KARDEX (TEAM B)

NAME: ___________________________________________________________________________________________ DEPARTMENT: ______________________________

AGE: __________ SEX: (M)___ (F) ____ CIVIL STATUS: ______________ OCCUPATION: ___________________________ RELIGION: _______________________________
ADMITTED ON: _______________________ AT _________ am/pm
ADMISSION NO. __________________
ROOM: __________________________________
TENTATIVE DIAGNOSIS: ___________________________________________________________________ ATTENDING PHYSICIAN: ________________________________
FINAL DIAGNOSIS: _____________________________________________________________________________________________________________________________
HEALTH HISTORY
PRESENT HEALTH HISTORY:
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
DOCTORS ORDERS:
Key:
( / ) carried out ( x ) not carried out
(
(
(
(
(
(

) __________________________________
) __________________________________
) __________________________________
) __________________________________
) __________________________________
) __________________________________

REFERRAL:
Key:
( / ) carried out ( x ) not carried out
(
(
(
(
(
(

) __________________________________
) __________________________________
) __________________________________
) __________________________________
) __________________________________
) __________________________________

LABORATORY/DIAGNOSTICS:
Key:
( / ) done, with result
( + ) done, without result
( x ) request made, not yet done

( ) Urinalysis
( ) Fecalysis
( ) Sputum 3x
( ) Hematology _________________
-------------------------------------( ) Blood Chemistry_____________
------------------------------------( ) Lipid Profile
( ) Blood Sugar
( ) X-ray
( ) ECG
( ) Ultrasound
( ) Thoracentesis
( ) Paracentesis
( ) Others: ____________________

NURSING INTERVENTIONS:
Key:
( / ) carried out
( x ) not carried out
(
(
(
(
(
(
(

) TSB
) Cold Compress
) Deep Breathing Exercises
) Suctioning
) Turn to side q 2 hr
) Bladder Training
) I & O monitoring

Range of Motion Exercises

( ) Passive ( ) Active
Enema
( ) Fleet ( ) Cleansing
Ultrasonic Nebulization
( ) Salbutamol ( ) NSS

PARENTERAL FLUIDS:
Amount Received: __________ mL
Amount Endorsed: __________ mL
Site: ( ) R ( ) L ________________
( ) Main Line ___________________
( ) Side Drip ____________________
( ) Others _______________________
Blood Transfusion:
( ) FWR __________________ units
( ) PRBC _________________ units
( ) Others ______________________
Clysis/ Drainage
( ) Peritoneal ( ) T- Tube
( ) Cystoclysis ( ) Penrose Drain
( ) Others _______________________

ACTIVITY:
Ambulatory from________________
to _________________________
( ) CBR
( ) CBR w/o BRP
( ) Others_______________________
_________________________________

DIET:
( ) DAT
( ) Soft ( ) Liquid
( ) Others_______________________
_________________________________

NEUROVITAL SIGNS:
A.Level of Consciousness
( ) Coherent
( ) Conscious
( ) Lethargic
( ) Stuporous
( ) Coma
( ) Obstunded
B.Orientation
( ) Time ( ) Place ( ) Person
C.Speech Language
( ) Clear
( ) Garbled
( ) Expressive ( ) Receptive
D.Abnormal Posturing
( ) Decorticate
( ) Decebrate
E.Pupillary Reactions
( ) BRTL ( ) SRTL ( ) NRTL
Size: R ______ L __________

MEDICATIONS:
Key:
( / ) Given
( x ) Not Given
(
(
(
(
(
(
(
(
(
(
(

F.Reflexes
( ) Babinski
( ) Gag
( ) Corneal
( ) DTR
G.Motor Function
( ) R ( ) L arm weakness
( ) R ( ) L leg weakness
H.Cranial Nerve Function
___________________________
I.Glasgow Coma Scale
________ Eye Opening
________ Verbal Response
________ Motor Response
________ TOTAL GCS SCORE

( P ) Prescribed

) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________
) ____________________________________________________________

TUBINGS:
Key:
( / ) Intact/Patent/Draining
( x ) Closed/Disconnected

( ) ET Tube
( ) Tracheostomy Tube
Attached to:
( ) Mechanical Ventilator
MV ______ TV _________ Ml
FIO2 ____% RR ________ cpm
SV _______________________

( ) Ambu Bag ( ) T-piece

O2 inhalation at _______ lpm
Via:
( ) Nasal Cannula
( ) Nasal Catheter
( ) Venturi Mask

SPECIAL PRECAUTION:
(
(
(
(

) Allergy _________________________________________
) No BP Taking
) No Blood Extraction
) Blood Precaution

NURSING CARE PLAN

DATE

CUES

NURSING
DIAGNOSIS

NURSING
OBJECTIVE

HEAD NURSE: _____________________________________________

NURSING INTERVENTION

RATIONALE

EXPECTED
OUTCOME/
EVALUATION

TEAM LEADER: ________________________________________

CLINICAL INSTRUCTOR: ________________________________
REMARKS: ______________________________________________________________________________________________________ DATE CHECKED:__________