Mindanao State University Iligan Institute of Technology

DEPARTMENT OF NURSING

ASSESSMENT FORM
Student: ________________________ Area of Assignment: ______________ Date Submitted: __________________ Score: ____________ Clinical Instructor: _________________

PATIENT PROFILE Name: ________________________ Age:_____ Sex: _______ Address: _________________________________________________ Status:_____________ Religion: ___________

NURSING ASSESSMENT I A A Chief complaints: History of Present Illness (HPI) (location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms, previous treatment and result, social and vocational responsibilities).

A History of Past illness (previous hospitalization, injuries, procedures, infectious

Heath Habits Frequency 1 2 3 Tobacco Alcohol OTC drugs/non-prescription drugs Amount Period

Family History with Genogram Legend:

History of Heredo-familial diseases: Cancer _______ Diabetes _______ Asthma _______ Hypertension _______ Cardiac Disease _______ Mental disorder _______ Others _______

Patients Perception of Present Illness:

Hospital Environment:

Summary of Interaction

REVIEW OF SYSTEM
Name: _________________________________ Vital Signs Temperature: __________ Pulse: __________ Respiration: __________ Blood Pressure:__________ 1 2 3 4 5 6 7 8 9 General HEENT Integumentary Respiratory Cardiovascular Digestive Excretory Musculoskelet al Nervous Date: _____________________

Height: __________ Weight:__________ Observation: _________________________________________

10 Endocrine

NURSING ASSESSMENT II
Name of Patient: ______________________________ Chief Complaints: _____________________________ Impression/Diagnosis: __________________________ Date of Admission: _____________________________ Diet: ________________ Type of Operation (if any): Normal Pattern 1 Activities Rest 2 3 4 Activities Sleeping pattern Before Hospitalization Initial Age: __________ Sex: __________ Inclusive Dates of Care: ________________ Allergies: ____________________________

Clinical Appraisal Day 1

Day 2

Rest

Nutrition Metabolic 6 7 8 9 Typical intake (food or fluid) Diet Diet restriction Weight

10 Medication / Supplement food

Normal Pattern 1 Elimination 2 Urine (frequency, color,

Before Hospitalization Initial

Clinical Appraisal Day 1

Day 2

transparency) 3 Bowel (frequency, color)

Ego Integrity 5 6 7 8 Perception of self Coping Mechanism Support Mechanism

Mood / Affect

Neuro Sensory 10 Mental sate 11 Condition of 5 sense: (sight, hearing, smell, taste, touch)

Normal Pattern 1 Oxygenation and Vital signs 2 3 4 5 6 Respiratory rate Pulse rate Heart rate Blood pressure Lung sounds

Before Hospitalization Initial

Clinical Appraisal Day 1

Day 2

History of respiratory problems

Pain comfort 9 Pain (location, onset, intensity, duration, associated symptoms, aggravation) 10 Comfort measure / alleviation 11 Medication

Normal Pattern 1 Hygiene and activities of daily living

Before Hospitalization Initial

Clinical Appraisal Day 1

Day 2

Sexuality 3 Female (menarche, menstrual cycle, civil

status, number of children, reproductive status) 4 Male (circumcision, civil status, number of children)

SUMMARY OF MEDICATION Date Medication Remarks

SUMMARY OF INTRAVENOUS FLUID Date/Time Started Intravenous Fluids & Volume Drop Rate No. of Hours Date/Time Consumed

LABORATORY AND DIAGNOSTIC PROCEDURE NAME OF PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

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DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Recommended Dosage, Frequency, and route of Administration Mechanism of Action Indication Contraindication Adverse Reaction Nursing Responsiblities

Generic name: Lactulose Brand name: Classification: laxative

30 cc PO, hold if Produces osmotic > constipation BM > 3x a day effect in colon. >prevent and treat Resulting hepatic distention encephalopathy promotes > induce bowel peristalsis. evacuation in geria Decreases blood with colon retention ammonia build-up of barium. that causes hepatic >restore BM after encepalopathy, hemorrhoidectomy probably as a result of bacterial degradation,

> low-galactose >DM >pregnant >lactating mothers

GI: abdominal cramps, distention, belching, diarrhea, flatulence, nausea, vomiting

1) 1)Advise patient and SO to dilute drug with juice or water, or take with food to improve taste. 2) 2) Encourage SO and patient to increase fluid intake.

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which lowers pH of colon contents.

3) 3)Teach patient and SO about the adverse reactions of the drug and encourage them to inform the pyhsician or nurse if stool is soft and having morehtan 3 frequency. 4) 4) Monitor patient's electrolyte levels.

DRUG STUDY

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Generic Name Brand Name Classifications

Generic name: Acetylcysteine Brand name: Acetadote Mucomyst Classification: mucolytic

Prescribed and Mechanism of Recommended Action Dosage, Frequency, and route of Administration 600 mg tab OD (in Increases 20 mL water) x 3 respiratory tract days fluids to help liquify tenacious infectious secretions. Thins respiratory secretions.

Indication

Contraindication

Adverse Reaction

Nursing Responsiblities

> Pneumonia > bronchitis > PT > complications of throacic and CV surgery

>hypersensitivity EENT: hemoptysis, to drug rhinorrhea >debilitated patient with GI: nausea, severe respiratory stomatitis, vomiting insufficiency >asthma, Respiraory: bronchospasm bronchospasm >pregnant >lactating mothers >elderly with severe respiratory insufficiency

1) 1) Instruct SO to dilute drug first to prescribed amount before giving drug 2) 2) Instruct SO to alert physician or nurse if secretions thicken or bronchospas ms occur. 3) 3) Instruct SO to notify physician if patient condition doesn't improve. 4) 4) educate patient and SO about adverse reactions of drug.

DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Recommended Dosage, Frequency, and Mechanism of Action Indication Contraindication Adverse Reaction Nursing Responsiblities

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Generic name: Tramadol Brand name: Ultram Classification: analgesic

route of Administration + Binds to opioid > moderate to Paracetamol receptors and severe pain BID PO inhibit reuptake of norepinephrine and serotonic thus relieving pain.

>hypersensitivity to CNS: stimulation, drug confusion, >acute intoxication dizziness, to alcohol, euphoria, hypnotics, opioids, headache, malaise, analgesics. nervousness >seizure or respiratory CV: vasodilation depression EENT: visual disturbance GI: pain, anorexia, constipation, diarrhea, dry mouth, flatulence, nausea, vomiting GU: menopausal symptoms, urinary frequency musculo: hypertonia respiratory: respiratory depression skin: pruritus, rash, sweating

1) 1) assess pain before starting therapy. 2) 2) monitor for drug dependence. 3) 3) ready laxative since drug causes constipation. 4) 4) instruct SO and patient to take drug only as prescribed and don't increase dosage unless instructed.

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DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Mechanism of Indication Contraindication Recommended Action Dosage, Frequency, and route of Administration 500 mg tab OD x 7 Inhibits bacterial > acute sinusitis >hypersensitivity days DNA gyrase and >acute exacerbation >pregnant prevents of chronic bronchitis >lactating mothers replication, > CAD >children transcription, repair >skin infection >elderly with renal and recombination >UTI impairment in susceptible >gonorrhea hosts. Adverse Reaction Nursing Responsiblities

Generic name: Levofloxacin Brand name: Levaquin Classification: broad-spectrum antibiotic

CNS: dizziness, encepalopathy, headache, seizures CV: chest pain, palpitation, vasodilation GI: constipation, diarrhea, nausea, flaulence, pseudomembrano us colitis GU: vaginitis hema:

1 1) monitor glucose level and blood studies. 2 2) instruct to take med with plenty of water 1 hr before or 2 hrs after eating. 3 3) Take seizure preacaution. 4 4) Educate patient and SO about adverse

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lymphocytopenia metabolism: hypoglycemia musculoskeletal: back pain, tendon rupture respiratory: allergic pneumonitis skin: erythema, stevens-Johnson

effects and if seizure or diarrhea occurs, stop drug and notify physician.

DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Recommended Dosage, Frequency, and route of Administration Mechanism of Action Indication Contraindication Adverse Reaction Nursing Responsiblities

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Generic name: Cefuroxime Brand name: Ceftin Classification: 2nd generation cephalosporin

1.5 gm IVTT

Inhibits cell wall synthesis, promoting osmotic instability. Hinders or kills bacteria including grampositive and gramnegative bacilli

> lower respiratory tract infection > UTI > peri-operative prevention >otitis media >bacterial chronic bronchitis >tonsillitis >skin infections >gonorrhea

>hypersensitivity to drug and other cephalosporin >history or penicillin hypersensitivity

CNS: dizziness, headache GI: cramps, diarhhea, nausea, pseudomembranou s colitis, vomiting GU: pruritus hema: thrombocytopenia respiratory: dyspnea skin: erythema, rashes

1) 1) assess for hypersensiti vity 2) 2) instruct patient and SO to take drug as prescribed 3) 3) tell SO to report any onset of adverse 4) reactions.

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DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Recommended Dosage, Frequency, and route of Administration Mechanism of Action Indication Contraindication Adverse Reaction Nursing Responsiblities

Generic name: Ranitidine Brand name: Zantac Classification: antiulcerative H2 receptor antagonist

50 mg IVTT on call Inhibits action of H2 >duodenal cancer to OR at receptor sites or >gastric ulcer parietal cells, >GERD decreasing gastric >erosive acid secretions esophagitis

>hypersensitivity CNS: malaise, to drugs vertigo >hepatic dysfunction EENT: blurred >pregnant vision >lactating mothers hema: leukopenia, thrombocytopenia hepatic: jaundice

1) 2) 1) don't use aluminum needles since it is incompatible 3) 2) Instruct patient to avoid smoking while on drug.

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DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Mechanism of Action Recommended Dosage, Frequency, and route of Administration Indication Contraindication Adverse Reaction Nursing Responsiblities

1)

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Generic name: Diphenhydramine hydrochloride Brand name: Benadryl Classification: antihistamine

50 mg IVTT on call Competes with >rhinitis, allergic to OR histamine for H1symptoms receptor sites. >motion sickness Prevents the action >Parkinson's of histamine on disease smooth muscles, GI >sedation tract, uterus and >night time sleep blood vessels. aid Provides local >nonproductive anesthesia by cough preventing initation and transmission of nerve impulses and suppresses cough reflex by direct effect on medulla of brain.

>hypersensitivity to drugs >asthma attacks >cardiovascular problems >pregnant >neonates, premaure, lactating mothers

CNS: confusion, dizziness, drowiness, fatigue, seizures, sedation CV: hypertension, palpitations, tachycardia EENT: blurred vision, diplopia, nasal congestion GI: anorexia, constipation, diarrhea, dry mouth, nausea, vomiting GU: dysuria, urinary frequency, urine retentioin hema: agranulocytosis, thrombocytopenia skin: rash other: anaphylactic shock

2) 1)encourage to take drug with food or milk. 3) 2)instruct that coffee or tea may reduce drowsiness. 4) 3)instruct that ice chips, gum, hard candy may relieve dry mouth. 5) 4)Advise using sunblock for photosensitivity

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DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Recommended Dosage, Frequency, and route of Administration Mechanism of Action Indication Contraindication Adverse Reaction Nursing Responsiblities

Generic name: Hydroxyzine Brand name: Atarax, Neucalm, Vistaril Classification: anxiolytic, sedative

25 mg tab PO @ May suppress bedtime now activity in key regions of subcortical area of CNS

>anxiety >hypersensitivity CNS: drowsiness, >pruritus from to drugs involuntary muscle allergies >early pregnancy activity >post-op and preop adjunct therapy GI: dry mouth >alcoholism >nausea and other: vomiting hypersensitivity reaction, discomfort

1) 2) 1) Never give drug via IV. 3) 2)warn patient and SO to avoid hazardous activities. 4) 3)instruct to avoid alcohol while on this drug. 5) 4)encourage hard candy or gum for dry mouth.

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DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Mechanism of Indication Recommended Action Dosage, Frequency, and route of Administration 30 cc PO, hold if Produces osmotic > constipation BM > 3x a day effect in colon. >prevent and treat Resulting hepatic Contraindication Adverse Reaction Nursing Responsiblities

Generic name: Lactulose

> low-galactose >DM >pregnant

GI: abdominal cramps, distention, belching, diarrhea,

1) 1)Advise patient and SO to dilute

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Brand name: Classification: laxative

distention encephalopathy >lactating promotes > induce bowel mothers peristalsis. evacuation in geria Decreases blood with colon retention ammonia build-up of barium. that causes hepatic >restore BM after encepalopathy, hemorrhoidectomy probably as a result of bacterial degradation, which lowers pH of colon contents.

flatulence, nausea, vomiting

drug with juice or water, or take with food to improve taste. 2) 2)Encourage SO and patient to increase fluid intake. 3) 3)Teach patient and SO about the adverse reactions of the drug and encourage them to inform the pyhsician or nurse if stool is soft and having more than 3 frequency. 4) 4)Monitor patient's electrolyte levels.

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DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Recommended Dosage, Frequency, and route of Administration Mechanism of Action Indication Contraindication Adverse Reaction Nursing Responsiblities

Paracetamol (Tylenol, Tempra)

Antipyretic: > temporary reduction > allergy to reduces fever by of fever,t emporary acetaminophen acting directly on relief of minor aches >use catiously the hyporhalamic and pains caused by with impaired heat-regulating common cold and hepatic function, center to cause influenza, headache, chronic vasodilation and sore throat, alchoholism, sweating, which toothache. pregnancy, helps dissipate lactation heat. Analgesic: site and mechanism of action unclear.

> headache, 1) Do not exceed myocardial the recommended damage, hepatic dosage toxicity and failure, 2) Reduce acute renal failure, dosage rash, fever with hepatic impairmen t 3) Give drug with food if GI upset occurs. 4) Discontinue drug if hypersens itivity reactions occur 5) take the drug

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only for complaint s indicated; it is not an antiinflammat ory agent.

DRUG STUDY
Generic Name Brand Name Classifications Prescribed and Recommended Dosage, Frequency, and route of Administration Mechanism of Action Indication Contraindication Adverse Reaction Nursing Responsiblities

Ketorolac

>anti-inflammatory > short-term 25

> contraindicated > headache,

1 1) be aware that

classification: antipyretic, nonopioid analgesic, NSAID

and analgesic management of pain with significant dizziness, activity; inhibits renal impairment, somnolence, prostaglandin and during labor and insomnia, rash, leukotriene delivery, lactation, pruritus, nausea, synthesis. patient's soft dyspepsia, GI pain, contact lenses diarrhea, vomiting, constipation, gastic or duodenal ulcers, renal impairment

patient may be at increased risk for CV events, GI bleeding, renal toxicity; monitor accordingl y 2 2)Do not use during labor, delivery, or while nursing, serious adverse effects to the fetus or baby are possible 3 3) Administe r every 6 hours to maintain serum levels and control pain.

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NURSING CARE PLAN

DISCHARGE PLAN

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Patients Name: ______________________________________________ Condition upon Discharge: _____________________________________ Advice ( ) 1 Medication

Date of Discharge: ___________________________ Nature: Home per request ( ) Discharge Against Medical

2 Exercise 3 Diet 4 Health Teaching 5 Schedule for Next Visit 6 Spiritual 7 Lifestyle 8 Referral

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