You are on page 1of 1

LEVEL III CLINICAL ROTATION

NURSING CARE GUIDE


Name of STUDENT: MACABONTOC, LAVENIA P. Section/Group: A-4
Date: APRIL , 2017 Institution: BGHMC Area: MEDICAL WARD 5

Patients Name: ________________________________________ Age:_____ Gender: _____ Room#: _______


Doctors : _________________________________________________________________________________
Diagnosis : _____________________________________________ Activity restriction: ___________________
Chief complaint: _____________________________________________ Diet: _______________________________
Brief History:
Present Illness : ___________________________________________________________________________
Past Med/Sur : ___________________________________________________________________________
Family : ___________________________________________________________________________
OB-Gyne : ___________________________________________________________________________
Personal/Social : ___________________________________________________________________________
Care Concerns/Nursing Diagnosis: ___________________________________________________________________

8 hrs shift Expected Actual Medications Frequency Medications Frequency

IV Main Line 1st hour


IV Side drip 2nd hour
IV Level 3rd hour
received
IV regulation 4th hour Treatment
IV to consume 5th hour
in 8hr
IV level to 6th hour Relevant laboratory Results
endorse data
Others: 7th hour
8th hour
Intake: Output: Others:

Contraptions

Special
Endorsement

Nursing PLAN: Nursing PLAN: Nursing Learning


Diagnosis/Focus Interventions Interventions

Short term goal: Caring experience

Evaluation

Recommendation Errors: