I.

DEMOGRAPHIC PROFILE
M. I.
A. Name:
(Last) (Given)
Lot 38 One
(Unit/Lot No.) (Bldg. No.) (Street)
B. Address
Brgy San Jose Calamba City
(Barangay) (Municipality)
C. Date of Birth NOVEMBER 9 1936 D. Age 84 E. Sex FEMALE
H. Mobile No. 0905 760 2372 I. Landline: (02) 949-3342
Right brain stroke
Chief Complaint:

Contact in case of emergency

K. Name: R.C.M. L. Mobile/ Landline No.
Lot 38 One
(Unit/Lot No.) (Bldg. No.) (Street)
M.Address
Brgy. San Jose Calamba City
(Barangay) (Municipality)
Medical History Physical Assessment Gordon's Assessment Vital Signs MAR
II III IV V VI
 insert patient photo here

PHIC PROFILE
. S. --
ven) (Middle) (Prefix)
One Jenel Subdivision
(Street) (Subdivision)
Laguna Philippines 1400
(Province) (Country) (Postal Code)

F. Religion Roman Catholic G. Marital Status MARRIED

02) 949-3342 J. e-mail address: abelmori@yahoo.com

se of emergency
obile/ Landline No. 0927 916 3489
One Jenel Subdivision
(Street) (Subdivision)
Laguna Philippines 1400
(Province) (Country) (Postal Code)
MAR Laboratory Tests Interventions Nurse's Notes
VI VII VIII IX
 M. I.
Name:
(Last) (Given)
II. MEDICAL HISTORY RECORD
A. Do you have problems with any of these systems? If yes please check box.
Gastrointestinal Systrem ✘
Nervous System Integumentary System
✘
Respiratory System ✘
Musculoskeletal System Blood
Cardiovascular System Endocrine Sytem Skin
Genitourinary System
B. Are you in good health? Yes ✘ No
C. Any allergic reactions to food, medications or other substances? Yes ✘ No
D. Do you have family history of any of the following? Please check.
✘
Hypertension ✘
Cancer ✘
Congenital Heart Disease
Macular Degeneration Sickle Cell Anemia Cataract
✘
Diabetes Glaucoma Kidney Disease
E. Are you experiencing any of the following?
Smell disorder Hearing Problem ✘
Difficulty in breathing
Taste disorder Difficulty in swallowing Loss appetite
✘
Eye problem
F. Have you undergone surgery? ✘
Yes No
Embolectomy - March 2020

If yes, please specify and include the year.

G. Immunization Record
Vaccine Date Vaccine
Demographic Profile Physical Assessment Gordon's Assessment Vital Signs MAR
I III IV V VI
 insert patient photo here

S. --
(Middle) (Prefix)
CORD

Mental
Endocrine
Blood/ Lymph

if yes, please list

Congenital Heart Disease Osteoporosis

Cystic Fibrosis
Kidney Disease Others, specify.

Vaccine Date
Laboratory Tests Interventions Nurse's Notes
VII VIII IX
 M. I.
A. Name:
(Last) (Given)
III. PHYSICAL ASSESMENT
A. Level of Conscious ✘
Alert Drowsy Lethargic ✘

B. Orientation
Is able to state her name.
Person

The client can recognize that she is at home receiving bedridden care.
Place

At times she is not aware of the year and time because of shifting moods
Time

At times she is experiences sudden disorientation about the current event due to mentioning questions
Situation occurred in the past as stated by her relatives.

C. General Assessment Weight: 64.3 kg Height: 1.65 m

D. Pain Assessment
The patient cannot be understandable at time because lack of association in thoughts and due to the soft and slow pace of sp
Character distress expression she demonstrates when experiencing the pain and applies immediate massage on her left arm to relieve i

The pain started when 3 months ago when the patient started receiving physical therapy sessions.
Onset

It spreads longitudinally in the left arm only.

Location

It lasts about an hour until massage is applied and hot pressure pack is administered for relief. Sometimes the pain occurs the
Duration

On the scale of 10 being the worst pain and 1 being the least pain, the client chose 6 out of 10.
Severity

After every physical therapy session and at times the day after.
Pattern

The client expresses bothersome and distress when experiencing the pain.
Associated Factors

Pain Intensity 2
E. Skin Assessment
Skin Turgor ✘
Normal Delayed
Skin Color Pink ✘
Light to deep Brown
Skin Temperature Hot ✘
Warm : Uniformed
✘
 ✘

Capillary Refill ✘
Normal Delayed
Lesion: Yes, Location: ✘

Bruising: Yes, Location: ✘

Edema: Yes, Location: ✘

F. Hair G. Nails
Evenly Distributed? ✘
Yes None
Infestation? Yes ✘
None
Scalp Lesion Yes ✘
None
Infection? Yes ✘
None
G. Eyes Size: Remarks: Redness on the palpebral conjunctiva H
a . Ears
Equal? ✘
Yes No
Round? ✘
Yes No
Reactive to Light? ✘
Yes No
✘
Accomodation? Yes No
I. Mouth
Dentures Yes ✘

Lesions Yes ✘

Redness Yes ✘

Sore Throat Yes ✘

Pink and Moist Appearance ✘

Yes
Foul Odor ✘
Yes
J. Neck Remarks: enlarged neck mass at the left side due to joint and bone immobility, and frequ
Veins ✘
Flat Distended Mass ✘

K. Heart Assessment L. Lungs

Aortic Normal Breath Sound ✘

Pulmonic Normal Clear Bilaterally ✘

Erb's Point Normal Air Flow

Tricuspid Normal
Mitral Normal
M. Abdomen Stomach Soft
Tender? Yes, part: ✘
None
Bowel Sounds RUQ: RLQ: LUQ:
N. Muscle, Joints, and Bones
Muscle Size: Equal ✘
Unequal, remarks: Atropy on the left side
Contractures: None ✘
Yes, remarks: Left arm involuntarily goes to her chest, le
Tremors ✘
None Yes, remarks:
Muscle Tonicity
Tenderness in Bones None Yes, remarks:
Joint Swelling None ✘
Yes, remarks: Presence of crepitations
 ✘

Joint Range
Demographic Profile Medical History Gordon's Assessment Vital Signs MAR
I II IV V VI
 insert patient photo here

I. S. --
ven) (Middle) (Prefix)
L ASSESMENT
✘
Conscious Coma

n care.

ng moods

rent event due to mentioning questions or statements that are in the present tense but

BMI: 23.62

hts and due to the soft and slow pace of speech. The pain can be only characterized by the
ediate massage on her left arm to relieve it.

erapy sessions.

d for relief. Sometimes the pain occurs the next day after the session.

6 out of 10.

Pale Jaundice Cyanotic

Cold
 ✘
None
✘
None
✘
None
Remarks: broken nail on index finger of the right hand
Shape: Clubbing Spoon Nail
Nail Color: ✘
Pink Tones Cyanotic/Pale

Remarks:
Tenderness: Yes ✘
None
Discharge Yes ✘
None
Able to hear on both ears ✘
Yes None

✘
None
✘
None
✘
None
✘
None
None
None
to joint and bone immobility, and frequency of right position of neck
✘
Yes None

✘
Normal Abnormal, type:
✘
Yes No, side:
Yes

LLQ:

Atropy on the left side Muscle Movement:

Left arm involuntarily goes to her chest, left leg involuntarily folds inwa
Muscle Strength
Equal Strength
✘
Less Muscle Strength
Presence of crepitations Remarks:
 upper and lower left side of body at 25%
MAR Laboratory Tests Interventions Nurse's Notes
VI VII VIII IX
 M. I.
A. Name:
(Last) (Given)
IV. GORDON'S HEALTH ASSESSMENT
A. Health Perception - Health Management Pattern
The patient’s husband reported that before the patient became bedridden, she takes care of her health through self-medicati
to hospitals often unless she feels extremely sick. Although her husband always pushes her to go on regular check-ups, she is s
healthy and is capable of taking care of her own health. This is probably because she does not get sick often and, when she do
fallen into being bedridden, she is not capable of taking care of herself since then and is dependent of her nurses and caregive

B. Cognitive and Perceptual Pattern

The patient wears eyeglasses when she was still not bedridden as she is near sighted. She also has difficulty in hearing, but not
to help her. It is unknown if her sense of taste has changed but she eats normally and, when asked, she says that the food is g
would laugh with her nurses and would suddenly be withdrawn and agitated. Her thoughts are sometimes disorganized, she c
relatives, are unknown to them. She also calls her husband sir and captain sometimes, which was their formality when they w
sometimes understandable but often times it’s not.

C. Self Perception - Self Conception Pattern

This area is not assessed comprehensively as the patient is unable to formulate and deliver thoughts. However, the patient, on
and coats and likes to put on make-up.

D. Role - Relationship Pattern

The patient is a middle child out of three children. Her parents died early, and they were raised by a rich family. However, she
her studies growing up. She does not have a lot of friends because she does not go out often, however she is close with their y
worked as a nurse in Germany, where she met her husband, her first and last boyfriend, and they lived in the Philippines since
only have her husband and their household helper for 13 years as company.

E. Sexuality - Reproductive Pattern

The client is already menopausal. She did not bear a child, but the reasons are unknown and are unanswered by the relatives.
experienced by the patient regarding her reproductive system.
F. Coping - Stress Tolerance Pattern
Before being bedridden, their household helper reported that the patient stresses over mess and dirt. She wants to keep eve
cleans the house thoroughly every morning. She is also particular with money and does a lot of things to save, so she often kee
present, her stressors are unknown but she often seem agitated when she can’t sleep or when she cant move her left arm, be
while frowning.

G. Values - Belief Pattern

The religion of the client is Roman Catholic. The household keeper reported that the client seldom go to church, and she hasn
moved in with them, there are also no religious statues in their house.

H. Nutritional - Metabolic Pattern

The client eats three to four times a day, depending on her mood since she sometimes refused to. She was on NGT tube, but
already. However, she’s only allowed to eat soft foods according to the doctor. Mostly, she eats oatmeal, sopas, lugaw, soft ric
bread or biscuit dipped in milk or yogurt ice cream. Her estimated fluid intake per day is 850 to 1,110 mL, including milk and w
drinking water.

I. Elimination Pattern
The client urinates three to four times a day, depending on her fluid intake. It is yellowish and sometimes has a strong odor. S
ordered lactulose every two days of no bowel elimination to help her since she is also not allowed to struggle in defecation of
on airconditioned room.

J. Activity and Exercise Pattern

The client has a physical therapist that comes every Monday, Wednesday, and Friday. Aside from these, daily exercises are ini
afternoon when the patient is on the mood. She is also transferred to a chair and is faced to the garden, or is transferred to a w
once a day. She’s bathed and changed clothes in the afternoon and is assisted in vocalization by the care providers.

K. Sleep and Rest Pattern

The client often encounters difficulty in sleeping so she was prescribed ¼ Rivotril to help her. This is given when she is still wid
9pm. She often wakes up at 10AM to 11AM, and often takes a nap at 2PM to 4PM. Based on observation, it helps the patient s
her head is being massaged.

Demographic Profile Medical History Physical Assessment Vital Signs MAR

I II III V VI
 insert patient photo here

S. --
(Middle) (Prefix)
ESSMENT

alth through self-medication and traditional interventions. She also does not go
regular check-ups, she is strongly against it because she believes that she is
ck often and, when she does, she recovers from it quickly. However, as she has
of her nurses and caregivers.

ifficulty in hearing, but not as bad as needing a hearing aid or any interventions
she says that the food is good or is delicious. Her mood changes quickly, she
etimes disorganized, she calls out names that, when asked to her husband and
eir formality when they were still getting to know each other. She talks often,

s. However, the patient, on her previous years, likes to collect fashionable shoes

rich family. However, she did not grow close to them and was only focused on
ver she is close with their youngest, who she spends most of the time with. She
ved in the Philippines since marriage. As of before being bedridden, the patient

answered by the relatives. Aside from these, there were no problems ever
dirt. She wants to keep everything in order and clean, so even the patient herself
gs to save, so she often keeps track of expenses and budgets their money. At
cant move her left arm, because she holds it with her right arm and tries to lift it

go to church, and she hasn’t seen her doing the rosary nor praying since she

She was on NGT tube, but it was removed last month since the patient can eat
meal, sopas, lugaw, soft rice and soup, and the likes. For snacks, she often eats
0 mL, including milk and water. It is a little low because she refuses often on

times has a strong odor. She does not defecate regularly, so the physician
o struggle in defecation of “pag-ire”. She also does not sweat easily and is often

ese, daily exercises are initiated by her caregivers and nurses every morning or
den, or is transferred to a wheelchair and is roamed around the house at least
care providers.

given when she is still wide awake or is agitated due to difficulty in sleeping at
ation, it helps the patient sleep when only a small night lamp is open and when

Laboratory Tests Interventions Nurse's Notes

VII VIII IX
 M. I.
A. Name:
(Last) (Given)
V. Vital Signs
Date: OCTOBER 10 2020
Time: 12am 4am 8am 12pm
Temperature 36.3000000000001 36.1000000000001 35.9000000000001 35.9000000000001
Blood Pressure 100 /60 100 /60 100 /60 100
Pulse Rate 81 83 74 78
Oxygen Saturation 95 96 95 97
Respiratory Rate 19 20 18 19
Date: OCTOBER 11 2020
Time: 12am 4am 8am 12pm
Temperature 36.0000000000001 35.9000000000001 36.0000000000001 35.4000000000001
Blood Pressure 90 /60 90 /60 120 /60 100
Pulse Rate 72 69 80 75
Oxygen Saturation 94 95 92 97
Respiratory Rate 19 18 20 21
Date: OCTOBER 12 2020
Time: 12am 4am 8am 12pm
Temperature 36.2000000000001 35.4000000000001 35.8000000000001 35.7000000000001
Blood Pressure 110 /70 110 /60 100 /70 110
Pulse Rate 71 76 86 73
Oxygen Saturation 95 95 95 96
Respiratory Rate 19 20 20 20
Date:
Time:
Temperature
Blood Pressure
Pulse Rate
Oxygen Saturation
Respiratory Rate
Date:
Time:
Temperature
 Blood Pressure
Pulse Rate
Oxygen Saturation
Respiratory Rate
Date:
Time:
Temperature
Blood Pressure
Pulse Rate
Oxygen Saturation
Respiratory Rate
Date:
Time:
Temperature
Blood Pressure
Pulse Rate
Oxygen Saturation
Respiratory Rate
Date:
Time:
Temperature
Blood Pressure
Pulse Rate
Oxygen Saturation
Respiratory Rate
Date:
Time:
Temperature
Blood Pressure
Pulse Rate
Oxygen Saturation
Respiratory Rate
Date:
Time:
Temperature
Blood Pressure
Pulse Rate
Oxygen Saturation
Respiratory Rate
Date:
 Time:
Temperature
Blood Pressure
Pulse Rate
Oxygen Saturation
Respiratory Rate
Demographic Profile Medical History Physical Assessment Gordon's Assessment MAR
I II III IV VI
 insert patient photo here

. S. --
ven) (Middle) (Prefix)
al Signs

12pm 4pm 8pm

35.9000000000001 35.4000000000001 35.4000000000001 °C
/60 100 /60 100 /60 mmHg
78 85 77 bpm
97 95 95 %
19 20 19 bpm

12pm 4pm 8pm

35.4000000000001 36.2000000000001 35.6000000000001 °C
/60 110 /60 100 /60 mmHg
75 82 73 bpm
97 94 93 %
21 20 21 bpm

12pm 4pm 8pm

35.7000000000001 35.9000000000001 35.5000000000001 °C
/70 110 /70 100 /60 mmHg
73 72 82 bpm
96 95 97 %
20 19 19 bpm

°C
mmHg
bpm
%
bpm

°C
mmHg
bpm
%
bpm

°C
mmHg
bpm
%
bpm

°C
mmHg
bpm
%
bpm

°C
mmHg
bpm
%
bpm

°C
mmHg
bpm
%
bpm

°C
mmHg
bpm
%
bpm
 °C
mmHg
bpm
%
bpm
MAR Laboratory Tests Interventions Nurse's Notes
VI VII VIII IX
 M. I.
A. Name:
(Last) (Given)
VI. MEDICATION ADMINISTRATION RECORD
Date Date
OCT 10 2020 OCT
Medication Freq Time ADM Time
Citicholine (Zynapse) 1ml PO 10:00 AM Given 10:00 AM
6:00 PM Given 6:00 PM
BID

Carvedilol (Dilatrend) 6.25 mg PO 10:00 AM Given 10:00 AM

6:00 PM Given 6:00 PM
BID

Rivoraxaban (Xarelto) 10 mg 10:00 AM Discontinued 10:00 AM

OD

Mosegor Vita 1 cap PO 6:00 PM Given 6:00 PM

OD

Ritvotril 1/4 tab (For inability to sleep) 4:00 PM Not Given 4:00 PM

PRN

Dolcet 1 tab (for pain)

PRN

Ensure Gold 1 scoop in 50 ml water 4:00 AM Given 4:00 AM

10:00 AM Given 10:00 AM
QID
4:00 PM Given 4:00 PM
10:00 PM Given 10:00 PM
Lactulose (If PT has no BM for 2 days)

PRN
Lactulose (If PT has no BM for 2 days)

PRN

Demographic Profile Medical History Physical Assessment Gordon's Assessment Vital Signs
I II III IV V
 insert patient photo here

. S. --
ven) (Middle) (Prefix)
MINISTRATION RECORD
Date Date
11 2020 OCT 12 2020
Time ADM Time ADM
10:00 AM Given 10:00 AM Given

6:00 PM Given 6:00 PM Given

10:00 AM Given 10:00 AM Given

6:00 PM Given 6:00 PM Given

10:00 AM Discontinued 10:00 AM Discontinued

6:00 PM Given 6:00 PM Given

4:00 PM Not Given 4:00 PM Not Given

4:00 AM Given 4:00 AM Given

10:00 AM Given 10:00 AM Given

4:00 PM Given 4:00 PM Given

10:00 PM Given 10:00 PM Given

Vital Signs Laboratory Tests Interventions Nurse's Notes
V VII VIII IX
 M. I.
A. Name:
(Last) (Given)
VII. LABORATORY TESTS AND RESULTS
Laboratory Procedure Interpretation

Hematology (Clinical Blood Chemistry)

Ordered by:
Dr. Shepherd
Date: OCTOBER 10 2020
Time: 10 :30 PM

ABNORMAL

Clinical Microscopy (Urinalysis)

Ordered by:
Dr. Sloan
Date: OCTOBER 11 2020
Time: 10 :30 AM

ABNORMAL

X-RAY (Chest)
 X-RAY (Chest)

Ordered by:
Dr. Grey
Date: OCTOBER 12 2020
Time: 12 :00 PM

ABNORMAL

Ordered by:

Date:
Time:

Ordered by:

Date:
Time:
 Ordered by:

Date:
Time:

Ordered by:

Date:
Time:

Ordered by:

Date:
Time:
 Ordered by:

Date:
Time:

Demographic Profile Medical History Physical Assessment Gordon's Assessment Vital Signs
I II III IV V
 insert patient photo here

. S. --
ven) (Middle) (Prefix)
TESTS AND RESULTS
Results
Fasting Blood Sugar - 86 mg/dL (74-106 mg/dL)
Blood Urea Nitrogen (BUN) - 16 mg/dL (7-20 mg/dL)
Creatinine - 0.9 mg/dL (0.5-1.0 mg/dL)
Total Cholesterol - 185 mg/dL (<200 mg/dL)
Triclycerides - 403 mg/dL (<150 mg/dL)
HDL - 35 mg/dL (40-60 mg/dL)
LDL - 69 mg/dL (<130 mg/dL)
Blood Uric Acid (BUA) - 6.7 mg/dL (<2.5-6.2 mg/dL)

SGOT (AST)
25 U/L (1-59 U/L)

Color - Yellow Epithelial Cells - FEW

Transparency - Turbid Mucus Thread - Occasional
Urine Chemical pH - 0.6 (5.0-7.0) Amrphous Urates/Phosphates - RARE
Specific Gravity - 1.010 (1.005-1.030) Bacteria - MANY
Protein - 1+ (NEGATIVE)
Glucose - Negative (NEGATIVE)
Bilirubin - Negative (NEGATIVE)
Blood (ERY/HGB) - Negative (NEGATIVE)
Leukocytes - 3+ (NEGATIVE)
Nitrite - Negative (NEGATIVE)
Urobilinogen - Normal (NORMAL)
Ketone - Negative (NEGATIVE)
Pus Cell - TNTC/HPF (0-3/HPF)
Red Blood Cell - 8-10/HPF (0-3/HPF)
Shadow on the left Lung

Infiltrates around Lungs

Vital Signs MAR Interventions Nurse's Notes
V VI VIII IX
 M. I.
A. Name:
(Last) (Given)
VIII. INTERVENTION
Interventions Time and Date RN Name
Date: OCT 10 2020
Checked patient’s blood sugar level JM
Time: 7 :00 AM
Date: OCT 10 2020
Fed the patient (one bowl of oatmeal) JM
Time: 7 :15 AM
Date: OCT 10 2020
Checked Vital Signs of the pt JM
Time: 8 :00 AM
Date: OCT 10 2020
Administered Medications to the pt JM
Time: 10 :00 AM
Fed the Patient (One bowl of soft food; sopas) Date: OCT 10 2020
JM
Time: 11 :45 AM
Date: OCT 10 2020
Checked Vital Signs of the pt JM
Time: 12 :00 PM
Date: OCT 10 2020
Assisted Patient to Physical Exercise and Vocalization JM
Time: 2 :00 PM
Date: OCT 10 2020
Administered Medications to the pt JM
Time: 4 :00 PM
Date: OCT 10 2020
Gave 120ml of warm milk to the patient LL
Time: 9 :30 PM
Date: OCT 11 2020
Checked patient’s blood sugar level LL
Time: 7 :00 AM
Date: OCT 11 2020
Fed the patient (one bowl of oatmeal) LL
Time: 7 :15 AM
Date: OCT 11 2020
Checked Vital Signs of the pt LL
Time: 8 :00 AM
Date: OCT 11 2020
Administered Medications to the pt LL
Time: 10 :00 AM
Date: OCT 11 2020
Fed the patient (One bow of soft food; nido soup) LL
Time: 11 :45 AM
Date: OCT 11 2020
Administered Medications to the pt JJ
Time: 4 :00 PM
 Date: OCT 11 2020
Checked Vital Signs of the pt JJ
Time: 4 :00 PM
Date: OCT 11 2020
Assisted to the patient’s Physical Therapy JJ
Time: 5 :30 PM
Date: OCT 11 2020
Administered Dolcet and gave hot compress to the patient JJ
Time: 7 :00 PM
Date: OCT 11 2020
Checked Vital Signs of the pt JJ
Time: 8 :00 PM
Date: OCT 11 2020
Gave 120ml of warm milk to the patient JJ
Time: 9 :30 PM
Date: OCT 12 2020
Checked patient’s blood sugar level AN
Time: 7 :00 AM
Date: OCT 12 2020
Fed the patient (one bowl of oatmeal) AN
Time: 7 :15 AM
Date: OCT 12 2020
Administered Medications to the pt AN
Time: 10 :00 AM
Date: OCT 12 2020
Changed the bed linens of the pt AN
Time: 10 :30 AM
Date: OCT 12 2020
Oral Care, Sponge bath, and change of clothes AN
Time: 11 :00 AM
Date: OCT 12 2020
Fed the patient (One bow of soft food; lugaw) AN
Time: 11 :45 AM
Date: OCT 12 2020
Checked Vital Signs of the pt KP
Time: 12 :00 PM
Date: OCT 12 2020
Assisted Patient to Physical Exercise and Vocalization KP
Time: 2 :00 PM
Date: OCT 12 2020
Administered Medications to the pt KP
Time: 4 :00 PM
Date: OCT 12 2020
Checked Vital Signs of the pt KP
Time: 4 :00 PM
Date: OCT 12 2020
Checked Vital Signs of the pt KP
Time: 8 :00 PM
Date: OCT 12 2020
Gave 120ml of warm milk to the patient KP
Time: 9 :30 PM
Date: OCT 12 2020
Assisted the patient to sleep JO
Time: 10 :00 PM
Date: OCT 12 2020
Administered ¼ of Rivotril since the pt cannot sleep JO
Time: 11 :15 PM
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
 Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Date:
Time:
Demographic Profile Medical History Physical Assessment Gordon's Assessment Vital Signs
I II III IV V
 insert patient photo here

. S. --
ven) (Middle) (Prefix)
ERVENTION
RN Name Purpose
JM To monitor the blood sugar of the patient

JM To make sure that the patient has eaten before administering the medications

JM To monitor and maintain normal range of vital signs

JM Maintenance for the illness of the patient

JM To make sure that the patient has eaten before administering the medications

JM To monitor and maintain normal range of vital signs

JM To help improve muscle strength and for blood circulation

JM Maintenance for the illness of the patient

LL To help the patient induce sleep

LL To monitor the blood sugar of the patient

LL To make sure that the patient has eaten before administering the medications

LL To monitor and maintain normal range of vital signs

LL Maintenance for the illness of the patient

LL To make sure that the patient has eaten before administering the medicat

JJ Maintenance for the illness of the patient

JJ To monitor and maintain normal range of vital signs

JJ To help improve muscle strength

JJ To help reduce pain of the patient due to physical therapy

JJ To monitor and maintain normal range of vital signs

JJ To help the patient induce sleep

AN To monitor the blood sugar of the patient

AN To make sure that the patient has eaten before administering the medicat

AN Maintenance for the illness of the patient

AN To have clean surroundings and environment

AN To maintain proper hygiene of the patient

AN To make sure that the patient has eaten before administering the medications

KP To monitor and maintain normal range of vital signs

KP To help improve muscle strength and for blood circulation

KP Maintenance for the illness of the patient

KP To monitor and maintain normal range of vital signs

KP To monitor and maintain normal range of vital signs

KP To help the patient induce sleep

JO For the patient to have rest and relax

JO To help the patient induce sleep

Vital Signs MAR Laboratory Tests Nurse's Notes
V VI VII IX
 M.
A. Name:
(Last) (G
VIII. INTERVENT
Date Time Focus
10/1/2020 Self-care deficit
r/t impaired physical mobility and alteration in
cognitive thinking

10/11/2020 7 : 15 AM
11 : 45 AM
10 : 00 AM
2 : 00 PM
10/11/2020 7 : 15 AM
11 : 45 AM
10/12/2020 7 : 15 AM
10 : 30 AM
11 : 00 AM
11 : 45 AM
10 : 00 PM
Demographic Profile Medical History Physical Assessment Gordon's Assessment
I II III IV
 insert patient photo here

I. S.
(Given) (Middle)
VIII. INTERVENTION
D (Data) A (Action) R (Responses)
D - The client has been in a bedridden condition for 8 months since February in the year 2020.
She has impaired ability to access bathroom, wash or dry body, reach toilet & sit/ rise from toilet,
choose & gather clothing, put clothing on upper & lower body, put/ remove items such as socks on clothing,
prepare food, handle utensils & get food on it, bring food to mouth, pick up cup & open containers

A - Fed the patient (one bowl of oatmeal)

Fed the patient (One bow of soft food; sopas)
Assist Administered Medications to the pt
Assisted Patient to Physical Exercise and Vocalization
Fed the patient (one bowl of oatmeal)
Fed the patient (One bowl of soft food; nido soup)
Fed the patient (one bowl of oatmeal)
Changed the bed linens of the pt
Oral Care, Sponge bath, and change of clothes
Fed the patient (One bowl of soft food; lugaw)
Assisted the patient to sleep in a semi-fowler's position

R - The client demonstrate her individual areas of needs to the healthcare practices performed.
Performed self-care activities such as fixing her clothes upon wearing, and tried handling utensils onto mouth.
Facilitates on the health routine by exhibiting visual cues of adhering to the self-care at her level of own ability
There is reduced risks of injury or fall upon assisting the client.
Gordon's Assessment Vital Signs MAR Laboratory Tests Interventions
IV V VI VII VIII
 atient photo here

--
(Prefix)

ear 2020.
rom toilet,
cks on clothing,
containers

rformed.
nsils onto mouth.
vel of own ability
Interventions
VIII