, with
Arabic numerals, in red ink and progressively. For patients admitted
minutes before 24 hours, write (1) in the corresponding space and (0) if the
admission occurs after 24 hours.
Example: 3
11 Heart Rate (HR),

Incubator Mark a point on the site where the figures obtained corresponding to the
Temperature (TI), heart rate (HR), incubator temperature (TI) and/or body temperature (CT)
Body coincide, in relation to the time at which the measurement is carried out;
Temperature (BT). Join the points with lines to form the corresponding graphs.
Use blue ink for heart rate, green for incubator temperature, and red for
body temperature.
NOTE: The taking and recording of vital signs must be carried out in shifts and as
many times as necessary according to the patient's health status.
2660-021-002

MEXICAN SOCIAL SECURITY INSTITUTE
No Data Annota
te
12 Visual Analog Place a dot with black ink, in the place where the figure obtained from the
Pain Scale patient and the time at which the measurement is taken coincide. To
(VAS) create the graph, join the corresponding points with lines.
Visual Analogue Scale (VAS)
The Visual Analogue Scale (VAS) is another valid approach to measuring pain and is
conceptually very similar to the numerical scale. The best known EVA consists of a 10
cm line. with one end marked “no pain” and another end indicating “worst pain
imaginable.”
The nurse asks the patient to indicate on the graph the point that best describes the
intensity of the pain. The length of the patient's line is measured and recorded in
millimeters. The advantage of the VAS is that it is not limited to describing 10 units of
intensity, allowing greater detail in the rating of pain.
Example: 5
NOTE: The pain assessment and recording must be carried out in shifts and as many
times as necessary according to the patient's health status, record the corresponding
interventions in section No. 53.
13 Blood Pressure The values obtained from taking the patient's blood pressure with a stethoscope
and sphygmomanometer, above the diagonal the systolic pressure and
below the diastolic pressure, with colored ink according to the shift.
Example: 130/90
NOTE: Morning Shift: blue, Afternoon Shift: green and Night Shift: red
2660-021-002

No Fact Annotate
14 PVC The value obtained from taking the patient's central venous pressure, with
colored ink according to the shift.
Example: 7.5
15 Frequency The value obtained from quantification of the patient's respiratory rate, with
Respiratory colored ink according to the shift.
Example: 18
16 Code of
Temperature The initial O (oral), A (axillary) or R (rectal), depending on the anatomical
site where the temperature was taken. With ink color according to the shift.
Example: Axillary (A)
17 Size The value obtained from measuring the patient's height in meters and
centimeters or only in centimeters, as the case may be, upon admission or
for a necessary reason. With blue ink
Example 1: 1.70
Example 2: 0.50
18 Weight The value obtained from the patient's weight in kilos and grams. With ink
color according to the shift.
Example: 67,500 Kg
19 Perimeter The initial of the anatomical perimeter according to the case PC (head
circumference), PT (thoracic perimeter) or PA (abdominal perimeter), the
value obtained from the measurement in centimeters and with ink color
according to the shift.
Example: PC 35 cm
20 Formula The type of milk or special formula indicated by the Non-Family Doctor,
quantity, calories and number of feedings, as appropriate.
Example: Lactose-free formula, 20 ml for 8 feedings, 100cal ⁄ kg.
The type of diet indicated by the Non-Family Doctor and number of
21 Diet calories, as well as the type of liquids and quantity prescribed.
2660-021-002
No Fact Annotate
The types of foods and amount in milliliters of liquids ingested in each

meal at the corresponding time.
NOTE 1: In the morning shift, record breakfast and lunch.
NOTE 2: In cases of change in dietary therapy, make the record in the space
corresponding to the shift, day and time in which it is indicated and underline it.
NOTE 3: When it comes to fasting until further notice, write down the initials “AHNO”
and the start time, if it is a fast for a certain period of time, write down the word
“fasting” and the time it starts and ends.
NOTE 4: Diet consumption per serving, per shift, will be described with ink color
Example: ½ bread, 1 apple, 1 serving of chicken.
22 Oral liquids The type of liquids and quantity prescribed by the Non-Family Doctor, in
milliliters. With ink color according to the shift.
Example: Clear liquids 200 ml.
23 TOTAL Total fluid consumption, in milliliters, per shift. With ink color according to
the shift.
Example: 500 ml.
24 Parenteral fluids and

electrolytes
The type of solution (glucose, physiological or mixed) and electrolytes
(KCl, Ca, etc.); amounts administered in milliliters and milli equivalents,
duration, start and end time and/or suspension (susp.)
Solution abbreviations Electrolytes abbreviations

concentrates
Sun. 5% glucose SG 5% Potassium chloride KCl
Sun. normal mixed YE Sodium chloride NaCl
Sun. Mixed in the middle SM 1/2 Calcium AC
Sun. Physiological S.F. Magnesium Mg
Example: SG 5%, 1000 ml + 20 mEq KCl P / 8 hours, I: 7:00 hours. T:

15:00
NOTE 1: The solutions, electrolytes and blood elements administered to the patient
will be noted with the respective abbreviations and symbols, concentration and
quantities in milliliters.
2660-021-002
A
65)4
i MEXICAN SOCIAL SECURITY INSTITUTE
• SECURITY AND SOCIAL SOLIDARITY
No Fact Annotate
NOTE 2: Upon delivery of the shift, write down at the top of the space corresponding
to the next shift the amount of installed solution pending to be passed, prefixing the
letter “R” that indicates what remains with the color of the ink according to the shift.
Example: R 200 ml.
25 Blood and blood

products The type and amount of blood element (red blood cell packet, platelets,
plasma, etc.) administered, of each of them, duration, start and end time
and/or suspension of the same.
Example: plasma: 200 ml P / 2 hours, I: 15:00 hours, T:17:00
NOTE 1: The blood elements administered to the patient will be noted with the
respective abbreviations and symbols, concentration and quantities in milliliters.
NOTE 2: Upon delivery of the shift, write down at the top of the space corresponding
to the next shift the number of installed blood elements pending to be passed,
prefixing the letter “R” that indicates what remains with the color of the ink according
to the shift.
NOTE: Additionally require form 2430-021-026 “Records of the transfusion process”
Example: R 200 ml.
26 Total The sum of parenteral solutions, electrolytes, blood and/or blood products
administered during the shift in milliliters. With ink color according to the
shift.
Example: 450 ml
27 Orally The total amount of liquids ingested in each shift, in milliliters. With ink
color according to the shift.
Example: 600 ml.
NOTE: From this section onwards, liquid control is considered .
28 Probe The amount of fluids administered through any tube to the patient each
shift, in milliliters. With ink color according to the shift.
Example: 300 ml.
2660-021-002

A
65)4
No Fact Annotate
29 Sun. parenteral and The total amount of solutions administered intravenously during the shift, in
electrolytes milliliters. With ink color according to the shift.
Example: 800 ml
30 Blood The amount of blood and its derivatives administered each shift, in
milliliters. With ink color according to the shift.
and
Blood derivatives Example: 400 ml.
31 Total Parenteral
Nutrition (TPN) The amount of total parenteral nutrition (TPN) administered during the shift
to the patient, in milliliters. With ink color according to the shift.
Example: 200 ml.
32 Medicines
The amount of total solution administered for drug dilution, including the
drug content, during the shift. With ink color according to the shift.
Example: 55 ml
33 Others
The total infusion amount of other fluids administered to the patient, each
shift, in milliliters. With ink color according to the shift.
Example: 40 ml
34 Total The sum of income that includes: oral, enteral and parenteral solutions,
blood electrolytes and/or blood products, total parenteral nutrition and
medications, administered during the shift in milliliters. With ink color
Example: 450 ml
35 Uresis The number of urinations with the conventional sign ( ^ ) and quantity, in
milliliters, if fluid control is indicated or if the case requires it.
Example: 200 ml.
NOTE: Describe the characteristics in the box corresponding to signs and symptoms
2660-021-002

No Fact Annotate
36 Evacuations The amount in milliliters and macroscopic characteristics of the first
evacuation and with the conventional sign ( ^ ) the following if they are
equal, according to the established evacuation code.
TYPE OF EVACUATIONS
Guy Abbreviation Guy Abbreviation
Formed F Acholic Ac
Liquid l food remains Ra
Semi-liquid SL Mucous membrane M
Pasty Q Bloody Yes
Coffee c Lumpy g
Green V Fetid Fet.
Black N Meconium Mech.
Yellow TO
NOTE 1: Describe the characteristics in the box corresponding to symptoms and

signs.
NOTE: 2: When more than one characteristic is presented, a diagonal (/) will be used
for registration.
37 Bleeding
Example 1: 100 ml L( ^ )
Example 2: 50 ml L/V. (^^)
The amount in milliliters of blood lost.
Example: 100 ml surgical wound.

38 Vomiting
NOTE: Describe the characteristics of bleeding in the signs and symptoms box.
The amount in milliliters of fluid lost through vomit(s).
Example: 300 ml vomit of food content.

39 Suction NOTE: Describe the characteristics in the box corresponding to signs and symptoms
The milliliters of the amount of fluid lost through suction or aspiration.
Example: 200 ml bronchial secretions.
NOTE: Describe the characteristics in the box corresponding to signs and symptoms.
2660-021-002

No Fact Annotate
40 Drains Milliliters of the amount of fluid lost through any external drainage device in
the body.
Example: 200ml fresh blood per penrose

NOTE: Describe the characteristics in the box corresponding to signs and symptoms
41 Insensible
losses It is the result of multiplying the weight x the constant used according to the
body temperature x the number of hours calculated.
NOTE: Use the corresponding formula according to the patient's weight
42 Total revenues The amount of the sum of the total liquids administered, during the shift,
with the ink color corresponding to the shift.
Example: 1000 ml
43 Total The amount of the sum of the total liquids eliminated, during the shift, with
expenses the ink color corresponding to the shift.
Example: 800 ml
44 Fluid balance The amount resulting from the fluid balance (positive or negative per shift
and in 24 hours).
Example:
Total Income……………………..2000 ml
Total Expenses………….…………..2250 ml
Fluid balance…………………...-250 ml
45 Studies of The abbreviations of the studies and biological products requested and
Laboratory when some are pending to determine the date, make the corresponding
annotation in the column of that day and record when it has been carried
out with the conventional sign ( ^ ) and the results in the corresponding
site ( write down study to be carried out).
Example: Bh, QS, Es ( ^ )
Studies of The name of the office studies carried out and their results in the box
Cabinet
corresponding to Observations, with the ink color corresponding to the shift.
Example: Abdominal USG ( ^ ).
2660-021-002

A i MEXICAN SOCIAL SECURITY INSTITUTE
))A SECURITY AND SOCIAL SOLIDARITY
No Fact Annotate
NOTE 1: Record when this has been done with the conventional sign ( ^ ) .
NOTE 2: When a study is pending for a certain date, make the corresponding
annotation in the column for that day.
47 Biological
products (vaccines) The name of the vaccines, toxoids, immunoglobulins, or antitoxins
administered to the patient and when any are pending, place pend.
Example: anti-scorpion serum
48 Scheduled The name of the scheduled surgical intervention.

surgeries
Example: Exploratory laparotomy
NOTE 1: When the surgical intervention is pending for a certain date, make the
corresponding annotation in the column for that day.
49 Surgeries The name of the surgical intervention performed, with the conventional
performed sign ( ^ ), with the ink color corresponding to the shift.
Example: Craniotomy ( ^ )
NOTE 1: Record “susp”. in cases in which surgery has been suspended, as well as
the causes.
Example: (susp) Due to lack of surgical time
50 Universal protocol The conventional symbol ( ^ ) when it has been corroborated: the correct
identification of the patient, its correlation with the procedure and
anatomical area to be intervened , in addition to ensuring that all the
documentation of the clinical record is available, as well as the diagnostic
aids.
NOTE: If the universal protocol is not complete, record in the “Observations” section
the missing parts of the universal protocol until its conclusion and inform your
immediate superior.
51 Reagents
The type of tests and the result obtained, with the corresponding ink
(capillary blood glucose, bililabstix, etc.)
NOTE 1: When the reagents are carried out more than once per shift, write down the
time they were carried out.
No Fact Annotate
52 Medications Name, presentation, dose, routes of administration, frequency and time of
application, circulating in ink of the color corresponding to the shift the
time in which the medication was applied, in the case of antibiotics, record
the prescription in red ink.
To control the number of days of application of an antibiotic or some other

specific medication, write down onset (I) when it is administered for the
first time and enclose the subsequent number of days in a circle, counting
as one day at the end of the 24 hours of administration. administered and
so on progressively. Do not administer different antibiotics at the same
time (consult pharmacokinetics).
The initial dose of the medication is administered immediately after the

medical indication is received and subsequently adjusted to guide
schedules established in the Operation instructions for Nursing care .
When a medication is suspended, write the abbreviation (susp) in the

corresponding space.
The route of administration will be noted with abbreviations based on the

Operation instructions for Nursing care 2660-005-001. The dose will be
noted in Arabic numerals and abbreviations of the measured unit.
NOTE 10: When the indicated medication is not available due to lack of supply or
being out of the basic chart, put a diagonal (/) in the medication schedule after
notifying the treating doctor.
Example 1: (I) Dicloxacillin amp. 500mg IV every 6hrs. 6 12 18 24
Example 2: 2 Dicloxacillin amp. 500mg IV every 6hrs. 6 12 18 24
Example 3: Ketorolac tab. 10 mg PO every 8 hours. 6 14 22
53 Evaluation scales,
functional
Risk of pressure ulcers
patterns and pain
assessment
The assessment of the patient's risk of developing pressure ulcers should
be carried out upon admission of the patient, when their health conditions
change, and as often as necessary, use the Braden Rating Scale.
2660-021-002

No Data Annotate
BRADEN SCALE FOR PREDICTING THE RISK OF PRESSURE ULCERS
SENSORY 2 4
PERCEPTION Very limited No limitation
1 Completely limited 3 Slightly limited
EXPOSURE
TO THE 2
HUMIDITY 1 Constantly moist Often wet 3 Occasionally wet 4 Rarely wet
ACTIVITY 1 Bedridden 2 In chair 3 Wanders 4 Wanders

occasionally frequently
2 4
MOBILITY
Very limited Without limitation.
1 Completely still 3 Slightly limited
1
NUTRITION 2 Probably 3 Adequate 4 Excellent
Very poor
inappropriate
RUBING AND
2 Potential 3
DANGER OF 1 Problem
problems There is no
INJURIES
apparent problem
PREDICTION OF THE RISK OF PRESSURE ULCERS

Level Points Code
High risk ≤ of 12 Red
Medium risk 13-14 Yellow
Low risk 15-16 if < 75 years or 15-18 if ≥ 75 years Green
Once the assessment is completed, add each of the weights obtained from
the patient and based on the result, classify and code the risk of
developing pressure ulcers.
Record the corresponding interventions according to the result of the
assessment.
NOTE: Under no circumstances use conventional symbols such as (%)
Risk of falls:
The assessment of the patient's risk of falls, in turn, using the patient's
condition assessment scale, this assesses functionality in all its spheres.
ASSESSMENT OF THE PATIENT'S CONDITION

Risk factor's Points
Physical limitation 2
altered mental status 3
Pharmacological treatment that involves risks 2
Language or sociocultural problems 2
Patient without obvious risk factors 1
Total points 10
2660-021-002

No Fact
Annotate
DETERMINATION OF THE DEGREE OF RISK OF FALLS

Level Points_________1 Code
High risk 4 – 10 Red
Medium risk 2–3 Yellow
Low risk 0-1 Green
Once the assessment is completed, add each of the weights obtained

from the patient and based on the result, classify and code the risk of falls.
Record the corresponding interventions according to the result of the

assessment.
Patterns With an “X” the number of the functional pattern assessed in the patient
Functional during each shift, in order to systematically know their response to vital or
health processes, real or potential, and thereby contribute to the nursing
diagnosis.
The areas to be assessed by functional pattern are the following:
1. Perception - health management

2. Nutritional - metabolic
3. Elimination
4. Activity - exercise
5. Sleep - rest
6. Cognitive - perceptual
7. Self-perception - self-concept
8. Role - relationships
9. Sexuality - reproduction
10. Adaptation – stress tolerance
11. Values – beliefs
Pattern 1: Perception - health management: This pattern aims to

determine:
• Perceptions about general health management,

• Preventive practices to maintain and recover it (hygienic habits,
vaccinations, among others);
• Adherence to prescribed treatments and
• Avoidance of practices harmful to health (drug use, alcohol, tobacco,
etc.)
that the patient has.

2660-021-003

No Data Annotate
Pattern 2: Nutritional - metabolic: By evaluating this pattern, the aim is to
determine:
• Food and liquid consumption habits, in relation to the patient's

metabolic needs,
• Possible problems in its intake,
• The characteristics of the skin and mucous membranes and
• Inquire about the patient's height, weight and temperature.
Pattern 3: Elimination: This pattern aims to determine the pattern of

intestinal, urinary and skin excretory function, characteristics of excretions,
frequency, personal routines, use of devices (colostomy bag, urine
collection bag, etc.) or materials for its control.
Pattern 4: Activity – exercise: This pattern aims to determine:

• The capabilities for mobility and autonomous activity,
• Assessment of cardiovascular and respiratory status,
• Mobility and daily activity (type of exercise, leisure and recreation
habits).
Pattern 5: Sleep – rest: This pattern aims to know:

• Patterns of sleep, rest and relaxation throughout the day (insufficient
sleep or insomnia, nervousness, anxiety, irritability, lethargy, apathy,
etc.),
• The individual uses and customs to obtain them.
Pattern 6: Cognitive – perceptual: This is intended to determine the

patient's sensory-perceptual and cognitive pattern, observed in him.
• Its visual, auditory, gustatory, tactile and olfactory functions;
• Checking, if applicable, the existence of prostheses for correction,
• Assessing non-verbal indicators of pain (facial expression, agitation,
diaphoresis, tachypnea, defensive position), to determine its existence
or not.
Pattern 7: Self-perception and self-concept: This aims to know:
2660-021-002

A i MEXICAN SOCIAL SECURITY INSTITUTE
))A SECURITY AND SOCIAL SOLIDARITY
No Data Annotate
• The pattern of the patient's perceptions and attitudes towards himself,
his body image and his identity,
• The conversation pattern and the manifestations of non-verbal
language, observing body posture, eye contacts, anxiety, fear,
alteration of self-esteem, etc.
• atron 8: Role – relationships: This aims to determine:
• The role or social role that the patient plays,

• Responsibility within the family, work and society,
• The responsibilities you have to assume,
• The existence of communication problems,
• The pattern of family, work and social intervention.
Pattern 9: Sexuality – reproduction: This aims to determine:
• The pattern of satisfaction or dissatisfaction with sexuality,

• The reproductive pattern (number of children, abortions) and
• Everything related to the same patient (man-woman prostate, vaginal,
menstrual, coital problems).
Pattern 10: Adaptation - stress tolerance: This aims to determine:
• The general pattern of adaptation and effectiveness in terms of

tolerance to stress and ways of managing it,
• Individual reserve or the ability to resist threats to one's own integrity
(coping with illness, fatigue),
• Family or other support systems (change in communication patterns)
and
• The perceived ability to control and manage situations.
Pattern 11: Values – beliefs: This aims to determine:
• The patterns of values, goals, expectations, and beliefs (including

spiritual beliefs) that guide an individual's life decisions and choices.
• What you perceive as important in life (interference from religious
practices, habits and family traditions) and
• The perception of conflict in values that are related to health.
Interventions for pain control

2260-021-002

No Fact Annotate
Record the corresponding interventions according to the result of the pain
assessment obtained in section No. 12.
54 Symptoms and Signs The objective and subjective manifestations detected in the patient
(pathophysiological responses: the way the body responds to the disease
process), that is; “problem identification”, the time at which they refer or
observe.
Example: diaphoresis, cyanosis, diarrhea.
NOTE 1: When symptoms and signs continue, record the time.
NOTE 2: The symptoms and signs that are recorded must be based on a careful
nursing assessment in accordance with the Operating Instructions for Nursing care and
effective communication with the patient and/or family member.
NOTE 3: Under no circumstances use conventional symbols such as (%)
55 Interdependent
problem The clinical situation that arises as a consequence of an illness and/or
diagnostic tests or medical-surgical treatments, where nursing collaborates
with health personnel and carries out interventions for the prevention,
resolution or reduction of a real problem or health risk. .
NOTE 1: In real interdependent problems, the Problem, the Etiology of the problem
and Symptoms are needed (when writing them you must consider the PES format). To
link the Problem to Etiology, it is recommended to use the words “secondary to” and to
integrate the Symptoms into the formulation, the words “manifested by” will be used.
NOTE 2: Interdependent risk problems only require the Problem and the Etiology of
the problem. When writing, it is recommended to use the words “risk of” at the
beginning of your formulation; To link the Problem to Etiology, it is recommended to use
the words “secondary to”.
Examples of real interdependent problems:
1. Respiratory failure, secondary to chronic obstructive pulmonary

disease, manifested by dyspnea, tachypnea, tachycardia and nasal
flaring.
2. Alteration in the level of consciousness, secondary to hepatic

encephalopathy, manifested by drowsiness and delirium.
2660-021-002

A
65)4
No Fact Annotate
Examples of interdependent risk problems:
1. Risk of seizure, secondary to hyperthermia
2. Risk of cardiac arrhythmias secondary to acute myocardial infarction
The way in which the patient responds to a health condition or

56 Diagnosis of
Nursing disease (physiological reactions of the body, perceptions,
feelings, behaviors).
NOTE 1 For its preparation, take into account the patient's responses, both real and
risky.
NOTE 2: For registration, the NANDA format (Diagnostic Label, Related Factor and
Defining Characteristics) must be considered.
Example 1: Self-esteem disorder related to abandonment by family

members, manifested by: sadness, difficulty in making decisions and
resistance to change.
Example 2: Impairment of physical mobility r/c loss of bone continuity m/p

limitation of range of motion.
Example 3: Risk of infection r/c invasive procedures.
NOTE 3: The priority nursing diagnosis(es) will be recorded in turn, taking into account
the link between the problem assessed and the judgment issued.
NOTE 4: Write down the connections Related to : r/c and Manifested by : m /p , to

develop the actual nursing diagnosis. For risk diagnosis use only the r/c connection.
The activities carried out on the patient and that were previously
57 Interventions
of colaboration were prescribed by another member of the health personnel (Doctor,
Inhalotherapy, Rehabilitation)
Example 1: Respiratory therapy

Example 2: Type of rest and positions
Example 3: Micro nebulizations
Also the time they were carried out, in the space corresponding to each
shift.
NOTE 1: Each nursing action must be the result of an assessment, the application of
critical thinking and clinical judgment.
2660-021-002

A
65)4
No Fact Annotate
NOTE 2: Will register the conventional sign ( = ), when the prescription continues
NOTE 3: When suspended, record the abbreviation (susp) in the space corresponding
to the schedule.
58 Nursing Activities The actions that the nursing staff takes to the patient to carry out an
intervention independently.
It is suggested to consult the book “Classification of Nursing Interventions
(NIC).
NOTE: All education or information provided to the patient, family member or legally
responsible person must be recorded in this section.
59 Response and The patient's response to the therapeutic scheme, to the care provided
evolution and other interventions carried out, with the real and risk interdependent
problems and established clinical judgments.
It is suggested to consult the book “Nursing Outcomes Classification
(NOC).
60 Obs.
The complementary information that is considered necessary in the case,
as well as the relevant aspects not considered in other sections.
NOTE: Only place aspects inherent to the patient

61 Discharge plan
The recommendations (hygienic-dietary, specific care, medication
schedules, rehabilitation exercises, warning signs and symptoms, and
others) that are provided to the patient or family member or legally
responsible person at the time of discharge, to adequately respond to the
needs generated. due to the condition, to prevent relapses, complications
or the appearance of new diseases and to adopt self-care practices.
62 E.G. The initial of the name, the first surname and registration of the General
Nurse, responsible for the patient's care.
Example: a. Valencia 9087652
63 EJP The initial of the name, the first surname and registration of the Head
Nurse of the Floor, responsible for the service or area that supervises
compliance with the therapeutic scheme, interventions related to
interdependent problems and established clinical judgments, as well as
timely, sufficient registration, accurate, reliable and readable data.
Example: P. Zamudio 8965432
2660-021-002

No Fact Annotate
64 SJE The initial of the name, the first surname and registration of the Deputy
Chief of Nurses, responsible for the service or area and who randomly
evaluates this format.
Example: D. Gomez 7676184
2660-021-002

Instructional Nursing Sheet

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Instructional Nursing Sheet

Uploaded by

Copyright:

Available Formats

Obverse

Cy MEXICAN INSTITUTE OF SOCIAL SECURITY

NAME: (1) SOCIAL SECURITY NUMBER: (2)

Oral liquids (22)

Parenteral fluids and(24)_____________________________________________________________________________________________________________________________________________

Example: Fuentes Cienfuegos Marcelo.

Example 1: 38 years old (Adult)

Example: Prob. Fat Embolism

Example: General Hospital of Zone No. 1 “Dr. Luis Ernesto

Page4 of 22 Password: 2660-003-056

Example 1: Emergency Observation.

All header data must be recorded in blue ink.

11 Heart Rate (HR),

Page5 of 22 Password: 2660-003-056

Visual Analogue Scale (VAS)

Page6 of 22 Password: 2660-003-056

Example: Axillary (A)

Example: Lactose-free formula, 20 ml for 8 feedings, 100cal ⁄ kg.

The type of diet indicated by the Non-Family Doctor and number of

21 Diet calories, as well as the type of liquids and quantity prescribed.

The types of foods and amount in milliliters of liquids ingested in each

NOTE 1: In the morning shift, record breakfast and lunch.

Example: ½ bread, 1 apple, 1 serving of chicken.

Example: Clear liquids 200 ml.

Example: 500 ml.

24 Parenteral fluids and

Solution abbreviations Electrolytes abbreviations

Example: SG 5%, 1000 ml + 20 mEq KCl P / 8 hours, I: 7:00 hours. T:

Example: R 200 ml.

25 Blood and blood

Example: plasma: 200 ml P / 2 hours, I: 15:00 hours, T:17:00

NOTE: Additionally require form 2430-021-026 “Records of the transfusion process”

Example: R 200 ml.

Example: 600 ml.

NOTE: From this section onwards, liquid control is considered .

Example: 300 ml.

Page10 of 22 Password: 2660-003-056

Example: 200 ml.

Example: 200 ml.

Page11 of 22 Password: 2660-003-056

NOTE 1: Describe the characteristics in the box corresponding to symptoms and

Example 2: 50 ml L/V. (^^)

The amount in milliliters of blood lost.

Example: 100 ml surgical wound.

The amount in milliliters of fluid lost through vomit(s).

Example: 300 ml vomit of food content.

The milliliters of the amount of fluid lost through suction or aspiration.

Example: 200 ml bronchial secretions.

Page12 of 22 Password: 2660-003-056

Example: 200ml fresh blood per penrose

NOTE: Use the corresponding formula according to the patient's weight

Example: Bh, QS, Es ( ^ )

Example: Abdominal USG ( ^ ).

Page13 of 22 Password: 2660-003-056

Example: anti-scorpion serum

48 Scheduled The name of the scheduled surgical intervention.

Example: (susp) Due to lack of surgical time

To control the number of days of application of an antibiotic or some other

The initial dose of the medication is administered immediately after the

When a medication is suspended, write the abbreviation (susp) in the

The route of administration will be noted with abbreviations based on the

Example 1: (I) Dicloxacillin amp. 500mg IV every 6hrs. 6 12 18 24

Example 2: 2 Dicloxacillin amp. 500mg IV every 6hrs. 6 12 18 24