This document appears to be lecture notes for nursing students on clinical pharmacology. It covers topics like collecting a patient's bio-demographic information and medical history, assessing vital signs and performing a physical examination, documenting current medical problems and lab investigations, reviewing the patient's current medications and identifying any potential drug-related issues. The notes provide examples and details on documenting each of these aspects of a patient assessment.

1. 5 January 2016 1
By:
Seragaldin M. Abdulqader
Clinical pharmacology for nurses
University of Raparin/school of nursing
The lecture for undergraduate students:
2015 -2016

2. Bio-demography:
Personal information from the client, e.g.:
 Patient's full name:
 Sex: Age:
 Residential area: Occupation:
 Hospital: Ward/Unit:
 Level of education:
 Date of admission: Date of interview:
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3. Chief Complaint:
Subjective date Objective date Duration
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Headache Hypertension 5 days
The main problem that made patient to come to you.
•Subjective date: The data that the patient will tell you.
•Objective data: The data that you will get it from the
patient via the examinations. For example:

4. Medical History:
 Medical Diagnosis:
 Past Medical History (PMH):
 Past Surgical History (PSH):
 Smoking History:
 Drug allergy:
 Social History (SH):
 Diet:
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5. Vital signs:
 Blood pressure:
000
000
mm Hg.
 Radial pulse: bpm.
 Apical pulse: beat per minute (bpm).
 Respiration Rate: breath per minute (Bpm).
 Body temperature: 00.0oC. (By axillary + 0.5oC)
(By rectally – 0.5 oC).
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6. Vital signs:
Pain:
oDegree of the pain:
oLocation of the pain:
oDuration of the pain:
oRadiation of the pain:
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7. Physical examination:
 Inspection: using eyes to found morphological abnormalities
of the bodies organ.
 Percussion: using finger taping to detect the structure of
the body organs.
 Palpation: using hands to determined the texture of
the body’s organ.
 Auscultation: using stethoscope to check body’s sound
abnormalities.
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8. Current problems:
Any problem that founded in patient’s body systematically.
For example:
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Related system Problem
Cardio Vascular system Tachycardia
Nervous system Convulsion
Renal system Polyuria

9. Problem assessment:
A. Etiology
B. Risk factors
C. Stability
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Lab investigation:
A. Chemical tests
B. Hematology
C. Others

10. Therapeutic Intervention
Therapeutic intervention is dependent on
progression of the condition. For example;
Women identified in intervention clusters as having severe
hypertension (systolic greater than 160 mmHg) by the community
health worker during visiting will be given 750 mg of oral methyldopa
prior to transfer to a nearby facility for further care interventions.
Therapeutic objectives
Accounting the goals that reduce the health
barriers and enhance the healing of the disease.
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11. Current medication
Any medications that patient get it on hand.
For example;
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Medication Type Dosage Route Frequency
Dextrose 5% Solution 500cc IV 1 x 2
Piperacillin/Tazobactam Vial 4g/0.5g IV 1 x 3
Furosemide amp 40mg IV 1 x 2
Pantoprazole Tab 20mg PO 1 x 2

12. Index of drug related problem
The medication information that patient get it on hand.
For example;
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Drug Side effect Alternative Teaching point
Dextrose 5%
Carbohydrate
Caloric product
Fluid replacement
Nil Non - Explain needs for drug.
- Tell patient to notify adverse
effects promptly
Piperacillin/Tazobactam
Antibiotic
Anti-bacterial
Thrombophlebitis The physician suggest
to change Pipracillin to
Ampiclox
- Do not use this drug if it contain
particles or if the vial is cracked
or damaged.
- Tell the patient use the drug as
soon as possible if she misses it.
But don't use two doses at once.

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Thanks