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    KARDEX

    Uploaded by

    Christine Joy Camacho
    This document contains a patient's kardex, or medical record, including their name, age, sex, admission date, diagnoses, health history, doctor's orders, referrals, laboratory and diagnostic test results, nursing interventions, vital signs, medications, and nursing care plan. It lists the patient's current status, activities, diet, level of consciousness, neurological assessment, respiratory support needs, tubes, catheters, precautions, and parenteral fluids. The kardex provides a comprehensive overview of the patient's condition and treatment plan during their hospital stay.

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    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd

    KARDEX

    Uploaded by

    Christine Joy Camacho
    313 views2 pages
    This document contains a patient's kardex, or medical record, including their name, age, sex, admission date, diagnoses, health history, doctor's orders, referrals, laboratory and diagnostic test results, nursing interventions, vital signs, medications, and nursing care plan. It lists the patient's current status, activities, diet, level of consciousness, neurological assessment, respiratory support needs, tubes, catheters, precautions, and parenteral fluids. The kardex provides a comprehensive overview of the patient's condition and treatment plan during their hospital stay.

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    This document contains a patient's kardex, or medical record, including their name, age, sex, admission date, diagnoses, health history, doctor's orders, referrals, laboratory and diagnostic test results, nursing interventions, vital signs, medications, and nursing care plan. It lists the patient's current status, activities, diet, level of consciousness, neurological assessment, respiratory support needs, tubes, catheters, precautions, and parenteral fluids. The kardex provides a comprehensive overview of the patient's condition and treatment plan during their hospital stay.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    313 views2 pages

    KARDEX

    Uploaded by

    Christine Joy Camacho
    This document contains a patient's kardex, or medical record, including their name, age, sex, admission date, diagnoses, health history, doctor's orders, referrals, laboratory and diagnostic test results, nursing interventions, vital signs, medications, and nursing care plan. It lists the patient's current status, activities, diet, level of consciousness, neurological assessment, respiratory support needs, tubes, catheters, precautions, and parenteral fluids. The kardex provides a comprehensive overview of the patient's condition and treatment plan during their hospital stay.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    KARDEX

    Name Age Sex: M Admitted on Tentative Diagnosis Final Diagnosis Health History: Present Health History DOCTORS ORDER: key. [/] carried out [x] not carried out REFERRAL: key. [/] carried out [x] not carried out. LABORATORY/ DIAGNOSTICS: key: [/] done, with result. [+] done, without result. [x] request made, not yet done [ ] urinalysis [ ] Fecalysis [ ] sputum 3x [ ] hematology:______________ [ ] blood chemistry:______________________ [ ] lipid profile [ ] blood sugar [ ] X-matching [ ] X-Ray [ ] ECG [ ] ultrasound [ ] thoracentesis [ ] paracentesis [ ] others:___________ [ ] TSB, Cold compress [ ] Deep breathing exer. [ ] Suctioning [ ] Turn to side q___hrs. [ ] Bladder training [ ] I&O monitoring: __________________ ROM exercises: [ ] Passive [ ] Active Enema: [ ] Fleet [ ] Cleansing Ultrasonic nebulization [ ] Salbutamol [ ] NSS Amt.Received______ml Endorsed:_________ ml Site: [ ] Right[ ]Left arm [ ] Main line_________ [ ] Side Drip:_________ [ ] Others:___________ Blood Transfusion: [ ] FWB__________unit [ ] PRBC_________unit [ ] Others:___________ Clysis/Drainage: [ ] Peritoneal [ ]T-Tube [ ] Cystoclysis [ ] Penrose Drain [ ] Others: Department F Civil Status at Occupation am pm Religion Admission # Attending Physician Rm.

    ______ [] [] [] [] [] Ambulatory from_____ _______to___________ ACTIVITY: [ ]CBR [ ]CBR w/o BRP [ ]Others: DIET: [ ]DAT [ ]soft [ ] Liquid Others:______________ Level of Consciousness [ ] coherent [ ]conscious [ ] lethargic [ ]stuporous [ ] coma [ ] obStundation A. Orientation: [ ]time [ ] place [ ]person B. Speech/ Language [ ]clear [ ]garbled [ ]expressive [ ]receptive C. Abnormal posturing [ ] decorticate [ ] decerebrate 2. Pupillary reactions: [ ] BRTL [ ] SRTL [ ] NRTL Size: R._ L._ Reflexes: [ ] babinski [ ] gag [ ] corneal [ ] DTR. 3.Motor Function: [ ] R.[ ] L. arm weakness [ ] R.[ ] L. leg weakness Cranial nerve function ____________________ Glasgow Coma Scale { } best eye opening: { }best verbal response { }best motor response ____ Total Score. [ ] Endotracheal tube [ ] Tracheostomy tube Attached to: [ ] Mechanical ventilator MV_____ TV______ml FiO2_____%RR___cpm SV_________________ [ ] Ambu bag[ ]T-piece O2 inhalation at____lpm via: [ ] nasal cannula [ ] nasal catheter [ ] venture mask [ ] Nasogastric tube [ ] Thoracostomy tube attached to______way bottle [ ] Colostomy [ ] Urinary Catheter [ ]indwelling[ ]condom Others:_____________ ___________________ [] [] [] [] [] [] [] [] [] []

    NEURO VITAL SIGNS:

    NURSING INTERVENTIONS: key: [/] carried out [x] not carried out

    key: [/] elicited [x] not elicited

    PARENTERAL FLUIDS:

    TUBINGS: key : [ ] intact/patent/draining [ ]closed/ discontinued

    SPECIAL PRECAUTION

    [ ] Allergy___________ [ ] No BP taking______ [ ] No blood extraction [ ] Blood precaution___

    MEDICATIONS key: [/] Given [x] Not given [P] Prescribed

    VITAL SIGNS:

    BP:_______ T.______ PR._______ RR._____

    FOCUS CHARTING
    DATE/TIME FOCUS PROGRESS NOTES

    NURSING CARE PLAN


    CUES DAIGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

    __________________________________ Students Name

    ___________________________ Clinical Instructor

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