SILLIMAN UNIVERISTY

COLLEGE OF NURSING
DUMAGUETE CITY

Student Nurse: Cadiz, Loisa Faye

I. Demographic Data

Name: ____________________________________________________________ Sex: __________ Age: __________ Civil Status: _______________________________

Address: __________________________________________________________ Educational Attainment: _________________Occupation: ______________________

Room and Bed number: _____________________________________________ Doctor(s) in charge: ______________________________________________________

______________________________________________________

Nationality: ___________________________Religion: ____________________ Date and time of admission: ________________________________________________

Chief complaint: ______________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

History of present illness: ______________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

Diagnosis: ___________________________________________________________________________________________________________________________________

General Impression of client: ___________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

CUES AND EVIDENCES & NURSING
DIAGNOSIS
Subjective:
 “labad akong ulo unya nag suka-
suka pud ko” as verbalized by the
patient
 Mother reported that the headache
was probably due to the infection
in his right ear
Objective:
 Skin is dry to touch
 Appears weak but is ambulatory
 The inside of the right ear appears
red
Nursing Dx: Risk for Acute pain related to
increased pressure in the right middle ear
KARDEX
OBJECTIVES
Within my 7 hours of care, the patient:
 describes satisfactory pain control
at level less than 3 to 4 on a rating
scale of 0 to 10
 displays improved well-being such
as baseline levels for pulse, BP,
and respirations
INTERVENTIONS EVALUATION
 assessed patient’s description of Within my 7 hours of care, the patient was
the pain and rated pain level of a 4 able to experience a satisfactory pain
on a scale of 0 to 10 control level of 4 on a scale of 0 to 10 and
 vital signs were taken and was able to maintain baseline levels for
pulse (81 bpm), BP (110/80 mmHg), and
recorded
 teaching was done to the mother respirations (20 cpm)
regarding the importance of taking
the antibiotics and complying with
the whole prescription
 referred an ear specialist for the
patient