College of Nursing

USSO Building
Visca, Baybay City, Leyte, Philippines
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

FM-CON-###-### N U R S E S N O T E S
Name Reason for Admission
Age Sex Medical Impression

Date F = Focus D = Data A = Action R = Response

VSU's Vision: A globally competitive university for science, technology, and environmental conservation.
VSU's Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and
innovative technologies for sustainable communities and environment.
 College of Nursing
USSO Building
Visca, Baybay City, Leyte, Philippines
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

FM-CON-###-### NURSING CARE PLAN # ______

Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective

Objective Scientific Basis Desired Outcome Collaborative

Dependent

NURSING CARE PLAN # ______

VSU's Vision:  A globally competitive university for science, technology, and environmental conservation.
VSU's Mission:  Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.
 Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective Acute pain or impaired After 8 hour duty, the  Assess pain  Can be used as
The patient verbalize, comfort related to pain will be relieved. characteristics and baseline data
“sakit akong tinahian sa surgical trauma as intensity.
tiyan”. evidenced by verbal  Ascertain patient’s  Provides baseline
reports e.g. incisional knowledge of and for interventions and
pain. Desired Outcome expectations about teaching, provides
Objective  Report pain is acute pain opportunity to allay
Pain scale of 5 which is Scientific Basis relieved or management. common fears and
classified as moderate Acute pain is an controlled. misconceptions.
pain. unpleasant sensory and  Follow prescribed  Patient education  To help the patient
emotional experience pharmacologic about pain gain skills in
associate with actual or regimen. management managing pain.
potential tissue damage.  Demonstrate use of
relaxation skills and Collaborative
diversional activities,  Collaborate with the  Student nurses are
as indicated, for nurse on duty or the not allowed to
individual situation. clinical instructor in administer
 Verbalize sense of giving treatment like medications without
control of response in administering pain the supervision of
to acute situation medications or the licensed nurses.
and positive outlook analgesics as
fo the future. indicated

NURSING CARE PLAN # ______

FM-CON-###-### Visayas State University - College of Nursing | Page | 3

 Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Self-care deficit related to Goal Independent
Subjective pain and discomfort After 8 hour duty the  Assess the patient’s  To save time and
none patient will be able to level of knowledge energy.
demonstrate self-care about proper
Scientific Basis activities. hygiene.
Objective Proper hygiene gives  Assist the patient  Experiencing the
Messy hair and messy comfort and prevents Desired Outcome with grooming normal process of a
hospital bed. acquiring  Identify individual activities. Encourage task through
Not so clean clothes. microorganisms that can areas of weakness participation, guiding established routine
cause disease. or needs patient’s hand and guided practice
 Verbalize knowledge through tasks, as facilitates optimal
of healthcare indicated. relearning.
practices  Encourage patient to  These may be
 Demonstrate use adaptive clothes helpful for client with
techniques and limited body
lifestyle changes to movement.
meet self-care  Patient education  To widen
needs about self-care understanding.
 Perform self-care
activities within level
of own ability.

NURSING CARE PLAN # ______

FM-CON-###-### Visayas State University - College of Nursing | Page | 4

 Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective Risk for infection related After 8 hours shift, 1. Asses for presence of - Loss if skin and tissue
No verbalization to surgical incision. patient will be able to host-specific factors integrity; invasive
identify signs of infection that affect immunity. diagnostic procedures
and demonstrate or surgery; are
interventions to prevent common paths of
Objective Scientific Basis infection. pathogen entry.
Presence of post- Infections occur when the
operative incision natural defence Desired Outcome 2. Monitor elevated
mechanisms of an - Verbalize temperature, redness,
- These are signs of
individual are inadequate understanding of swelling, increased
infection.
to protect them. individual causative or pain or purulent
Organisms such as risk factors. drainage at incisions.
bacterium, virus, fungus, - Identify interventions
and other parasites to prevent or reduce 3. Emphasize the - Premature
invade susceptible hosts discontinuation of
risk of infection. necessity of taking
through inevitable injuries treatment when patient
- Demonstrate antibiotics or antiviral
and exposures.
techniques, lifestyle as ordered. begins to feel well may
changes to promote result in return of
safe environment. 4. Patient education infection and
- Achieve timely wound about the signs of potentiation of drug
healing. infection so the patient resistant strains.
- Be free of purulent will be guided as to
drainage or erythema; when report to
be a febrile healthcare provider.

NURSING CARE PLAN # ______

FM-CON-###-### Visayas State University - College of Nursing | Page | 5

 Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective Ineffective breastfeeding After 8 hours, patient will 1. Assess patient - Provides baseline for
The patient verbalized: related to pain. be able to express knowledge about interventions, provides
“maglisod ko ug patotoy physical and breastfeeding and opportunity to allay
kay sakit akong tinahian”. psychological comfort in extent of instruction common fears and
breastfeeding practices that has been given. misconceptions.
and techniques. 2. Evaluate the mother's - Correct positioning
Objective Scientific Basis
ability to position and and getting the infant
- Improper positioning Breastfeeding is a very Desired Outcome
help the infant to latch to latch on is critical for
of the baby observed beneficial for both the - Demonstrate
mother and her baby. It on. breastfeeding
during breastfeeding. techniques to enhance
3. Promote comfort and - Discomfort associated
- Infant crying at the has a lot of benefits if a breastfeeding
mother is continuously relaxation to reduce with breastfeeding can
breast experience.
breastfeeding her child pain and anxiety. cause to discontinue
- Verbalize
during the first years of breastfeeding.
understanding of
life. 4. Suggest using a - To find the most
causative or
variety of nursing comfortable for mother
distributing factors.
positions. and infant.
- Achieve mutually,
satisfactory 5. Educate father/SO - Enlisting the support of
about benefits of the father/SO is
breastfeeding regimen
breastfeeding and how associated with a
with infant content
to manage common higher ratio of
after feedings, gaining
lactation challenges. successful
weight appropriately,
breastfeeding.
and output within
normal range

NURSING CARE PLAN # ______

Name Reason for Admission

FM-CON-###-### Visayas State University - College of Nursing | Page | 6

 Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective Disturbed sleep pattern After 8 hours duty, the 1. Identify presence of - Sleep problems can
The patient verbalized, related to nonrestorative patient will be able to factors known to arise from internal and
“kung makamata ko dili sleep pattern. understand and establish interfere with sleep external factors and
nako makatug ug balik” own way to enhance may require
sleeping pattern. assessment over time
The patient verbalized, to differentiate specific
“kung matug kog hapon Scientific Basis
cause.
kadiyot ra pud di kaabot Time-limited interruptions Desired Outcome
2. Perform monitoring - Allows for longer
ug 30 minutos”. of sleep amount and - Identify individually
quality due to external and care activities periods of
appropriate
factors. without waking client uninterrupted sleep,
interventions to
Objective whenever possible. especially during
promote sleep.
- Alteration in sleep 3. Assure the patient that night.
- Report improved
pattern occasional - Knowledge that
sleep.
sleeplessness should occasional insomnia is
-Report increased sense not threaten health universal and usually
of well-being and feeling and that resolving not harmful may
rested promote relaxation
time-limited situation
can restore healthful and relief from worry,
sleep which can perpetuate
the problem.

FM-CON-###-### Visayas State University - College of Nursing | Page | 7

 NURSING CARE PLAN # ______
Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Hyperthermia Goal Independent
Subjective After 8 hour duty the
The significant other, baby’s temperature will
“init-init man si baby kung be in normal range
hikapon”
Scientific Basis Collaborative
Hyperthermia is a core Desired Outcome
Objective body temperature above - The baby’s
Temperature of 38.6 the normal diurnal range temperature will be
degree Celsius due to failure of in normal range
thermoregulation. - Dependent

FM-CON-###-### Visayas State University - College of Nursing | Page | 8

 NURSING CARE PLAN # ______
Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective

Objective Scientific Basis Desired Outcome Collaborative

Dependent

FM-CON-###-### Visayas State University - College of Nursing | Page | 9

 NURSING CARE PLAN # ______
Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective

Objective Scientific Basis Desired Outcome Collaborative

Dependent

FM-CON-###-### Visayas State University - College of Nursing | Page | 10

 NURSING CARE PLAN # ______
Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective

Objective Scientific Basis Desired Outcome Collaborative

Dependent

FM-CON-###-### Visayas State University - College of Nursing | Page | 11

 NURSING CARE PLAN # ______
Name Reason for Admission
Age Sex Medical Impression
PLANNING NURSING INTEVENTIONS
OUTCOME
ASSESSMENT CUES NURSING DIAGNOSIS RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
(with references)
Goal Independent
Subjective

Objective Scientific Basis Desired Outcome Collaborative

Dependent

FM-CON-###-### Visayas State University - College of Nursing | Page | 12

 DRUG THERAPEUTIC RECORD # ______
Name Reason for Admission
Age Sex Medical Impression
SIDE EFFECTS/
MECHANISM OF CONTRA- NURSING
DRUG NAME DRUG CLASS INDICATIONS ADVERSE
ACTION INDICATIONS CONSIDERATION
EFFECTS
Generic: Therapeutic: Inhibits the action of Patient’s Hypersensitivity; CNS: confusion, Before:
histamine at the H2- Indications: some products dizziness, Assess for epigastric
Ranitidine Antiulcer agents receptor site located Pre-operative contain alcohol and drowsiness, or abdominal pain
primarily in gastric medication to should be avoided in hallucinations, and frank or occult
parietal cells, resulting decrease acidity to patients with known headache. CV: blood in the stool,
Brand: in inhibition of gastric the stomach and intolerance; some arrthythmias. GI: emesis, or gastric
Dom-Ranitidine Pharmacologic acid secretion. prevent gastric products contain constipation, aspirate.
ulcer as the patient aspartame and diarrhea, drug-
Histamine H2 is ordered with should be avoided in induced hepatitis During:
Complete antagonists NPO. patients with (nizatidine, Shake oral
Prescription: phenylketonuria. cimetidine) nausea. suspension before
Given 1 hr. prior to General: GU: decreased administration.
operation Treatment of and sperm count, erectile Discard unused
Post-op: 50mg IVTT maintenance Pregnancy dysfunction. Endo: suspension after 30
q8hrs therapy for erosive Category: B gynecosmatia. days.
esophagitis. Short- Hemat: anemia,
term treatment of neutropenia, After:
Date of Rx: active duodenal thrombocytopenia Advise patient to
February 25,2020 ulcers and benign report onset of black,
gastric ulcers. tarry stools; fever;
sore throat; diarrhea;
dizziness to
healthcare
professionals.

FM-CON-###-### Visayas State University - College of Nursing | Page | 13

 DRUG THERAPEUTIC RECORD # ______
Name Reason for Admission
Age Sex Medical Impression
SIDE EFFECTS/
MECHANISM OF CONTRA- NURSING
DRUG NAME DRUG CLASS INDICATIONS ADVERSE
ACTION INDICATIONS CONSIDERATION
EFFECTS
Generic: Therapeutic: Bind to the bacterial Patient’s Hypersensitivity to CNS: seizures Before:
cell wall membrane, Indications: cephalosporins; GI: diarrhea, Assess for infection.
Cefuroxime Anti-infectives causing cell death Prophylaxis serious diarrhea, cramps, Obtain history to
hypersensitivity to nausea, vomiting determine previous
Brand: penicillins Derm: rashes, use of and reactions
urticarial to penicillins or
Ceftin General: Hemat: cephalosporins
Pharmacologic Meningitis, agranulocytosis,
Complete gynecologic bleeding , During:
Prescription: second generation infections, and Pregnancy eosinophilia, Dilute each
Cefuroxime 750mg cephalosporins Lyme disease. Category: B hemolytic anemia, cephalosporins in at
IVTT prior to OR. neutropenia, least 1g/ 10 ml.
thrombocytopenia Administer slowly
over 3-5 mins.
Date of Rx:
February 25,2020 After:
Advise patient to
report signs of
superinfection
(vaginal itching or
discharge, loose or
foul-smelling stools)
and allergy reactions.

FM-CON-###-### Visayas State University - College of Nursing | Page | 14

 DRUG THERAPEUTIC RECORD # ______
Name Reason for Admission
Age Sex Medical Impression
SIDE EFFECTS/
MECHANISM OF CONTRA- NURSING
DRUG NAME DRUG CLASS INDICATIONS ADVERSE
ACTION INDICATIONS CONSIDERATION
EFFECTS
Generic: Therapeutic: Binds to mu-opioid Patient’s Hypersensitivity; CNS: seizures, Before:
Analgesics receptors. Inhibits Indications: cross-sensitivity with dizziness, Assess type, location,
Tramadol reuptake of serotonin For pain. opioids may occur; headache, and intensity of pain
and norepinephrine in patients who are somnolence, before and 2-3 hr
Brand: the CNS. acutely intoxicated anxiety, CNS after administration.
with alcohol, stimulation, Assess vital signs
Ultram Pharmacologic General: sedative/ hypnotics, confusion, and bowel function
none Moderate to centrally acting coordination routinely.
Complete moderately severe analgesics, opioid disturbance,
Prescription: pain. analgesics, or euphoria, malaise, During:
Tramadol 50mg IVTT psychotropic agents; nervousness, sleep Explain therapeutic
q8hrs patients who are disorder, weakness value of medication
physically EENT: visual before administration
dependent on opioid disturbances to enhance the
Date of Rx: analgesics. CV: vasodilation analgesic effect.
February 26,2020 GI: constipation,
nausea, flatulence, After:
Pregnancy vomiting Instruct patient on
Category: C Derm: pruritus, how and when to ask
sweating for pain medication.

FM-CON-###-### Visayas State University - College of Nursing | Page | 15

 DRUG THERAPEUTIC RECORD # ______
Name Reason for Admission
Age Sex Medical Impression
SIDE EFFECTS/
MECHANISM OF CONTRA- NURSING
DRUG NAME DRUG CLASS INDICATIONS ADVERSE
ACTION INDICATIONS CONSIDERATION
EFFECTS
Generic: Therapeutic: Patient’s Side Effects: Before:
Indications:

During:
Brand:

Pharmacologic General: Pregnancy Adverse After:

Category: Reactions:
Complete
Prescription:

Date of Rx:

FM-CON-###-### Visayas State University - College of Nursing | Page | 16

 DRUG THERAPEUTIC RECORD # ______
Name Reason for Admission
Age Sex Medical Impression
SIDE EFFECTS/
MECHANISM OF CONTRA- NURSING
DRUG NAME DRUG CLASS INDICATIONS ADVERSE
ACTION INDICATIONS CONSIDERATION
EFFECTS
Generic: Therapeutic: Patient’s Side Effects: Before:
Indications:

During:
Brand:

Pharmacologic General: Pregnancy Adverse After:

Category: Reactions:
Complete
Prescription:

Date of Rx:

VSU's Vision:  A globally competitive university for science, technology, and environmental conservation.
VSU's Mission:  Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.