ADMINISTERING MEDICATIONS MEDICATION CARD (USTH)

COLOR FREQUENCY FREQUENCY USTH SCHED

GLOSSARY OF ABBREVIATIONS Orange OD OD 9AM
OD Once a day A.U. Both ears Blue BID, QID BID 9AM, 6PM
BID 2x a day q or Q Every White TID TID 9AM, 1PM, 6PM
TID 3x a day c̅ With Pink Q3, Q6, Q12 Q6 12AM, 6AM,
QID 4x a day s̅ Without Yellow Q4, Q8, HS 12PM, 6PM
PRN As needed x̄ For Green STAT, PRN, Q12 6AM, 6PM
HS Hours of sleep h or º Hour Single Order Q8 6AM, 2PM, 10PM
a.c. Before meals (ante) ml Milliliter OD-HS 9PM
p.c. After meals (post) tsp Teaspoon
O.D. Right eye Tbsp Tablespoon CARD SHAPES (2X2)
O.S. Left eye gtts Drops
O.U. Both eyes PO Per orem NON-PARENTERAL: NON-PARENTERAL:
A.D. Right ear SIVP Slow IV push
A.S. Left ear ANST After negative skin test ORAL INTRADERMAL
TOPICAL SUBCUTANEOUS
TYPES OF MEDICATION ORDERS
SUPPOSITORY INTRAMUSCULAR
1. Standing Order
➢ Carried out as a specified until it is canceled by another INTRAVENOUS
Ex. FeSO4 OD
➢ May also be self-limiting
Ex. Amoxicillin 500mg/cap Q8 x̄ 7 days SOLID ORAL MEDICATION PREPARATION

Types of Solid Oral Medications

2. Single Order (STAT)
Powdered medicine compressed into a hard disk
➢ Directive is carried out only once TABLET
Dissolves in the stomach
➢ Usually done for procedures such as operation, CT- Tablet shaped as a capsule
scan, etc. CAPLET
Enter-coated for ease of swallowing
Ex. Give Diphenhydramine 50mg/IV prior to OR Suitable for splitting or cutting into half using a pill
SCORED TABLET cutter
3. As Needed (PRN) Dissolves in the intestine
➢ Medication that is given whenever a specified condition ENTERI-COATED
Used for less GI upset
arises TABLET
Ease of swallow
Ex. Give Paracetamol 500mg/tab Q4 x̄ CAPGEL Capsule containing liquid
Temperature ≥ 37 ºC Powder encased in a gelatin shell
CAPSULE
Dissolves in water
BASIC R’s OF DRUG ADMINISTRATION
✓ Right medication Materials
✓ Right patient
• Medicine tray
✓ Right dosage
• Drug/Medicine
✓ Right time/frequency
✓ Right route • Medicine cup
✓ Right documentation • Medicine card
✓ Right client education • Mortar and pestle
✓ Right to refuse • Glass with straw
✓ Right assessment
✓ Right evaluation From Container
1. Check the medication being given for 3x from the
PARTS OF A DOCTOR’S ORDER STANDING ORDER SHEET, PHYSICIAN’S ORDER,
MEDICAL SHEET, MEDICAL CARD, etc.
July 15, 2019 Ma. Frances Dela Cruz 2. Open the container → cover → medicine cup (DO NOT
10:00 AM TOUCH MEDICINE)
3. Put medication into the medicine tray with the medicine card

Give Methylergonovine From Blister Pack

maleate (methergine) 125 1. Check the medication 3x
mg/tab Q8 x̄ 5 days 2. Using bandage scissors, cut a portion of the medication from
the pack (DO NOT OPEN)
3. Place medicine into medicine cup
abcoquia
Dr. ABM Coquia NOTE: 1 medicine = 1 medicine cup (ideally) and always practice
LIC# 09122000 ASEPSIS

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

LIQUID ORAL MEDICATION PREPARATION
1. Check the R’s of drug administration
2. Proper handling of container (LABLE FACING PALM)
3. Always pour at meniscus (EYE-LEVEL)
4. If medication is a SUSPENSION, shake well

SUPPOSITORY MEDICATION
1. Medication passed through the rectum or vagina
2. Melts when it meets body temperature
3. Patient must be at SIM’S POSITION
4. ALWAYS GIVE PRIVACY
5. Insert using INDEX FINGER

PARENTERAL MEDICATION
• Deals with administration of drugs through needles or
syringes
• Fast absorption rate for drugs and results are almost
immediate

Syringe
• Size of needle depends on medication and calibration

Ampule
1. Check expiration date and label
2. Make sure that the medication is in the body
3. Locate line/dot
4. Use alcohol swab to rub the head to the neck
5. Use an OS pad (gauze) to cover the tip and break it away
from you by using thumb and forefinger

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

Vial Intradermal
1. Check expiration date and label • Used for skin test
2. Open the vial cup • Skin is stretched thinly for injection
3. Use alcohol swab to rub the rubber stopper • Reconstitute medication for skin test
4. Aspirate using sterile syringe o 500mg and below = 2ml
o Above 500mg = 5ml
• Control: 0.5ml plain solution (sterile water)
• Drug: 0.9ml plain solution + 0.1ml medication

Subcutaneous
• Angle varies if area is fatty or not
o Thin: pinch skin and inject at 45º
o Thick: could inject at 90º
TYPES OF INJECTIONS • Always check the type of syringe
NEEDLE MAX. • INSULIN is immediately absorbed in the fatty layer
PURPOSE SITE
SIZE DOSE • NOTE: If patient is diabetic, always rotate the site for insulin
ID Injects medication Inner aspect Syringe with 0.01 to 0.1 injection because it can cause damage to the SC layer which
below the dermis; of forearm; short bevel; ml results into dimpling of skin
drugs are upper chest; 24- to 27-
absorbed slowly; upper back gauge; 3/8 to Intramuscular
typically used for ½ inch • Four-Finger Rule for injection site
diagnosis of TB o Four fingers from deltoid muscle
and allergens o Four fingers from the great trochanter
SC Injects medication Abdomen; 25-gauge, 0.5 to 1 ml
between dermis lateral and 5/8 inches DOSAGE COMPUTATION
and muscle; anterior needle
absorbed slowly; aspects of Formula:
typically used for upper arm and 𝐷𝑒𝑠𝑖𝑟𝑒𝑑 𝑑𝑜𝑠𝑒
insulin and thigh; 𝑥 𝑞𝑢𝑎𝑛𝑡𝑖𝑡𝑦
𝑆𝑡𝑜𝑐𝑘 𝑑𝑜𝑠𝑒
anticoagulants scapular area
on back; Examples:
ventrogluteal
IM Used to promote Ventrogluteal; Gauge and Adult: 4ml ORDER: Digoxin (Lanoxin) 0.25 mg OD
rapid drug dorsogluteal; length of in large STOCK: 0.125 mg/tablet
absorption and to anterolateral needle are muscle;
provide an aspect of selected infant & 𝐷 0.25 𝑚𝑔
alternate route thigh (vastus based on small = 𝑥 1 𝑡𝑎𝑏𝑙𝑒𝑡 = 2 𝑡𝑎𝑏𝑙𝑒𝑡𝑠
𝑆 0.125 𝑚𝑔
when drug is lateralis); medication child: 0.5-
irritating to SC deltoid volume and 10ml;
tissue viscosity and children ORDER: Famotidine 20 mg/slow IV q 12º
client’s body and STOCK: 10 mg/ml in a 2 ml ampule
size elderly: 1-
2ml; 𝐷 20 𝑚𝑔
deltoid = 𝑥 1𝑚𝑙 = 2𝑚𝑙
𝑆 10 𝑚𝑔
muscle:
0.5-1ml
MEDICATION CARD (PARENTERAL)

211B
8/3/19

MARY AMY A. SANTIAGO

CEFUROXIME 250 mg/IV

Q8

(6AM, 2PM, 10PM)

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

 PATIENT’S MEDICAL RECORDS AND CHARTS Methods of Writing NURSE’s NOTES
1. Narrative
DOCUMENTATION 2. Source-oriented
3. Problem-oriented (SOAP)
• Means to be reflect the complexity of care rendered to
4. Focus Charting
patient
5. Critical Pathway
• Embodies accuracy, completeness, and evidence of
professional practice with efficient and cost-effective
Narrative
systems
• Traditional means to record patient assessment
COMMON CHART FORMS • Story-like format → complete, chronological, relevant,
1. Standing Order Sheet assessment, intervention done, evaluation
➢ Located at the 1st page of the patient’s chart • Time-consuming and repetitive
➢ Summary of patient’s diet, medications and treatments
➢ TOP: Basic information, identifiers, diet, admission no., Problem-Oriented (SOAP)
hospital no., date ordered, date discontinued • Primary focus is patient’s individual problems
➢ MIDDLE: Medications, frequency, dosage, dates • Major Sections:
➢ BOTTOM: Treatments o Database (history, PE, lab tests)
o Problem list (nursing diagnosis)
2. Vital Signs Sheet o Care plan/Expected outcomes
➢ BLACK INK: BP, RR, Temperature o Progress notes (SOAP/SOAPIE)
➢ RED INK: PR ▪ Subjective
➢ Includes PAIN scale, stool output (CB: colostomy bag), ▪ Objective
and urine output (__D: diapers; FC: Foley catheter), ▪ Assessment (nursing diagnosis)
and activity (EMV) ▪ Planning Interventions
▪ Intervention
3. Fluid Intake and Output Sheet ▪ Evaluation
➢ Intake ▪ Recommendation
o Venoclysis (IV) → check volume of fluid
o Blood (Transfusion) → weigh the bag Focus Charting (FDAR)
o Oral → 1 glass ≈ 250ml • 1981, Eitel Hospital (Minneapolis)
o Others (NGT, GI tube, etc.) • “not limited to problems but allows identification of ALL
➢ Output concerns”
o Urine → urinal, bedpan (approx. 250ml), o F - Focus → nursing diagnosis
diaper o D - Data → observation of status and behavior,
o Secretion → phlegm, blood data from chart
o Vomitus o A - Action → immediate action, plan for future
o Others → blood, Jackson-Pratt tube actions, and even changes in previous plan of
care
4. IV Fluid Sheet o R - Response → reflects the evaluation phase
➢ Basic information of nursing process
➢ IV number
➢ Name of solution, date and time started, remarks (gtts) Discharge Teachings (METHODS)
• Medication, Exercise, Treatment, Hygiene, Outpatient, Diet,
5. Physician’s Order Sheet Spiritual
➢ Observations
➢ Assessment of patient TRANSCRIBING/CARRYING OUT
• Physician’s Order sheet → charts
6. Medication Sheet
➢ FRONT: dosage, medication, signature MEDICATION SHEET ENTRY (USTH)
➢ BACK: STAT, PRN (single order and as needed) • X → medication not applicable
• Signed initials encircled → medication not given
7. Laboratory Sheet • Signed initials → medication given
➢ GREEN: operating room
➢ BLUE: other procedures

8. Nurse’s Notes
➢ Plans and assessments of nurses
➢ “Treatment not written is treatment not given”
➢ Documentation
➢ Communication of health care professionals for quality
client care

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

 COMMUNITY HEALTH NURSING ELEMENTS OF EPI
EXPANDED PROGRAM ON IMMUNIZATION (EPI) → ➢ Target setting → estimation of target population size
NATIONAL IMMUNIZATION PROGRAM (NIP) o Infants = total population x 2.7%
o Children (12-59 m/o) = total population x 10.8%
FORMS OF RESISTANCE o Pregnant women = total population x 3.5%
1. Natural ➢ Cold Chain Logistics → maintaining potency of vaccines
➢ Body defenses based on species, race, body ➢ IEC (Information, Education, Communication)
constitution ➢ Assessment and Evaluation of the program’s over-all
➢ Has always been with the person from womb to tomb performance
➢ Surveillance, studies, research
2. Acquired
➢ Body defenses that a person develops in the course of SUPPLEMENTART IMMUNIZATION ACTIVITY (SIA)
his life ➢ Usually done during times of epidemic
ACQUIRED
➢ A.K.A. “speed up” or “catch up” immunization
➢ Special Targets → children (urban poor/slum areas)
ARTIFICIAL NATURAL
CONTRAINDICATIONS FOR VACCINATION
✓ History of seizures after vaccination of DPT1
ACTIVE
(ANTIGENS)
PASSIVE
(ANTIBODIES)
ACTIVE
(EXPOSURE)
PASSIVE
(MOTHER)
o If seizures lasted for seven days or more, do not
give any DPT/DT vaccine
VACCINE TOXOID
HUMAN ANIMAL o If seizure lasted for only 3 days or less, give DT
SERUM SERUM
vaccine only
✓ Clinical AIDS
➢ Active: Antigens (bacteria, toxins, carriers, etc.) → ✓ Immunosuppression
Antibodies
NOT CONTRAINDICATIONS FOR VACCINATIONS
o Attenuated/ Weakened: vaccine created by ✓ Fever up to 38.5 ºC
reducing the virulence of a pathogen, but still ✓ Simple/Mild acute respiratory infection
keeping it viable. (MMR, Varicella, etc.) ✓ Simple diarrhea with dehydration
✓ Malnutrition
o Killed/Inactivated: vaccine consisting of
virus particles, bacteria, or other pathogens VACCINATIONS FOR INFANT
that have been grown in culture and then lose 1. Infant BCG
disease producing capacity. (Polio, ➢ For Tuberculosis
Influenza, Typhoid, Cholera, Plague, ➢ Target Age: Immediately given after birth
Pertussis, etc.) ➢ Dose: 0.05 ml (ID, right upper arm/deltoid)

➢ Passive: Antibodies (immunoglobulins, antitoxins, etc.) School Entrance BCG:

➢ 7 y/o
EXPANDED PROGRAM ON IMMUNIZATION (1976) ➢ Dose: 0.1 ml from ampule/vial
➢ Launched by HWO, DOH, and INICEF
➢ TB, Diphtheria, Pertussis, Tetanus, Polio, Measles Instructions for BCG:
➢ PD No. 996 (Sept. 16, 1976) → compulsory basic ✓ Don’t massage the area, cold compress only if sore
immunization for infants up to 8 y/o ✓ Paracetamol Q4 in case of fever
✓ Tell the mother that it will scar and will heal within a
ADMINISTRATIVE ORDER NO. 39, S. 2013 week
➢ “IMMUNIZATION IS A BASIC RIGHT OF EVERY CHILD” ✓ Do not expose to sunlight
➢ Every Wednesday is IMMUNIZATION DAY ✓ If scarring does not occur, repeat vaccine after 2
months
GOALS OF EPI ✓ Have someone check the vaccination area if:
✓ 95% Fully Immunized Child (FIC) Coverage o Scar does not heal within a week
o FIC → all vaccines were received before 1 y/o o Signs of possible secondary bacterial
o CIC → all vaccines were received after 1 y/o infection
✓ Maintenance of Polio Eradication o Deep subcutaneous abscesses due to wrong
✓ Elimination of Measles technique of vaccination
✓ Elimination of maternal and Neonatal Tetanus
✓ Vaccinations for TB, Pertussis 2. Hepatitis B
➢ Target Age: Immediately given after birth or within 7
PRINCIPLES OF EPI days after birth
➢ Epidemiologic situation ➢ 1 dose for two types
➢ Mass approach ➢ Dose: 0.5 ml (IM, upper outer thigh/vastus lateralis)
➢ Integrated to the health services of the country

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

 Instructions for Hepatitis B: Additional Notes for Vaccinations for Infants
✓ Soreness and Inflammation → cold compress ➢ Reconstituted BCG & AMV → can only last for up to 6 hrs.
✓ Only low fever should occur ➢ Previous doses do not have to b repeated regardless of
interval
3. Pentavalent Vaccine (DPT-HepB-HiB) ➢ Boosters are not really necessary
➢ For Diphtheria, Tetanus, Hepatitis B (2nd Dose),
Pertussis, Pneumonia, and Meningitis Other Vaccines:
➢ Target Age: 6, 10, and 14 weeks old ➢ Cholera
➢ Dose: 0.5 ml (IM, vastus lateralis) with 4 weeks (28 ➢ Typhoid
days) interval ➢ Japanese Encephalitis (0.5 ml, SC, 9 months old)
➢ DPT Vaccine
o For up to 6 y/o only
o Older than 6 y/o are given DT vaccine only BIRTH – B! Months (9, 12)
➢ BCG ➢ Influenza (6m)
4. Oral Polio Vaccine (OPV) ➢ Hep B ➢ Measles (6-9m)
➢ For mucosal immunity against Polio Virus ➢ Jap B (9m)
➢ Target Age: 6, 10, and 14 weeks old Weeks (6-10-14) – DHiaPPeR ➢ MMR (12m)
➢ Dose: 2 drops (PO) pa si Baby! ➢ Varicella (12m)
o If child vomited, administer another drop (1 ➢ DPT ➢ Hep A (12m)
DROP ONLY) per orem ➢ Hib
➢ Polio Years
5. Inactivated Polio Vaccine (IPV) ➢ Pneumococcal ➢ Tdap
➢ For serum immunity against polio virus ➢ Rotavirus ➢ HPV (9y)
➢ Target Age: 14 weeks old ➢ Hep B
➢ Dose: 0.5 ml (IM, vastus lateralis)

6. Pneumococcal Conjugate Vaccine (PCV) Td VACCINATION FOR MOTHERS

➢ For Pneumonia and Meningitis ➢ For Tetanus and Diphtheria
➢ Target Age: 6, 10, and 14 weeks old ➢ Dose: 0.5 ml (IM, deltoid)
o For 2-5 years old, give only 1 dose
➢ Dose: 0.5 ml (IM, vastus lateralis) Dosage Number When/Frequency Immunity for
1st Possible pregnancy ---
7. Measles, Mumps, Rubella (MMR) 2nd After 4 months 3 years
➢ For Tigdas, Beke, German Measles 3rd After 6 months 5 years
➢ Target Age: 12-15 months old 4th After 1 year 10 years
➢ Dose: 0.5 ml (SC, outer arm) 5th After 1 year lifetime

Instructions for MMR METHODS FOR MAINTAINING EFFICACY OF VACCINES

✓ 200,000 IU of Vitamin A is given to promote 1. Freezer (-15 – -25 ºC) → OPV and measles vaccine
epithelialization and increase immunity 2. Refrigerator (2 – 8 ºC) → BCG, DPT, HBV, TT
✓ Rashes may occur
➢ Monitor temperature 2x a day (AM, PM)
8. Rotavirus (ROTARIX/ROTATEQ)
➢ For prevention of Diarrhea between 3 months to 2 y/o MAXIMUM STORAGE OF VACCINES
➢ Target Age: 6-15 weeks (1st dose), 32 weeks (2nd ➢ RHO/PHO/DHP → 3 months
dose) ➢ RHV → 1 month
➢ Dose: 1.5 ml (PO) ➢ During transportation → 3 DAYS
➢ Always practice FEFO → “FIRST EXPIRY, FIRST OUT”
9. Attenuated Measles Vaccine (AMV)
➢ Target age: 9 months, 1 y/o VACCINE VIAL MONITOR (VVM)
➢ Dose: 0.5 ml (SC, outer arm)
➢ At least 85% of measle cases could be prevented
➢ Freeze-dried → reconstitute with diluent water

Instructions for AMV:

✓ Fevers and rashes lasting 1-3 days within 2 weeks after
immunization may occur
✓ Vitamin A
o 100,000 IU → for 6-12 months old
o 200,000 IU → for older than 12 months

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

IMMUNIZATION SCHEDULE (DOH)

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)
 MANAGING NONCOMMUNICABLE DISEASES IN ADOLESCENTS
PHILPEN ➢ May lead to:
➢ Philippine Package of Essential Non-Communicable Disease o Transient/ Ischemic Attack (TIA)
Intervention ▪ Temporary problem in brain
▪ Partial occlusion of artery
NONCOMMUNICABLE DISEASES ▪ Low blood floe
➢ Cardiovascular diseases (hypertension, heart attack, etc.) ▪ ≈ mild stroke
➢ Diabetes ▪ Does not exceed 24hrs
➢ Chronic respiratory diseases (COPD, asthma, etc.) ▪ MRI → no infarction (dead brain cells)
➢ Cancer
o Stroke (Cardiovascular Accident)
DIABETES MELLITUS ▪ Total occlusion of blood vessel in brain
➢ Causes cellular starvation ▪ Embolus → infarction
➢ Type 1 → no production of insulin ▪ No blood supply → brain death
➢ Type 2 → low insulin production or insensitivity of cell receptors ▪ Aneurysm →hemorrhagic stroke
➢ Insulin
o Key for sugar to enter the cell o Kidney Disease
o No insulin → sugar stays in the blood stream
9 GLOBAL TARGETS (2015)
➢ May lead to: ➢ Lessen neonatal deaths and diseases
o Macrovascular Complications → stroke, ➢ Lessen alcoholism by 10%
hypertension, etc. ➢ Lessen physical sedentary by 10%
o Microvascular Complications → retinopathy, ➢ Salt reduction
neuropathy, nephropathy, etc. ➢ Lessen smoking → entry point of disease
➢ Lessen elevated by 25%
HYPERTENSION ➢ Lessen the increasing rate of obesity
➢ Lessen occurrence of heart disease by 5-%
➢ Increase medication of NCD

WHO PEN PROTOCOLS

➢ Prevention of heart attacks, strokes, and kidney disease through
management of diabetes and hypertension

ADMINISTRATIVE ORDER 2012-0029

➢ Implementation of PhilPEN
➢ Objectives:
o Diagnose and manage NCD (Main)
o Cost-effective alternatives
o Access to basic diagnostics and medications
o Develop a unified reporting system

HEALTH CENTER CLINIC ACTIVITIES AND DOCUMENTATION

PHASES OF CLINIC VISIT

PRE-CONSULTATION CONSULTATION POST-CONSULTATION
➢ Gather pertinent data from patient ➢ Patient-doctor interaction ➢ Give treatment
➢ Get chief complaint ➢ Doctor’s diagnosis ➢ Always triple check the medication
➢ History taking ➢ Give health teachings
➢ Physical examination ➢ Remind of next visit (if applicable)
➢ Focus assessment only
➢ Use ADPIE/SOAP
➢ ABCD
o Anthropometric Measurements
o Biochemical data
o Clinical Examination
o Dietary history

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

 PhilPEN PROTOCOL

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

NCD Total Risk Assessment and Management at the Health Facility Level

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

 ADULT PATIENT DATA SHEET
FAMILY NO. ____________
BRGY. NO. ____________
____________________________________________________
FAMILY NAME, FIRST NAME, M.I.

____________________________________________________
COMPLETE ADDRESS

PHYSICIAN’S ORDER NURSE’S NOTES

DATE: __________
S (SUBJECTIVE DATA):
- Chief complaint

O (OBJECTIVE DATA):
- Age (in years):
- Vital Signs:
o Temp: ____ Weight: _____
o PR: ____ Pain Scale: _____
o RR: ____ Height: ______
o BP: ____

A (ANALYSIS):
-

P (HEALTH TEACHINGS):
-

PEDIATRIC PATIENT (FOLLOW-UP) DATA SHEET

FAMILY NO. ____________
BRGY. NO. ____________
____________________________________________________
FAMILY NAME, FIRST NAME, M.I.

____________________________________________________
COMPLETE ADDRESS

PHYSICIAN’S ORDER NURSE’S NOTES

DATE: __________
S (SUBJECTIVE DATA):
- For possible Pentavalent2 and OPV2

O (OBJECTIVE DATA):
- Age (in years):
- Vital Signs:
o Temp: ____
o PR: ____
o RR: ____
o Weight: ____

A (ANALYSIS):
-

P (HEALTH TEACHINGS):
-

DOCUMENTATION (Vaccines given):

-

HEALTH TEACHINGS
-
-

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)

 PEDIATRIC PATIENT DATA SHEET (NEWBORNS OR INFANTS - NEW ADMISSION)
FAMILY NO. ____________
BRGY. NO. ____________

____________________________________________________
FAMILY NAME, FIRST NAME, M.I.

____________________________________________________
COMPLETE ADDRESS
DATE OF BIRTH:
PLACE OF BIRTH:
MODE OF DELIVERY:
BIRTHWEIGHT:
BIRTH ORDER:
TYPE/S OF FEEDING:
MOTHER’S NAME:
AGE (MOTHER):

Tetanus Diphtheria (TD): (YES/NO) Date Given: __________ → MOTHER

NEWBORN SCREENING DATE: ___________ RESULTS: ________________

BCG Vaccine: (YES/NO) Date Given: __________

Hepatitis B: (YES/NO) Date Given: __________

PHYSICIAN’S ORDER NURSE’S NOTES

DATE: __________
S (SUBJECTIVE DATA):
- For well-baby check-up
- For possible Pentavalent1 and OPV1

O (OBJECTIVE DATA):
- Age (in weeks/months): 6 weeks
- Vital Signs:
o Temp: ____
o CR: ____
o RR: ____
o Weight: 3.0 kgs → check if weight is appropriate for
age (overweight/underweight)

A (ANALYSIS):
- Well-baby

P (HEALTH TEACHINGS):
- Instructed mother to continue breastfeeding
- Burp baby after feeding
Abcoquia
ALYSS BEATRIZ M. COQUIA, UST-SN

DOCUMENTATION (Vaccines given):

- Pentavalent1, 0.5 ml, IM, right vastus lateralis
- OPV1, 2 drops, PO

HEALTH TEACHINGS
- Taught the mother what to do and not to do after vaccination
- Scheduled for next clinic visit and vaccination

Cassiemondragon
CASSANDRA MONDRAGON, SN

© ABCOQUIA 2019 (DIDACTIC LECTURES NOTES)