This is a general checklist of what the unit/ ward nurse is supposed to accomplish within the EMR within the s
Directions: The system will write " YES" if DONE and "X" if NOT DONE
DAILY CHECKLIST
Date: June 6, 2022 (7:00 am - 3:00 pm) Date: June 9, 2022 (7:00 am- 3:00
AM PM NIGHT PRN AM PM
VS YES x YES
I/Os X
MAR X
NCP YES
Monitoring YES
Fall Assessment X
Skin Assessment YES
Health Teachings YES
Laboratory Results Checking X X X
Health Assessment
Date: (MM/DD/YYYY) Date:
AM PM NIGHT PRN AM PM
VS
I/Os
MAR
NCP
Monitoring
Fall Assessment
Skin Assessment
Health Teachings
Laboratory Results Checking
hin the EMR within the shift.
T DONE
KLIST
e 9, 2022 (7:00 am- 3:00 pm) Date:
NIGHT PRN AM PM NIGHT PRN
Date:
NIGHT PRN AM PM NIGHT PRN
REGISTRATION SHEET
Patient's Name: (Last Name, First Name, Middle Name) Pandit, Kalpana
Birthday:
Hospital Registration #:
Religion: Hinduism
Address:
Date of Admission:
Chief Complaint:
Admitting Diagnosis:
Other Diagnoses:
Allergies: (Food, Meds, Scents, Particles, Others)
Reaction to Allergies:
Contact in Case of Emergency :
Name:
Address:
CellPhone # / Landline #: 00-977-1-4420858
PICTURE
24-Mar-98
48870
Patient Name: Ms. Kalpana Pandit OUR LADY OF FATIMA UNIVERSITY
COLLEGE
RESPIRATORY OF NURSING
SYSTEM
Note: Assess respiratory rate, rhythm, depth, pattern, breath sounds, comfort
LEGEND: / "CHECK" MANIFESTED BY THE PATIENT "BLANK" NOT MANIFESTED BY THE PATIENT
OBJECTIVE SUBJECTIVE
Breath Sounds: Previous/Recent Illnesses:
/ Diminished/Absent Stridor Bronchitis Emphysema
Rales/Crackles Rhonchi/Wheezing Asthma Bronchiectasis
Normal Vesicular Pneumonia Hydrothorax
None (Atelectasis) Bronchial Pneumothorax Hemothorax
Bronchovesicular CHF Chest Trauma
Resonance: Lung Cancer Others, specify
Hyper Hypo
Comment: (The statement here should be verbalized by the patient)
Respiration/Oxygenation:
Normal (Relax, Effortless, and Quiet)
Labored/Use accesory Muscle]
Dyspnea / Tachypnea
Bradypnea Cyanosis
Pallor Cheyne-stoke
Biot's Hyperventilation
Hypoventilation Nasal Flaring
Pursed Lip Barrel Chest
Pleuritic Pain Breathing Treatments/Medication:
O2 Inhalation
Rate: 22bpm liters/min
Tube/Drainage:
Ventilator Oral Airway
Endotracheal
Chest Tube:
Connected Location:
Drainage
:
Amount
Smoking: How many sticks/day
Brand: Please specify
Cough: Cough Type Duration: year/s month/s
Sputum: Commen (The statement here should be verbalized by the patient)
t:
Remarks
:
Remarks
:
NURSING DIAGNOSIS
Nursing Diagnosis Acute pain
High Related to surgical incisions
Priority
As Evidenced by Changes in vital signs and verbal complaint of patient
Nursing Diagnosis Risk for bleeding
Medium Related to postoperative wound
Priority
As Evidenced by
Nursing Diagnosis
Low
Priority
As Evidenced by
H
FB PAGE: BUKSU
THE PATIENT
VITA
Date: Date: 06/28/2024 (6:00 AM - 6:00 PM)
SHIFT: AM PM NIGHT PRN
TIME TAKEN: 6:00 AM 12:00 PM 6:00 PM
BP 130/90 130/100 120/100
TEMP (Degrees Celsius) 36.6 C 36.8 C 36.5 C
TEMP ROUTE (Oral, Axillary, PR, Forehead Scan) AXILLARY AXILLARY AXILLARY
PR 98 92 96
RR 19 18 20
O2 SAT 99% 99% 98%
Pain Scale: 8/10 7/10 5/10
TIME TAKEN: 9:00 AM 3:00 PM 9:00 PM
BP 130/90 120/100 120/90
TEMP (Degrees Celsius) 36.5 C 36.6 C 36.5 C
TEMP ROUTE (Oral, Axillary, PR, Forehead Scan) AXILLARY AXILLARY AXILLARY
PR 95 96 97
RR 18 17 16
O2 SAT 96% 99% 99%
Pain Scale: 8/10 6/10 4/10
VITAL SHEET
Date: 06/28/2024 (6:00 PM - 6:00 AM) Date: 06/29/2024 (6:00 AM - 6:00 PM) Date: 06/29/2024 (6:00 PM - 6:00 A
AM PM NIGHT PRN AM PM NIGHT PRN AM PM
12:00 AM 6:00 AM 12:00 PM 6:00 PM 12:00 AM
130/90 120/80 110/90 120/90 120/80
36.6 C 36.4 C 36.5 C 36.3 C 36.6 C
AXILLARY AXILLARY AXILLARY AXILLARY AXILLARY
96 98 97 99 88
17 15 16 18 16
96% 95% 93% 96% 93%
4/10 4/10 4/10 3/10 3/10
3:00 AM 9:00 AM 3:00 PM 9:00 PM 3:00 AM
120/80 110/100 110/80 120/80 120/80
36.6 C 36.7 36.5 C 36 C 36.6 C
AXILLARY AXILLARY AXILLARY AXILLARY AXILLARY
90 97 96 89 90
16 16 16 17 16
99% 97% 92% 99% 99%
4/10 4/10 4/10 3/10 3/10
29/2024 (6:00 PM - 6:00 AM)
NIGHT PRN
Nursing Care Plan #1
Date Started: 7/11/23 ( 7AM-3PM) (MM, DD, YYYY)
Cues/ Clues Nursing Diagnosis
sub:
Patient complained of pain on the right
upper part oh her abdomen
Obj
No leakage/ bleeding from incision site
Patient GCS= 15/15
Vital Signs
Temp= 98.2 F (36.78 C)
RR= 22cpm
BP= 130/80 mmHG
PR= 80bpm
O2sat= 98%
Target Date: (MM, DD, YYYY)
Nursing Objectives Nursing Interventions
Short term:
Long Term:
doctor (Inj Tramadol and Inj Phenergan)
Nursing Care Plan #2
Date Started:
Evaluations Cues/ Clues
Short Term Sub:
Patient complained of pain on the right
upper part of her abdomen.
Long Term
Obj
No leakage/ bleeding to the incision site.
Patient GCS= 15/15
Vital Signs
Temp= 98.02
RR = 22 cpm
BP= 130/80mmHg
PR= 80bpm
O2sat= 98%
(MM, DD, YYYY)
Nursing Diagnosis
Risk for infection related to post-operative wound
Target Date: (MM/ DD/ YYYY)
Nursing Objectives
Short Term
The patient will remain free from infection throughout hospitalization
The patient will describe how to perform dressing changes and
reportable signs of infection before dischharge
Long term :
The patirnt will be able to perform dressing changes and will
continuosly assess surgical wounf for reportable signs of infection
after discharge.
The patient will remain free from infection even after discharge.
Nursing Interventions
Introduce yourself to the client, confirm client's identity
and build rapport with the client.
Monitor the vital signs of the patient.
Assess post op wound for sign of infection like swelling,
redness, discharge or bleeding
Observe aseptic technique when changing post op dressing
and observe hand washing all the times.
Teach the patient on how to perform procedure at home, like
dressing changes, and reportable signs of infection. discharge
medication properly instructed.
Administer antimicrobial drug prescribed by the doctor as PRN
Nursing Care Plan #3
Date Started:
Evaluations Cues/ Clues
Expected outrcomes:
Short term:
Patient remained free from infection throughout hospitalization with
stable vital signs.
Long term:
The patient performed dressing changes and assessed surgical wound
for reportable signs of infection after discharge.
The patient will remained free from infection even after discharge.
sing Care Plan #3
(MM, DD, YYYY) Target Date: (MM/ DD/ YYYY)
Nursing Diagnosis Nursing Objectives Nursing Interventions Evaluations
Nurses' Notes
Date: 06/06/22 Time: 7AM-3PM
7:00AM: The patient was assessed (VS, BP - 130/80mmHg, T - 36.78 ℃, PR - 80bpm, RR - 2
Date: 8/1/22 Time: 7AM-7:50AM
Notes: 7:00AM: The patient was assessed (VS, BP - 120/80mmHg, T - 36.22 ℃, PR - 88bpm
Nurses' Notes
6.78 ℃, PR - 80bpm, RR - 22cpm, 02sat - 98%, Pain scale - 9/10, no soakage or bleeding from the incision site) ( DATA) She complained
g, T - 36.22 ℃, PR - 88bpm, RR - 20cpm, 02sat - 98%, Pain scale - 2/10, no soakage or bleeding from the incision site)
Date: 7/11/23 ( 7: 00 am-3:00pm)
24 hours
INPUT in ML OUTPUT in ML
ROUTE AMOUNT ROUTE AMOUNT
PO 25 ml URINE 1450 ml
IVF 1000 ml BM x
PEG TUBE x DRAINAGE TUBES x
VOMITUS x
NGT x JT x
TPN x
MEDS 750 mg
Others 325 mg Others x
Total INPUT: 2100 ml Total OUTPUT: 0
TOTAL 24 HRS: 208CC/hr
I and O SHEET
July 31,2068
PM SHIFT NIGHT SHIFT/GRAVEYARD
INPUT in ML OUTPUT in ML INPUT in ML
ROUTE AMOUNT ROUTE AMOUNT ROUTE AMOUNT
PO x URINE x PO
IVF x BM x IVF
PEG TUBE x DRAINAGE TUBES x PEG TUBE
JT x VOMITUS x JT
NGT x NGT
TPN x TPN
MEDS x MEDS
Others x Others x Others
Total INPUT: 0 Total OUTPUT: 1350 ml 0 Total INPUT 0
NIGHT SHIFT/GRAVEYARD
OUTPUT in ML
ROUTE AMOUNT
URINE
BM
DRAINAGE TUBES
VOMITUS
Others
Total OUTPUT 1500
HEALTH TEACH
#1 Nursing Diagnosis: ACUTE PAIN RELATED TO SURGICAL INCISIONS AS EVIDENCED BY CH
Start Date: JUNE 6, 2022
End Date: JUNE 9, 2022
Health Teachings: 1) Taught the
#2 Nursing Diagnosis: RISK FOR BLEEDING RELATED TO POST-OPERATIVE WOUND
Start Date: JUNE 6, 2022
End Date: JUNE 9, 2022
Health Teachings: 1) Reminded patient not to rub or scratch her postoperative wounds;
HEALTH TEACHINGS
ONS AS EVIDENCED BY CHANGES IN VITAL SIGNS AND VERBAL COMPLAINT OF CLIENT
ERATIVE WOUND
er postoperative wounds; instructed patient how to keep her wound clean and dry 2) Instructed
Directions: Change the administration box (yellow) to actions taken (see legend colors)
LEGEND: GIVEN DELAYED
NOT GIVEN DISCONTINUED
MEDICATION ADMINISTRATION
Feb. 01, 2020
MEDICATIONS TIME
INJ Cifran 200MG IV (BID) 8:10 AM
Start Date : JULY 30, 2068 END DATE: 8:00 PM
INJ Aciloc 50mg IV (BID) 1200
Start Date: JULY 30, 2068 End Date:
INJ TRAMONADOL 50MG IM (SOS) 2100
Start Date: Feb. 01, 2020 End Date: May 31, 2020
INJ PHENARGAN 25MG IM (SOS) 8:10 AM
Start Date: July 30, 2068 End Date:
TAB BECTO 500MG O (BID) 8:10 AM
Start Date: July 3, 2068 End Date: 8:00 PM
TAB RLOC 150MG O (BID) 8:10:00 AM
Start Date: July 30, 2068 End Date: 8:00 PM
TAB Nise 100mg O (BID) 8:10 AM
Start Date: July 30, 2068 End Date: 8:00 PM
N ADMINISTRATION RECORD (MAR)
Feb. 01, 2020 Feb. 02, 2020 Feb. 03, 2020
ADM TIME ADM TIME ADM
1000 1000
2200 2200
1200 1200
2100 2100
2100 2100
2100 2100
2100 2100
2100 2100
Date: June 6, 2022
Blood Exam Test: CBC with Differential Count
Date: 07/28/2068
2 Calculi (1cm-biggest) found in gallbladder lumen
Results: MRI SCAN OF THE PELVIS DEMONSTRATING THE FIBROUS DYSPLASIA O
MD NAME & ID: Dr. Farokh Contractor ID # 4321
THE FIBROUS DYSPLASIA OF THE RIGHT PROXIMAL FEMUR WITH THE FEMORAL NECK FRACTURE
Doctor's Progress
Date: June 06, 2022 Time: 7:00 a.m
Notes: Please Administer the following medications to the patient :INJ Cifran 200 mg IV BID, INJ Acil
Date: June 09, 2022 Time: 3:00 p.m
Notes: Discharge Medicine : Tab Nise 100 mg O BD - Cap Broclox 500 mg 1cap QID 5 days* Follow up
Doctor's Progress Notes
ran 200 mg IV BID, INJ Aciloc 50mg IV BID- Inj Tramadol 50mg IM SOS- Inj Phenargan 25 mg IM SOS -Tab B
cap QID 5 days* Follow up after 5 days for removal of suture. ( DISCHARGE PLANNING AND TEACHING : Adequate fl
