VII NURSES NOTES ( F D A R to Transcribe) VII OTHER PATIENT (KARDEX)

PATIENT #1: _______________________ ROOM & BED:________ DX: ___________________ PT. #2 NAME:______________________________________ Sex: _______Age: ________
ROOM/BED#: _______DATE OF ADMISSION: _____________ Wt:______Kgs. = ______ lbs.
FOCUS > DIAGNOSIS: _______________________________________ Ht: ________ BMI:________
CHIEF COMPLAINT:__________________________________ DIET:___________________
DATA > IVF ON: ___________________ IVF TO FF: _______________
IVF Rate:________________
SPECIAL ENDORSEMENT:_____________________________ _______________________
_________________________________________________ _______________________
Medications: ______________________________________ Give: ____________________
_________________________________________________ Give:_____________________
ACTIONS > _________________________________________________ Give: ____________________
Give: ____________________
8AM 12NOON
T: __________ RR:___________ T:__________ RR:__________
P: __________ BP:___________ P:__________ BP:__________
GENERAL APPEARANCE: ____________________________________________________

FOCUS >

DATA >

ACTIONS >

RESPONSE >

RESPONSE >
7

8
 VIII NURSING CARE PLAN (other problem/s) VI DOSAGE AND SOLUTIONS

PATIENT’S NAME: _________________________ ROOM/BED#: _______________________ INTRAVENOUS FLUID THERAPY

ASSESSMENT NURSING DIAGNOSIS PLANNING You received your patient with IVF of: (write the complete order and the LEVEL you received)
S > (IF ANY) _____________________________________________________________________________

What type of IVF is on-going?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What is the rate and or volume per hour? ___________________________________________

O>
What time/date the IVF will be consumed? __________________________________________
>
> At _________________ what is the level? ___________________________________________
>
> Write your computation below:
>
>

Definition of the Nursing

Diagnosis that you used.
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________

6
9
 VI DOSAGE AND SOLUTIONS INTERVENTIONS RATIONALE EXPECTED OUTCOME
OR
EVALUATION
MEDICATIONS: (Write the Generic and Brand Names, Dosage and Frequency; Specific Action or Classification)
NAME OF DRUGS, DOSAGE, SPECIFIC ACTION OR NURSING RESPONSIBILITIES
FREQUENCY CLASSIFICATION
AS ORDERED

MEDICATION COMPUTATION (IF ANY)

5 10
 IX TERMINOLOGIES V REVIEW OF ANATOMY AND PHYSIOLOGY
What part, organ or system of the body was affected? Draw, Label and Discuss the normal physiology.

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PATHOPHYSIOLOGY (If applicable)

______________________________________________________________________________
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11
4
 IV CASE ANALYSIS X DISCHARGE PLAN (for patient who has MGH order)
DIAGNOSIS OF THE PATIENT: (What is it all about?)
______________________________________________________________________________ M
______________________________________________________________________________ HOME MEDS

______________________________________________________________________________
______________________________________________________________________________ E
ENVIRONMEN
______________________________________________________________________________ T

T
SIGNS & SYMPTOMS TREATMENT
Book-Based Info Patient’s History (Narrative) Chief Complaints
H
HEALTH
TEACHING

DIAGNOSTICs & LABORATORY: (Write only abnormal findings and write nursing implications)
Name of Lab Findings Interpretation and Nursing Implications
Procedure

MEDICAL AND SURGICAL (if any) MANAGEMENT: (e.g. DIET) OPD WHEN, WHERE, WHAT TO BRING:
O
______________________________________________________________________________ Give Example:
______________________________________________________________________________
D
DIET
______________________________________________________________________________
______________________________________________________________________________

3 12
 IX HEALTH TEACHING I PATIENT’S PROFILE

TITLE NAME:___________________________________________ Sex: _______Age: ________

DATE OF ADMISSION: _______________________________ Wt:______kgs. = ______ lbs.
GENERAL ADMITTING DIAGNOSIS: _____________________________ Ht: ________
OBJECTIVE FINALDIAGNOSIS: __________________________________
SPECIFIC OBJECTIVE CONTENT 8AM 12NOON
T: __________ RR:___________ T:__________ RR:__________
P: __________ BP:___________ P:__________ BP:__________
BMI: _________Allergies_________ Oxygen: _____LPM via ________
Immunization: _______________________________________________________________

II PHYSICAL ASSESSMENT
General Appearance: __________________________________________________________
Mental Status: _______________________________________________________________
Skin: ___________ Head: _________ Hairs: ________Nails:________Eyes:_______________
Ears: ___________Nose: ___________Mouth:______________ Throat: _________________
Neurologic: __________________________________________________________________
Cardiovascular_____________________________________________________________
____________________________________________________________________________
Gastrointestinal: ______________________________________________________________
____________________________________________________________________________
Respiratory: __________________________________________________________________
____________________________________________________________________________
Genitourinary: ________________________________________________________________

III Developmental Assessment

Choose a Nursing Theory and a Developmental Theory (Erickson, Piaget, Freud)

Nursing Theory Developmental Theory

EVALUATION

2
13
This Related LEARNING Experience Worksheets/Booklet is designed to record and monitor XI REFLECTIVE JOURNAL
students’ progress during their SOCIALIZATION in the realities of the program of Bachelor of
______________________________________________________________________________
Science in Nursing. In this area of nursing education, student nurses need to apply and PRACTICE
______________________________________________________________________________
what they have learned from the four-corner walls of the classroom. They have to grasp with full
______________________________________________________________________________
UNDERSTANDING, that through these processes are where they will matter most as future
______________________________________________________________________________
nurses.
______________________________________________________________________________
-Jayson G. Celerio MAN, RN ______________________________________________________________________________
LSPU-SCC, Clinical Instructor
______________________________________________________________________________
______________________________________________________________________________
Vision Mission ______________________________________________________________________________
The Laguna State Polytechnic University is a LSPU Provides quality education through ______________________________________________________________________________
center of sustainable development initiatives responsive instruction, distinctive research, ______________________________________________________________________________
transforming lives and communities. sustainable extension and production ______________________________________________________________________________
services for improved quality of life. ______________________________________________________________________________
______________________________________________________________________________
Quality Goals and Objectives ______________________________________________________________________________
1. Provide Holistic, personalized nursing skills through quality instruction. ______________________________________________________________________________
2. Produce a fully functioning nurse and allied health care workers who is able to
perform the core competencies with responsibilities What Key Areas of Responsibility/ies and competencies were you able to utilize today?
3. Support the community in response to the needs of health care workers.
KAR COMPETENCIES
4. Produce highly skilled, morally upright young professionals and researcher’s
contributory to the national development
5. Encourage students to participate in social activities to develop community
consciousness and awareness and to foster camaraderie.

CORE VALUES
Love of God, Love of People, Love of Country
CARING Compassion Competence Confidence Conscience Commitment
Integrity Innovation Professionalism What LSPU – CONAH core values and other VALUES were you able to live today in your clinical
, duty?
RLE Grading System ______________________________________________________________________________
Knowledge Skills Attitude ______________________________________________________________________________
Quizzes, Term Exam Active Participation and Decorum ______________________________________________________________________________
Recitation Performance Apply LSPU & CONAH Values ______________________________________________________________________________
in the care of persons ______________________________________________________________________________
______________________________________________________________________________
1 __________________________________________________________________________
 14 15
Republic of the Philippines
Laguna State Polytechnic University
XII NOTES Province of Laguna
______________________________________________________________________________ College of Nursing and Allied Health
STA. CRUZ MAIN CAMPUS, LAGUNA
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ RELATED LEARNING EXPERIENCE Worksheets
______________________________________________________________________________ SOCIALIZATION
______________________________________________________________________________ PRACTICE
______________________________________________________________________________ UNDERSTANDING
______________________________________________________________________________ Course/Sem/Term: _________________________________________________
______________________________________________________________________________ Name: _________________________________________________
______________________________________________________________________________ Section & Group: _________________________________________________
______________________________________________________________________________ Hospital & Area: _________________________________________________
QUIZ # ________ DATE: ____________ DAY: __________ Date &Rotation#: _________________________________________________
Clinical Instructor: _________________________________________________
______________________________________________________________________________
______________________________________________________________________________ Nurses’ Prayer
(Online Prayers)
______________________________________________________________________________
O My God, teach me to receive the sick in Thy Name.
______________________________________________________________________________ Give to all my efforts success for the glory of Thy Holy Name
______________________________________________________________________________ It is Thy work; without Thee, I cannot succeed.
______________________________________________________________________________ Grant that the sick Thou hast placed in my care may be abundantly blessed and not one of them be lost
______________________________________________________________________________ because of any neglect on my part.
______________________________________________________________________________ Help me to overcome every temporal weakness and strengthen in me whatever may enable me to
bring joy to the lives of those I serve. Give me grace, for the sake of Thy sick ones and those lives that
______________________________________________________________________________
will be influenced by them. AMEN!
______________________________________________________________________________

INSTRUCTOR’S REMARKS (Performance Appraisal)

What’s Inside?
______________________________________________________________________________ Pag Contents Pag Contents
______________________________________________________________________________ e e
______________________________________________________________________________ 2 Patient’s Profile, Physical Assessment, Theory 11 Terminologies
Application
______________________________________________________________________________
3 Case Analysis 12 Discharge Plan
______________________________________________________________________________ 4 Review of Anatomy and Physiology 13 Health Teaching
______________________________________________________________________________ 5-6 Dosage and Solutions (Oral, Parenteral & 14 Reflective Journal, Key Areas of
Intravenous Fluids) Responsibilities & Core Values
_________________________________
7-10 Nurses Notes (FDAR) / Nursing Care Plan 15 Notes, Quiz, Instructor’s Remarks
Name and Signature