Ponr Inp
Ponr Inp
Ponr Inp
Has received blood in the past: Yes No If yes, indicate the dates
Reaction: Yes No
Allergies:
Medication Name Route, Dose &Frequency Date & Time of Last Dose Reaction
NURSING SYSTEM REVIEW CHART
Name: Date:
Vital Signs:
Pulse: BP: Temp.: RR: SpO₂: Height: Weight:
INSTRUCTION: Place an (X) in the area of abnormalities. Write comment on the space provided. Indicate the location of the problem
in the figure using (X).
EENT
[] impaired vision [] blind [] Pain
[] reddened [] drainage [] lesion seen
[] gums [] hard of hearing [] deaf
[] burning [] edema
Assess eyes, ears, and nose throat for abnormality
[] no problem
RESPIRATORY
[] asymmetric [] tachypnea [] apnea
[] rales [] cough [] barrel chest
[] bradypnea [] shallow [] rhonchi
[] sputum [] diminished [] dyspnea
[] orthopnea [] labored [] wheezing
[] pain [] cyanotic
Assess respiration, rate, rhythm, depth, pattern,
breathe sounds, comfort
[] no problem
CARDIO VASCULAR
[] arrhythmias [] tachypnea [] numbness
[] diminished pulses [] edema [] fatigue
[] irregular [] bradycardia [] murmur
[] tingling [] absent pulses [] pain
Assess heart sounds, rate rhythm, pulse, blood pressure, circulation,
fluid retention, comfort
[] no problem
GASTROINTESTINAL TRACT
[] obese [] distention [] mass
[] dysphagia [] rigidity [] pain
Assess abdomen, bowel habits, swallowing, bowel sounds,
comfort [] no problem
NEURO
[] paralysis [] stuporous [] unsteady
[] seizures [] lethargic [] comatose
[] vertigo [] tremors [] confuse
[] vision [] grip
Assess motor function, sensation, LOC, strength, grip, gait,
Coordination, orientation, speech.
[] no problem
[] cough
[] sputum R:
[] denied L:
Most supportive person: The person and his phone number that can be reached
any time:
DOCTOR’S ORDER SHEET
Patient: Attending Physician:
Diagnosis: Date Admitted:
Name of Patient:
Diagnosis:
LABORATORY RESULTS
Dx. Exam Results Normal Values Significant of the Result
Date Ordered Diagnostic/ Laboratory Clinical Significance
Exams
Date Ordered I.V. Fluids/ Blood Clinical Significance
TOTAL
FOR 24
HRS
TOTAL
FOR 24
HRS
TOTAL
FOR 24
HRS
TOTAL
FOR 24
HRS
TOTAL
FOR 24
HRS
MEDICATION WORKSHEET
DATE
DRUG, DOSE, ROUTE &
ORDERE Indicates date & shift Indicate date & shift Indicate date & shift
FREQUENCY
D
HEALTH TEACHINGS
Name of the Patient
MEDICATION RATIONALE
EXERCISE
TREATMENT
OUT PATIENT
(CHECK-UP)
DIET
KARDEX
Name: Chief Complaints:
Address: Diagnosis:
Age: Sex: Civil Status: Attending Physician:
Ward: Room: Date & Time Admitted:
Doctor’s IVF/
Date Observation Blood Medication Nursing Diagnosis Goal Nursing Intervention Special Endorsement
Order
DRUG STUDY
Name of Drug Special Indication Nursing Responsibility
Mechanism of Action (Relate it to
(Generic Name / (Based on patients (Based on drug’s
patient’s problem)
Brand Name) Problem) physiologic effects)
DRUG STUDY
Name of Drug Special Indication Nursing Responsibility
Mechanism of Action (Relate it to
(Generic Name / (Based on patients (Based on drug’s
patient’s problem)
Brand Name) Problem) physiologic effects)
PATHOPHYSIOLOGY
Name of Patients:
Diagnosis:
REFERENCES:
Score: Grade:
PONR
(Problem-Oriented Nursing Records)