Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES Agoo, La Union Embracing World Class Standards Tel. 072.682.0663/ichams.dmmmsu-sluc.com NURSING DEPARTMENT OPERATING ROOM WRITE UP Name: Patient’s Name: Address: Pre-op diagnosis: Post-op Diagnosis: Operation done: Date of operation: Time started: Time Ended: Surgeon: Scrub Nurse: History of the patient: Year/Section/Group: Age: Gender: Type of Anesthesia Anesthesiologist: Discussion of the disease/condition/pathophysiology: Discussion of the operation done: Instruments: (separate sheet) Name and Signature of the Clinical Instructor: Care to learn, Learn to care Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES Agoo, La Union Embracing World Class Standards Tel. 072.682.0663/ichams.dmmmsu-sluc.com NURSING DEPARTMENT Care to learn, Learn to care NURSING CARE PLAN ASSESSMENT EXPLANATION OF THE PROBLEM OBJECTIVE INTERVENTIONS RATIONALE EVALUATION Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES Agoo, La Union Tel. 072.682.0663/ichams.dmmmsu-sluc.com NURSING DEPARTMENT Embracing World Class Standards Care to learn, Learn to care FDAR CHARTING DATE/ TIME FOCUS Name of Clinical Instructor: Ward: Patient: DATA ACTION RESPONSE Signature: Shift: Age: Diagnosis: Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES Agoo, La Union Embracing World Class Standards Tel. 072.682.0663/ichams.dmmmsu-sluc.com NURSING DEPARTMENT Care to learn, Learn to care DRUG STUDY DRUG NAME (Generic Name, Brand Name, Dose, Route, Dosage) DRUG CLASSIFICATION MODE OF ACTION SIDE EFFECTS AND ADVERSE REACTIONS CONTRAINDICATION NURSING MANAGEMENT/ CONSIDERATION Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES Agoo, La Union Embracing World Class Standards Tel. 072.682.0663/ichams.dmmmsu-sluc.com NURSING DEPARTMENT Care to learn, Learn to care CASE PRESENTATION/ CASE STUDY Case Title: 1. Objectives/Goals 2. Introduction 3. Patient’s Demographic Data 4. History of the Present Illness 5. Past Health History 6. Family History 7. Social History 8. Genogram 9. Course of Confinement 10. Area 1 of the 13 Areas of Assessment 11. Area 2 of the 13 Areas of Assessment 12. Area 3 of the 13 Areas of Assessment 13. Area 4 of the 13 Areas of Assessment 14. Area 5 of the 13 Areas of Assessment 15. Area 6 of the 13 Areas of Assessment 16. Area 7 of the 13 Areas of Assessment 17. Area 8 of the 13 Areas of Assessment 18. Area 9 of the 13 Areas of Assessment 19. Area 10 of the 13 Areas of Assessment 20. Area 11 of the 13 Areas of Assessment 21. Area 12 of the 13 Areas of Assessment 22. Area 13 of the 13 Areas of Assessment 23. Laboratory Result Interpretation 24. List and Prioritization of nursing diagnoses 25. Anatomy and Physiology 26. Disease Entity and General Pathophysiology 27. Specific Pathophysiology 28. Assessment of NCP 29. Explanation of the Problem of the NCP 30. Nursing Outcomes/Objectives of the NCP 31. Nursing Interventions of the NCP 32. Rationale of the NCP 33. Evaluation of the NCP 34. Drug Study 35. References Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES Agoo, La Union Embracing World Class Standards Tel. 072.682.0663/ichams.dmmmsu-sluc.com NURSING DEPARTMENT Care to learn, Learn to care
