ILOILO MISSION HOSPITAL

Mission Road, Jaro, Iloilo City

NURSING KARDEX NO. 1 Hospital No: ________

12345
Room & Bed No. ______________
A-206

Tan, John
Name: ____________________________________Age: 25 M
______Sex:______Service:_______Attending Dr. Cruz
Physician:___________________________

Date of Admission:______________
12/02/2020 _______ Chief Complaint: ____________________Working
Abdominal pain Appendicitis
Diagnoses:_______________________________
Leon, Iloilo
Address:____________ City
________________________________________Date of Birth:_________ RC
July 29, 1995Civil Status:___________Religion:___________
Single
Health Insurance: ✔Phil Health Member Phil Health Department SSS/GSIS Member SSS/GSIS Dependent Service Case
IMH Employee IMH Dependent Self/Private Pay Charge to Bill On Hold Status/Excess HMO:______

MENTALSTATE MOOD & EFFECT EQUIPMENTS & MEDICAL SERVICES CONTRAPTIONS Date Date
✔ Conscious ___ Calm ___Cardiac Monitor ____Infusion Pump _____ET tube _______ ___Epidural Cath ________
___Drowsy ✔Anxious/Agitated ___Suction Machine ____Syringe Pump size: ___level___ _______ ___JP drain _______
GCS: ___Others:__________ Bill Light ____Pulse Oximeter ____Trach.Tube _______ ___AVF at __ arm _______ ___Balkan
Frame ___Droplight __NGT fr.___ _______ ___Vent. Tube _______
___Traction_____ ___Bedside Commode ___OGT fr. ___ _______ Level:___ _______
MOTOR STATUS BLADDER & BOWEL ___Weights___kgs
55 ___Ventilator ___IJ catheter _______ ___CTT __L__R _______
✔Normal ___Catheter Date:____ ___CVP Level:___ _______
__Slurred Speech ___Foley Fr:___ Oxygenation &Ventilator Parameters ___PEG__________ ✔I.V. Site: 12/02/20
__ Hemiplegic ___Straight ___T-tube _______ Gauge: ___ _______
___Paraplegic ___Suprapubic __Oxygen at __LPM via: ___ ___J-tube ___I.V. Tubing _______
___Paresis__L__R ___Cystoclysis__cc/hr FIO2:___________Peak Flow Rate:____ ___Penrose ____Saline lock _______
____Colostomy Tidal Volume:____PEEP:____________ ___Others:__________________________
_______ Back-up Rate:____Mode____________
Ambulatory ACTIVITY:________ ____________________________________ _______
Bedridden ________bed rest s BRP_____________Others:_______________________
✔Needs Assistance __________________ _______________________________ Blood Type: __A ___B ___AB___O ___Rh+ ___Rh-

DIET Delivery:_______________________ Blood and Blood Components Received

✔NPO ___Soft __Low fat Newborn Screening Test: _________ Whole Blood:_________________________________
___Clear Liquids ___Full/DAT __Low salt Hearing test:_____ BCG:___________ ____________________________________________
___Gen. Liquids ___Diabetic ___HypoallergenicOperation & Date: Appendectomy 12/03/20 PRBC: 1 unit requested
___Breastfeeding ___OTF Preparation:___kcal _____________________________ ____________________________________________
____________________________________ _______________________________ Platelet Concentrate:____________________________
_
Diet _______________________________ ____________________________________________
Specifications:______________________
____________________________________ Precautions: _____________________ FFP/Cryoprecipitate: __________________________
_
____________________________________ _______________________________ ____________________________________________
_
Food Allergies:________________________ Human Albumin: _____________________________
Idiosyncrasies;____________________
____________________________________ _______________________________ ___________________________________________
_
Initial Date Nursing Frequency Time Initial Date Laboratory Date Done Initial
Ordered Ordered
Intervention Examinations
JBECPUSN 12/02/20 TPR q4h JBECPUSN 12/02/20 CBS, platelet 12/02/20
JBECPUSN
BP q4h Na, K, Creatinine, BUN 12/02/20 JBECPUSN
Neuro-Vital Signs Lipid Profile
MIO qshift FBS
CVP Reading Fecalyisis
Oxygen Saturation Urinalyis
Monitoring
Weight Blood typing 12/02/20 JBECPUSN

Turning Cross matching 12/02/20 JBECPUSN

j Suctioning
Oral Care
Body Bath
Perineal Care
Colostomy Care
Tracheostomy Care
Wound Dressing
Head and Chest Circumference
Monitoring
ROM Exercises
Abdominal Girth Initial Date Date Initial
Ordered
Diagnostic Exams
Monitoring Done
Abdominal Status
Monitoring
JBECPUSN
JBECPUSN 12/02/20 ECG 12 leads 12/02/2020
Special Orders: Plain Abdominal x-ray 12/02/2020 JBECPUSN
JBECPUSN 12/02/20 Inform AP of this
admission
Refer prn
 Request 1 unit of
packed RBC

NURSING KARDEX No.2

Initial Date Bottle Time Time Initial Date Bottle Time Time
Ordered No.
Mainline Started Due Ordered No.
Side Started Due
IVF Drip/TPN
JBECPUSN 12/02/20 #1 PNSS 1L X 8H 11:30/ 7:30
MS
ward

Initial Date Medication & Dosage Time Initial Date PRN Medications & Dosage Time
Ordered Ordered
JBECPUSN Cefotaxime 750 mg IVTT q8H ANST 11 7 3 11 JBECPUSN 12/02/20 Paracetamol 300 mg IV now then q4h prn for temp >/=
12/02/20
37.5 C
Tramadol 25mg IV q6h for complaints of pain

Initial Date Pre-Procedure Medication & Dosage Time

Ordered (Chemotherapy, Blood Transfusion,Operation etc.)
JBECPUSN 12/02/20 1 unit of PRBC

Initial Date Medical Treatment & Dosage Time

Ordered

Initial Date Blood and Blood Components Time Time

Ordered Started Due

__A-206
Room & Bed No._________ 12345
Hospital No.________
Name: Tan,
______________________
John Age: 25 Sex: ______
M Service: __________ Attending Physician/s:_______________________________
Dr. Cruz
Prepared by: Jasmin B. Ermita CPUSN NSO Form: Nursing Care Plan Date Revised: June 26, 2018 Page 2 of 2 Recopied by: __________________
 Tan, John 25 M Dr. Cruz 12345

12/02/20 25 110/60
112
11:00 38.6
37.9 104 23 100/90
3:00
Tan, John

12/02/20
Day 0

O
N

A
D
M
I
S
S
I
O
N

25 23
110/ 100/
60 90
 Tan, John 25 12345 A-206
M Dr. Cruz

12/02/20 7-3 #1 PNSS 1 Liter 8 125 31 11:30 JBECPUSN

 Tan, John

JASMIN B. ERMITA CPUSN JBE

12/02/20

Paracetamol 300 mg IV now

then q4h prn for temp >/= 37.5 C 11:40/JBE
 Tan, John

JASMIN B. ERMITA CPUSN JBE

12/02/20
Cefotaxime 750 mg IVTT 12:40/JBE
q8H ANST
11 7 3 11

Tramadol 25mg IV q6h for

1:00/JBE
complaints of pain
 Tan, John

12/02/20 11:30
Received a 25 years old male conscious and alert with
a chief complaint of abdominal pain.

Vital sign taken Temp.= 38.6◦C, P=112 beat/min,

RR=25/min, BP 110/60 mmHg

Assessed by Dr. Cruz with orders, carried out.
11:35 PNSS 1 L x 8 hr Started as venoclysis @ Left cephalic vein gtts. Regulated
at 125 cc/hour.

11:40 Paracetamol 300 mg IV Administered IV for temperature 38.6

12:00 CBC, Platelet, Na, K, Creatinine, Done by laboratory personnel.
BUN, Blood typing, crossmatching

Cefotaxime 0.1cc Injected as skin test @ R volar area

12:10
ECG 12 leads Done by Heart Station personnel.
Brought to X-ray Dept per stretcher.

12:30 Plain abdominal x-ray Done by x-ray technician. Brought back to MS ward.
Skin test to Cefotaxime interpreted as negative by Cruz.
12:40 Cefotaxime 750 mg IVTT Injected IVTT as initial dose by SNOD Santiago.
Brought to MS ward per wheelchair.
Transferred to bed and made comfortable with side rails up.

12:50 Complained of severe pain at the right lower quadrant.

Pain scale 8/10. Referred to SNOD Santiago.

1:00 Tramadol 25mg IV Administered IV for patient’s complaints of pain.
2:30
Reduction of pain as verbalized. Pain scale 4/10.
Vital signs rechecked Temp.= 37.9◦C, P=104 beat/min,
3:00
RR=23/min, BP 100/90 mmHg
3:10 Resting on bed, IV infusing well. Endorsed to SNOD.
jbermita
Jasmin B. Ermita CPUSN/Charisse Pedroso CPUCI
 Tan, John
A-206

PNSS 1LX 8 hr

125 31
None

12/02/20 11:30 7:30

Jasmin B. Ermita CPUSN

Tan, John
12/02/20 25
MS ward

NPO

jbermita
JBE CPUSN
 12/02/20
Tan, John July 29, 1995 35 M MS ward
12/02/20 12:10
12:10 110/60 mmHg 112 bpm

Abdominal pain
Dr. Cruz
jbermita
Jasmin B. Ermita CPUSN/ Charisse Pedroso CPUCI

Tan, John
A-206
12/02/20- 11:30 MS ward Central Supply
Quantity
Tuberculin syringe - #1
Disposable syringe 10 cc - #2
IV tubing gauge 18 - #1
IV cannula gauge 18 - #1
PNSS bottle - #1

jbermita
Jasmin B. Ermita CPUSN/ Charisse Pedros CPUCI
 Tan, John July 29, 1995 25 M A-206
Leon, Iloilo City Dr. Cruz
Abdominal pain
12/02/20- 12:00 MS ward Laboratory Dept

CBC, Platelet
Na, K
Creatinine, BUN
Blood Typing
Cross Matching

jbermita
Jasmin B. Ermita CPUSN/ Charisse Pedroso CPUCI

Tan, John July 29, 1955 25 M A-206

Leon, Iloilo City Dr.Cruz
Abdominal Pain
12/02/20- 12:00 MS ward Laboratory Dept

Lipid Profile
FBS

jbermita
Jasmin B. Ermita CPUSN/ Charisse Pedroso CPUCI
 Tan, John July 29, 1955 25 M A-206
Leon, Iloilo City Dr. Cruz
Abdominal pain
12/02/20- 12:00 MS ward Laboratory Dept

Fecalysis

jbermita
Jasmin B. Ermita CPUSN/ Charisse Pedroso CPUCI

Tan, John July 29, 1955 25 M A-206

Leon, Iloilo City Dr. Cruz
Abdominal pain
12/02/20- 12:00 MS ward Laboratory Dept

Urinalysis

jbermita
Jasmin B. Ermita CPUSN/ Charisse Pedroso CPUCI
 12/02/20
Tan, John 25 A-206
Leon, Iloilo City M

Paracetamol 300 mg IV #4 vials

Cefotaxime 750mg IVTT #3 vials

Tramadol 25mg IV #3 ampules

PNSS 1L # 1 bottle

Dr. Cruz
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122344
Juana Tan
Juana Tan jbermita
jbermita Jasmin B. Ermita CPUSN
Jasmin B. Ermita CPUSN
 jbermita
Jasmin B. Ermita CPUSN

12/02/20
Tan, John 25 M MS ward
Leon, Iloilo City
Plain abdominal x-ray

Dr. Cruz
110 60 July 29, 1955

Abdominal pain
Tan, John 25 12345
12/02/20

IVL = PNSS 1L 50

50

IVL= 500 500 50

500 150

500
 Flaggings
For special endorsements (blue flag) For blood and oxygen (pink flag)

CBC, platelet 12/02/20 A-206 Tan, John

Na, K, Creatinine, BUN 12/02/20
Cross Matching and Blood
Typing 12/02/20 Request I unit of PRBC
FBS
Lipid Profile
Urinalysis
Fecalysis

ECG 12 leads 12/02/20

Plain abdominal x-ray 12/02/20
Inform AP of this admission12/02/20
Refer prn 12/02/20

Tan, John 12/02/20

JBE CPUSN

Medicine Cards
IVTT meds IV Infusion meds Oral meds and other treatments

A-206 Tan, John

A-206 Tan, John

Tramadol 25mg IV
Paracetamol 300 mg

IV
IVTT
q6H prn for complaints
of pain
q4h prn for temp >/= 37.5 C

12/02/20 JBE CPUSN

12/02/20 JBE CPUSN

A-206 Tan, John

Cefotaxime 750 mg

IVTT

q8h ANST

11 7 3 11

12/02/20 JBE CPUSN

 Tan, John

Cruz

appendectomy

Cruz

Cruz

Cruz

2nd of December the Lord 20

John tan
John Tan

PREOP CHECKLIST
John Tan 25 M MS
12/03/20 11
58 kgs
Seafood, eggs, peanuts
Emergency surgery
Dr. Alex Santos Dr. Christian Chu
General anesthesia

250

10

37 , 85, 20 120 70

Jane Santos Christian Santiago

7 00

10 30
Jasmin B. Ermita CPUSN jbermita