ANNEX B

ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

VICTORIANO LUNA MEDICAL CENTER
Camp Colonel Victoriano K Luna, V Luna Avenue, Quezon City

NURSING SYSTEMS FLOW SHEET

INSTRUCTION: Enter information/ findings as elicited from patient. Indicate with a ( √ ) mark on the tick boxes if it applies. Write “NA”
if item does not apply
Rank/Name: ___________________________________ Age: _______ Date: __________________
Time of Arrival: ________ Medication/s Presently Taken: _________________________________________________
Department/ Service: ( ) Surgery ( ) Orthopedic ( ) Medicine ( ) Pediatric ( ) ENT ( ) OB-GYN
Triage: ( ) RED ( ) WHITE ( ) BLUE ( ) BLACK
Mode of Admission: ( ) Ambulatory ( ) Wheelchair ( ) Semi ambulatory ( ) Stretcher ( ) Cuddled ( ) Ambulance
Condition on ( )ambulatory ( )Semi ambulatory ( )alert ( )semiconscious ( )calm ( ) depressed
admission ( )chair ridden ( )bedridden ( )confused ( )unconscious ( )nervous ( )fearful ( )angry
Chief Complaint/s /Duration _____________________ Pain Assessment Pain Scale: _____/10 Location:
______________
Initial Vital Signs: BP______ CR ____ PR_____ RR _____ T _____ O2 Sat. (%) ______ Wt ______Kg Ht _______In
Allergy/ies: _____________________________________ ( ) None Known
Initial System Assessment TICK (/) APPROPRIATE FINDING
NEUROLOGIC Assess motor functions, sensation, LOC, strength, grip, gait, coordination, orientation, MEDICAL EQUIPMENT/ DEVICES:
speech, vision, ( ) No Problem ( ) None
Weakness Numbness Headache Paralysis Stuporous Pupils ( ) Oxygen delivery System
Unsteady Tingling Seizures Lethargic Comatose Speech ___________________________
Vertigo Pain Tremors Confused Vision Grip ( ) Endotracheal/ Tracheostomy Tube
Explain: _____________________________________________________________________________ to Mechanical Ventilator/ T-piece
settings:
ENT - Assess eyes, ears, nose, throat for abnormality ( ) No Problem Mode: ( ) AC ( ) SIMV
Impaired Blind Pain Reddened Drainage gums TV _____ RR _____ FiO2 _____
vision PEEP _______ cmH2O
Hard hearing Deaf Burning Edema Lesion Teeth ( ) Feeding Tube, specify ______
Explain: ______________________________________________________________________________ ( ) Intravenous line, specify
PULMONARY - Assess chest configuration, resp rate, rhythm, depth, pattern, breath sound, comfort ___________________________
( ) No Problem ___________________________
Asymmetria Tachypnea Apnea Rales Cough Absent ( ) Indwelling catheter _________
Barrel Chest Bradypnea Shallow Rhonchi Sputum Diminished ___________________________
Dyspnea Orthopnea Labored Wheezing Pain Cyanotic
Explain: _____________________________________________________________________________ ( ) Others __________________
CARDIOVASCULAR Assess heart sounds, rate, rhythm, pulse, blood pressure, circulation, fluid retention, ___________________________
comfort ( ) No Problem ___________________________
Arrhythmia Tachycardia Rub Numbness Diminished Edema
Pulse Is the patient at risk for fall?
Barrel Bradypnea Shallow Rhonchi Sputum Diminished ( ) No ( ) Yes activate Fall Risk
chest Assessment Form
Explain: _____________________________________________________________________________ Does the patient show any signs of
GASTROINTESTINAL Assess weight, abdomen, bowel habits, swallowing, bowel sounds, comfort suspect abuse/ neglect or
( ) No Problem mistreatment? ( ) No
Weight N& Anorexia Diarrhea Distention Hypoactive Mass ( ) Yes, specify type and description of
loss V BS signs
Obese Thirst Dysphagia Constipation Rigidity Hyperactive Pain
BS If Yes, please inform the Attending
Explain: ______________________________________________________________________________ Physician for Management/ referral
GENITOURINARY & GYNE Assess frequency, control, color, consistency, odor, comfort/gyn-bleeding, ___________________________
discharge, pregnancy, ( ) No Problem ___________________________
Pain Hesitancy Oliguria Dysuria Urine Vaginal ___________________________
Color Color Input and Output
Frequency Incontinence Nocturia Hematuria Discharge Pregnancy Intake
Explain: _____________________________________________________________________________ Oral IV Misc Total
MUSCULO-SKELETAL Assess mobility, motion, gait, alignment, joint function, skin color, texture, integrity
MOBILITY ( ) No Problem
Appliance Stiffness Itching Petechiae Hot Drainage
Prosthesis Swelling Lesion Poor Turgor Cool Total
Deformity Wound Rash Skin Color Flushed
Atrophy Pain Ecchymosis Diaphoretic Moist Output
Urine Stool Misc Total
Explain:

Total

RN Printed Name and Signature___________________________

AFPMC – SOP/NSD-NDM-P-011 F01 2/2016 p 1 of 2

 ANNEX B
ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND
VICTORIANO LUNA MEDICAL CENTER
Camp Colonel Victoriano K Luna, V Luna Avenue, Quezon City

MEDICATION/S TIME SIGN DIAGNOSTICS TIME RESULTS RELAYED TO

TIME TREATMENT

NURSES NOTES
Date/ FOCUS D – DATA; A – ACTION; R - RESPONSE
Time
TIME BP PR RR TEMP O2SAT

AFPMC – SOP/NSD-NDM-P-011 F01 2/2016 p 2 of 2