Compilation - 7a

CAPITOL MEDICAL CENTER COLLEGES
COLLEGE OF NURSING
No 4 Sto. Domingo Ave., Quezon City
RELATED LEARNING EXPERIENCE

Leadership and Management
(HEAD NURSING)
CMC 7thA
In partial fulfillment of the requirements needed

In Nursing Care Management 105
Submitted to:
Mrs. Mary Grace Dela Torre, R.N., M.A.N
Submitted by:
Marasigan, Lance B.
BSN IV- 5
Group 16
I. INTRODUCTION
A head nurse is the one who assumes responsibility for managing the
Human and Material resources of a nursing unit and takes lead in
developing to provide quality patient care and environment conductive
to staff growth and satisfaction.
After learning the different theories and concepts in nursing, each

student needs to move up to another level of learning. As the school
year is nearing to an end, I am grateful for the opportunity to
experience what a Professional Nurse do daily in the work place.
Though the experience is somehow sugar coated because I am still
handled by my clinical instructor and we are only given limited task to
do. In this experience I will be able to understand deeper how a
Healthcare system in a hospital setting works and how delicate are the
nurse’s role in delivering quality care to the patients.
My experience in head nursing gave me a chance to lead a group, to

be the team leader, to face challenges, and to accept the differences
within the group. A future health care manager and leaders, I am eager
to ring out the best among each and every one of us to deliver the best
health care and to relay what our members could and could not do
effectively and efficiently.
As the end comes near in our student life, let us be cautious that it is
not enough that we mastered the different technical aspects of nursing
but it is also important is that how I value my patients and my peers.
Let us put this in mind that these people will help us grow and be
successful in our work. After this experience, I will be able to see our
limitations and things we are capable to do as a nurse and as a leader
of the group.
2
II. ACKNOWLEDGEMENT
I would like to express my graceful appreciation to the following special

people who had helped me in accomplishing my tasks.
Mrs. Mary Grace Dela Torre, RN, MAN, for guiding and teaching us how
to become a good leader and a effective head nurse.
To my family and to my classmates for giving me courage, persistence
and inspiration in doing all of the paperworks. And I would also like to thank
my duty mates for supporting me in my work as a head nurse.
To the CMC staff nurses and other health personnel’s, for giving me the
opportunity to act as a head nurse. For helping me and guiding me in my
tasks in the area.
Ms. Mary Jane Cortez, for letting us experience this one of a kind duty
that is so much fun and at the same time full of different experience.
And above all, the Almighty God, for the countless blessings, not only
good health but also sound mind, that made this study possible.
3
III. DESCRIPTION OF LOCALE
The 7th A floor ward is a combination of the pediatric ward and the general ward.
The pediatric ward is composed of 7 rooms from 701-707 while the general ward
which is composed of 14 bed capacity from 745A-745G, 746A-746E
4
CMC Vision
Capitol Medical Center envisions itself to be globally recognized health care

institutions by 2015.
CMC Mission
The Capitol Medical Center is dedicated to the delivery of total quality health
care services in partnership with competent and ethical physicians,
professionals and staff utilizing internationally accepted technology,
facilitates and systems.
Capitol Medical Center continually strives to be a role model in the delivery

of excellent and comprehensive health care services.
CMCHistory
For 35 years, Capitol Medical Center has been one of the leaders in providing
the best in health care delivery. Founded and incorporated March 13, 1973
by Dr. Thelma N. Clemente, her husband, Luis C. Clemente and close friends
and associates, Capitol Medical Center was envisioned by the founders to be
the perfect balance of modern medical technology and personalized quality
patient care.
The support and efficiency of the medical staff and employees combined
with the acumen of the management, proved to be essential in overcoming
obstacles and difficulties in its early years. Imbued with these core values,
the staff set out to work and CMC immediately posted tremendous growth.
Therefore, expansion in terms of space, facilities and services increased. In
1973 and 1974 purchase of adjacent lots was made. And in 1975,
construction of the CMC Building was finished with additional beds available
for patients. Consequently, the working areas of the departments were
enlarged to accommodate new equipment and increased workload. During
this time, Capitol Medical Center made its mark as a pioneer in the Philippine
medical industry with the distinction of having the first successful kidney
transplant. It also established the first and only Spine Care Center in the
country.
5
The following decade saw the need for more space as patient admissions
doubled from previous years. Thus, CMC III Building was constructed. CMC III
houses both the Comprehensive Out Patient Center and the different doctors'
clinics.
As we head towards the new millenium, the ever increasing desire of Capitol
Medical Center to provide the best care for its patients evolved with the
construction of the CMC IV Building, with more bed space, bigger and better
state-of-the-art facilities and doctors' clinics for optimum services. Capitol
Medical Center continues its commitment to uphold health care excellence in
the coming years. And with the quality of service from the dedicated men
and women working as one, CMC assures you that it will continue to be the
top health care provider in the community where it belongs.
CMCC VISION
An excellent learner-centered institution fostering globally competent health
professionals in the service of humanity.
CMCC MISSION
The Capitol Medical Center Colleges aims to develop students who are
globally competent practitioners who have passion for life-long learning
CMCC PHILOSOPHY AND OBJECTIVES
Capitol Medical Center Colleges of Nursing believes that quality nursing

education is significant in the provision of quality nursing services. Hence, in
collaboration with nursing service, it envisions to produce professional
nurses who are:
• Responsible, nationalistic, creative and critical thinking generalists with
attitudes, knowledge and skills in communication, nursing research
and leadership.
• Ready to face all circumstances of the outside world n which they will
move and perform as professionals with commitment and integrity.
• Committed to continuously seek learning to enhance their personhood
and not just their entrepreneurial capability and material affluence.
6
Specifically, the College of Nursing aims to produce graduates nurses to:
I. Possess caring behaviour
II. Practice legal, ethico-moral, social responsibilities/accountabilities
III. Demonstrate critical and creative thinking
Practice skills, knowledge and attitudes for the promotion of health,
prevention of illness, restoration of health, alleviation of suffering, and
assisting clients to face death with dignity and peace.
IV. 7th A Floor Ward
7
CAPITOL MEDICAL CENTER
ORGANIZATIONAL CHART
Board of
President
Chief Executive
Officer
Vice president
Nurse Nurse Nurse
Supervis Supervis Supervis
Central Floor Nurse
Chief Nurseor MICU- Charge
or MICU- or MICU- 8
Service Nurse Charge
Superviso
Staff IMCU Nurse
IMCU IMCU
Supervis
Clerk Clerk Staff
Charge
Supervis
Headnur
Orderly
Midwif rNurse
MICU-
Nurs
Headnur
Orderly
Assistant
Clerk Staff
Charge
Headnur
Orderly
ChiefClerk Staff
Headnur
Orderly
Clerk Staff
Charge
Headnur
Orderly
Clerk
CAPITOL MEDICAL CENTER COLLEGES INC.
College of Nursing
RLE ON LEADERSHIP AND MANAGEMENT
(HEAD NURSING)
V. DUTIES AND RESPONSIBILITIES OF STUDENT HEAD NURSE

AND STUDENT STAFF NURSE
STUDENT HEAD NURSE

• Plans the activities of the day
• Conducts pre conference, to discuss the activities, patient assignment and
the objectives for the entire shift
• Joins in the nursing rounds
9
• Gathers pertinent data’s of the patients to be handled by his/her student staff
nurses
• Carry out orders
• Assists the professional staff nurse on admission of patients and does the
charting
• Checks the sample charting of her students
• Reports or confronts any conflict or unclear informations or certain activity to
be done or other concerns to the clinical instructor
• Oversees to his/her subordinates if they are doing their tasks
• Gives examination
• Evaluates his/her student staff nurses
• Conducts post-conference, including the lessons learned for the day and the
evaluation if the goals for the day was met
STUDENT STAFF NURSE

• Hears the endorsement
• Gathers data on their patients
• Does the taking of vital signs
• Check on the IVF’s of their respective patients
• Renders nebulisation
• Interacts with the patients
• Does the charting
• Checks if there are new orders made by the doctors
• Does all the bedside care
10
Macaria G. Aseoche To: ALL USERS
04/24/2008 07:52 AM
Cc:
Subject: Midnight Snacks new SOP
Good Morning! Please be reminded on our New SOP on Midnight Snacks

Starting Today, April 24, 2008. Thank you!
To All Night Duty Employees:
In our desire to be of environmental friendly, we discouraged the usage of

styro materials for your midnight snacks, instead, using the plastic containers for
your rice and soup meals.
And in line with this, we would like to inform you that there will be a new SOP
in getting your Midnight snacks.
Please refer below for the procedure:
1. Employees reporting for night duty are required to deposit P10.00 each to the
Guard on duty where they will redeem their snacks placed in the plastic
containers. In case snacks is not distributed through the Guard on duty, the
Nurse Supervisor is responsible in the distribution at the Supervisor’s office.
2. Before going home, the same employees are required to return the plastic
containers to the guard on duty in exchange for the P10.00 deposit.
3. The plastic containers should be washed/cleaned before returning it to the
guard.
4. All collected containers will be endorsed to the Dietary department for
checking.
For your strict compliance. Thank you.
Note: This will be implemented on April 24, 26 and 29, 2008.

For questions and inquiries, please send it through lotus notes. Thank you.
Respectfully ypurs,
Ms. Macaria G.
Aseoche
Dietary / Canteen-OIC
11
CAPITOL MEDICAL CENTER, INC.
Quezon City
DATE : 14 July 2008

TO : The Nursing Service
FROM : Finance Division
SUBJECT : Color coding Scheme of Patient’s Accounts
To ensure that the accounts of the presently confined patients are kept within their
credit limit and to attain maximum collection and minimize bad debts, we shall
revive the implementation of the above subject pertaining to the problematic
patient’s accounts. The interpretation shall be as follows:
Yellow Color : means that the concerned patient is not able to meet the
required
Deposits
Red Color : means that the concerned patient has a patient has a
problem in
Paying his/her hospitals bills and is being recommended
to be put
under “cash basis” status
Blue Color : means that the concerned patient is presently under
“cash basis”
status.
Ms. Minnie Barawid, Credit and Collection In-Charge will coordinate with you on
matters pertaining to patient’s account. On a regular basis, a Credit and Collection
Staff will request you to paste the color coded tag to the patient chart’s cover.
Likewise, a written request/advise shall be issued to the attending physician of the
concerned patient and the letter-request shall be coursed through the Nursing
Floor.
Your cooperation and support will be highly appreciated.
Thank you.
EMMA L. MENDOZA
Chief Accountant
Noted by:
CARMINA C. DESALES, MHA, FPCHA
Vice President/ COO
Cc: Nursing Service Office, Asst. Chief Nurse, CQI Office, C&C
12
CODE 70 (CARDIOPULMONARY ARREST TEAM)
POLICY GUIDELINES AND PROCEDURES
Policy Guidelines:
a. Code 70 is sounded whenever a patient in any part of the hospital

develops sudden and unexpected cessation of respiration and ineffective
circulation.
b. Any physician or Floor Head Nurse / Charge Nurse may call for Code 70
whenever necessary.
c. The telephone operator or information personnel gives priority to Code 70
calls.
d. Members of Code 70 team should be at the area within 5 minutes
e. The following are members of Code 70 team:
1. Medical Resident on Duty for 24o or Pediatric Resident on Duty
depending on the case – TEAM CAPTAIN.
2. House Anesthesiologist
3. Surgical Resident on Duty for 24 o
4. MICU Head Nurse / Charge Nurse on duty
5. MICU Orderly and Floor Orderly
6. Floor Head Nurse / Charge Nurse
7. Floor Medication Nurse
8. Nurse Supervisor on Duty
9. Chaplain
10.K-10 / Internal Guard
f. The function of the team ends when the revived patient had been safely
transferred to the ICU, or, when the TEAM CAPTAIN has pronounced the
death of the patient.
g. Code 70 should be paged on the station and patient’s room number or
any part of the hospital.
Procedure:
1. Once the call is sounded, one service elevator should immediately standby at
the 6th floor to fetch the MICU defibrillator, MICU Nurse and Orderly.
2. After conducting the MICU personnel to the floor of code the elevator is held
on the floor for emergency errands, unless / otherwise ordered by the TEAM
CAPTAIN. Other member of the team should make use of the stairways in
responding to the call.
13
3. DUTIES OF TEAM MEMEBERS:
1. TEAM CAPTAIN
A. Coordinates action / movements of the team.
B. Initiates cardiac massage if the floor personnel have not started it
and orders the necessary treatments of medicines.
C. Declares the termination of the resuscitative efforts and ends the
function of the team.
D. Coordinates with the service resident in charge or the Attending
Physician for the plan of care and possible transfer to critical care
unit.
2. SERVICE RESIDENT ON DUTY

A. Coordinates and assist the TEAM CAPTAIN for the emergency
management of the patient.
B. Directly responsible for the Attending Physician and updates
member of the Code Team on the patients condition.
C. Administers all medicines ordered by the TEAM CAPTAIN
3. HOUSE ANESTHESIOLOGIST
A. Provide adequate airway for the patient making sure that oxygen
administered reaches the lungs, by endotracheal intubation and IV
access if necessary.
B. If the anesthesiologist is not available, the surgical or medical
resident may perform his / her function.
4. SURGICAL RESIDENT
A. Provides patient IV lines and does venous cut-down, if necessary.
B. Leaves the room if his function is accomplished, to give working
space for the other member of the team.
5. NURSE RECORDER / MICU NURSE

A. Securely connects the leads of the cardiac monitor and sees to it
that machine is functioning properly. Places the monitor in direct,
unobstructed view of the TEAM CAPTAIN, but far enough from the
bed to enable free movement around it.
B. Prepares the defibrillator, if necessary, and makes the necessary
adjustments on the machine.
C. Records all medications called out by the TEAM CAPTAIN, noting the
time of each administration if possible.
D. Calls out time interval of 10 minutes that serves as guide of other
emergency drugs to be given.
E. Collects and labels all ECG print outs if necessary.
14
6. MEDICATION NURSE
A. Brings the E-cart to the scene of code and place it in the specified
position.
B. Prepares all medicines and IV fluids ordered by the TEAM CAPTAIN.
C. Prepares one ampule of epinephrine ready for administration as
soon as she arrives on the scene.
D. Assists the nurse recorder when condition permits.
7. MICU ORDERLY / FLOOR ORDERLY

A. Makes oxygen tank available and functioning with the proper gauge
in the code scene.
B. Helps the medication nurse in bringing the E-cart at the code site.
C. Brings the cardiac monitor and defibrillator to the scene of the code
and assist in the placement of leads to the patient.
D. Sets the suction apparatus to operation.
E. Assists the anesthesiologist in the intubation.
F. Performs the cardiac massage to the patient.
8. FLOOR HEAD NURSE / CHARGE NURSE

A. Provides the immediate measures while waiting for the other
member of the team to arrive.
1. Places oropharyngeal airway on the patient and extends his
necks upwards, then administers oxygen with valve bag if
necessary or have someone to do it.
2. If the patient develops cardiac arrest, places cardiac board and
initiates proper cardiac massage or have someone to do it.
3. Positions the patient’s bed to give enough space for the other
members of the team.
4. Empties the room of unnecessary things and fixtures.
B. Reports to the TEAM CAPTAIN the immediate circumstances
preceding the arrest.
C. Coordinates with the MICU nurse (Nurse Recorder) in the final
charges.
D. Accomplishes the death certificate in coordination with the Resident
on Duty
E. Makes notice of discharges for final processing of hospital bills.
9. NURSE SUPERVISOR
A. Keeps human traffic at the code by clearing the room of
unnecessary personnel and/or relative
B. Make sure that all emergency medicines and supplies are available
at all times
C. Sees to it that the respective member of the team concerned are
doing their assigned duties
15
10.K-10
A. Maintains security at the scene of the code
11.CHAPLAIN
A. Performs the needed spiritual blessings if the condition permits
Subject: NOD ENHANCEMENTON PF PORTION

Good day to all:
The following are the revision in the “SELECTION LIST” on PF portion:
1. “PER DOCTOR’S ADVICE, PF TO BE SUBMITTED TO BO”
>>> This will mean that the nurse was able to talk to the doctor and the
doctor prefer to submit his/her PF directly to Business Office.
2. “PF SUBMITTED”
>>> this will mean that the doctor submitted the PF form (billing slip) to the
nurses and/or endorsed verbally. The nurse shall indicate in this portion the
amount submitted by the doctor and should not be left blank.
The IT Technician and for strict compliance. Thank you for the usual support and
cooperation
Business Office
16
POLICIES AND PROCEDURES
TITLE: Doc No. AAA-
BBB-000
Withdrawal of Date
Ventilator Support Effective
Page No. 1 Of 4
POLICY
1. It is presumed that the patient has terminal illness and has no reasonable
chance of recovery before DNR (Do Not Rescucitate) / NHM (No Heroic
Measure) is written. Furthermore, there are at least two disinterested doctors
who agree that the patient has terminal illness.
2. A written consent must be signed by at least two immediate relatives of legal

age.
3. The Attending Physician and a Pulmonologist must be involved in all cases of

ventilator removal.
4. A DNR (Do Not Resuscitate) / NHM (No Heroic Measure) must be written in
the Doctors Order Sheet by the Attending Physician / Pulmonologist prior to
the removal of ventilator support.
5. An appropriate entry in the progress note / doctor order sheet is made by the
Attending Physician / Pulmonologist involved in the case regarding
withdrawal of the ventilator. He should state reasons for withdrawing the
ventilator like.
a. The patient has a terminal condition
b. The patient has irreversible brain damage
c. The continuation of ventilator support would be futile
d. Etc…………….
6. Continued respectful comfort is provided until peaceful death
7. A DNR / NHM is effective upon its issuance
17
Signatures Revision History
Prepared by Lolita ISSUE No.
Gonzales
Reviewed by Process REVISION No.
Owner
Division Date Issued
Head
Approved by Chief
Operating
Officer
POLICIES AND PROCEDURES

TITLE: Doc No. AAA-
BBB-000
Withdrawal of Date
Ventilator Support Effective
Page No. 4 Of 4
DEFINITIONS
• DNR (Do Not Resuscitate) / NHM (No Heroic Measure) Order – An order
written on a patient’s medical record issued by a physician to the effect that
no attempts shall be made to resuscitate such patient in the event such
patient suffers cardiac or respiratory arrest. Such an order may cover all
cardiopulmonary resuscitation measures or may be limited to specific
procedures or equipment, depending on the scope of the consent.
• SURROGATE – The person selected to make a decision regarding

resuscitation on behalf of another person.
• MEDICALLY FUTILE – Cardiopulmonary resuscitation (CPR) will be

unsuccessful in restoring cardiac and respiratory function or that the patient
will experience repeated arrest in a short time period before death occurs.
• ADVANCE DIRECTIVES – means that a patient’s wishes regarding life

sustaining medical treatment in case the patient is no longer able to indicate
his own wishes is documented.
Signatures Revision History

Prepared by Lolita ISSUE No.
Gonzales
Reviewed by Process REVISION No.
18
Owner
Division Date Issued
Head
Approved by Chief
Operating
Officer
Capitol Medical Center

Quezon City, Philippines
GUIDELINES FOR DISCHARGING PATIENT
1. Order for Discharge of Patients
1.1Policy
No patient shall be discharged without the written order of the

attending physician and approval of referral physicians on the patient’s
chart.
1.2Special Cases
1.2.1 if patient is insisting to be discharged without the approval of

the attending physician, nurse has to inform Resident-in-charge
who will verify first with the attending physician about the
19
request. If okay with AP, Resident-in-charge can now write the
order.
1.2.2 If the patient still insists without the approval of the attending
physician, then the patient can be discharged after signing the
waiver or the discharge against medical advice form.
1.2.3 Discharge order through telephone shall be written by Resident-

in-charge or nurse on duty in the order sheet and countersigned
later by the doctor, either on the floor or on the Medical Records
Section.
2. Doctors must fill out the designated form for professional fee in the
patient’s chart in the floors. The nurse shall be responsible to have the
professional fee form accomplished by all attending doctors. If the doctor
refuses to fill up the professional fee form, the nurse should state the
reason.
• It is suggested that doctors talk with their patients regarding their

professional fees prior to sending of bills to the Business Office.
2.1professional Fee through telephone shall be countersigned by the

resident-in-charge or nurse on duty
2.2if direct billing is preferred, business office will not be responsible for
the collection of professional fees. It will now be the responsibility of
the doctor/secretary to collect.
3. Doctor’s secretary may be allowed to collect the professional fee of the

doctor in the patient’s hospital room provided she wears the prescribed
CMC secretary’s uniform with proper CMC ID. This is to prevent some
unscrupulous persons who may misrepresent the doctor’s secretary and
collect the professional fee.
4. Resident doctors, interns, nurses or any hospital staff are not allowed to
collect and receive payments from patients
5. If a doctor desires to have his professional fee collected by the Business

Office; he must write his professional fee in the designated form.
• Professional fees collected at the Business office are automatically deducted

ten percent (10%) or fifteen percent (15%) withholding tax, as required by
law.
6. PhilHEalth (Medicare)
• Doctors are required to fill up completely and sign the appropriate portion of
the PhilHealth form of their patients prior to discharge, so as not to delay the
filing of PhilHealth claims by the hospital
7. Referral
20
• If in case patient has been referred to other physicians, the attending
physician is required to advise patient that after giving their discharge order
other doctors must still be notified. Resident-in-charge/nurse will notify other
doctors.
8. As soon as the last doctor makes a discharge order, the nurse shall send
the Notice of Discharge (NOD) electronically to the business office and all
ancillary departments with pending charges. Likewise, he/she shall input
the professional fee of the doctors who accomplished a PF form. If the
doctors opted for direct billing, the nurse shall input “direct billing”
9. Guarantee payment
• Guarantee made by members of the active medical staff for the hospital
accounts of patients including the initial deposits must be personally signed
by the guarantor-physician.
• Guaranty forms are available at the admitting section and business office.
• Doctors can also write in the admitting order that he is guaranteeing the
deposit.
21
PROCEDURE ON NEEDLE STICK INJURY
1. The injured person should report the incident immediately to the charge
nurse on duty.
2. The charge nurse on duty to notify the infection control nurse.
3. The injured person will go down to ER for blotting immediately after the
incident.
4. The ICN will call the ICC chairman for the laboratory work up and necessary
prophylaxis to be given.
5. The ICN will inform the ER nurse what laboratory request to be done and
what medication/vaccine to be given.
6. The ER nurse to make the laboratory request and to administer the

medication/vaccine if there’s any.
7. All charge tickets should be tagged with ECC by the ER Clerk.
8. The injured staff then should secure a medical certificate from the ER and
make an incident report. Incident report forms available at the NSO.
9. Then the injured staff will go to the personnel office to get ECC form.
10.The injured staff should provide the ICN a copy of the incident report and
then to submit the ECC form, laboratory results, charge tickets, copy of
incident report, medical certificate to the personnel office within 5 days.
Prepared by:
Carmelette M. Manongsong
Infection Control Nurse
Noted by:
Dr. Edna-Sunga-Mallorca
Chariman Infection Control Nurse
22
Policies of 7th A
1. It is a routine that during endorsement, all incoming staff on duty must
receive the endorsement and must make their patient’s round after.
2. The 6th A station uses Doctor’s Code or list of doctors of confined
patients at the area in order not to miss a patient when physicians
make their rounds
3. The charge nurse is responsible in admitting, discharging patients, go
along with the Attending Physician during the rounds, carrying out and
transcribing doctor’s order. The charge nurse is also responsible in
giving assignments to his subordinates.
4. The medication nurse is responsible in giving medications (Oral, IV,
Subcutaneous, IM and topical), and charting the given medications.
5. The midwives are responsible in taking the patient’s Vital Signs, give
morning care to the patients, changing the beddings, give
Nebulizations, record the patient’s intake and output, and do the
errands needed in the area.
6. The station makes it a point that all physicians who have seen the
patients must be written at the Kardex so as not to miss their names
when patients are for discharge. This will also help the night duty nurse
on updating the Doctor’s Code.
Admission of Patient
Admission of patient starts by orienting the patient at the room where
he is about to stay and checking of list about the facilities and items found
inside the room. The facilities and items noted then should be signed by the
patient or guardian after.
The charge nurse is responsible in informing the attending physician,

resident on duty and the intern on duty about the admission of the patient
and carrying out the doctor’s order.
Administration of Medicines
23
The medication nurses are reminded to be cautious always when
administering medications to the patient. They are obliged to check it in the
chart very carefully, and when in doubt, they should verify it to the charge
nurse or doctor. The medication nurse is always reminded to observe the 10
Rights in administering medications.
Discharging of Patient
Once the patient has been given the discharge order from his
attending physician, the charge nurse will check for all the charges and
return the medicines of the patient before forwarding the notice of discharge
to the business office.
The charge nurse will see to it that all attending physicians have been
informed about the discharge and agreed to discharge the patient. Home
instructions including the prescriptions of the physician should be given without fail
before the patient goes home.

College of Nursing

(HEAD NURSING)
IV. CLINICAL FOCUS
GENERAL OBJECTIVE:
At the end of 128 hour of clinical exposure, the students will have
enhanced knowledge and skills on the planning, staffing, organizing, directing
and controlling functions of the nurse manager as well as on the performance
of direct, indirect and health teaching activities of the staff nurses.
SPECIFIC CONTENT ACTIVITIES EVALUATION

OBJECTIV
E
State the DISCUSS: Attend pre-exposure Paper and pencil
objective • Objective of the briefing test
of the experience
experience • Schedule of
, schedule activities
of • requirements
activities
and
24
requireme
nts
State ORIENTAION ON: Orientation Quiz
mission, • mission, vision
vision, • history
history, • capabilities/servi
capabilities ces offered
/services • Organizational
offered, structure
organizatio
• Standard
nal
operating
structure,
procedures of
standard
for students and
operating
clinical
procedures
instructors
for
students
and clinical
instructors
State the WARD ORIENTATION: Introduction to ward Random question
names of Ward staff staff and answer
the staff, Physical set-up Read ward manual sessions
be familiar Ward SOP’s and Browse chart
with policies
physical Chart arrangement
set-up of
the ward,
state the
ward SOP
and
policies,
chart
arrangeme
nt
Identify Introduction to the Observe the • Alternately
the headnurse headnurse in the assign
headnurse Orientation on the performance of her students to
and be duties and duties and function as
familiar responsibilities of the responsibilities headnurse
with head nurse • Let the
her/his students
duties and duplicate the
responsibili duties and
ties responsibiliti
25
es of a
headnurse
with her
fellow
students as
her staff
Identify Implementation of the Cite observations • Let he
how the functions of and experiences students
hospital management relevant to the observe and
implement management perform
s the process activities
functions relevant to
of the
manageme management
nt: process
• Plan • Process the
ning experience
• Orga
nizin
g
• Dire
ctin
g
• Cont
rolli
ng
Perform Proper implementation Assign student head • Use clinical
managerial of the principles of nurses with performance
functions management corresponding staff, evaluation
relative to allow them to tool for
the duties identify patients student
and according to the Headnurse
responsibili patient classification and student
ties of the system, allow them staffnurse
headnurse to plan daily
activities, direct and
lead their subgroup,
establish criteria for
evaluating staffs
performance
Student Formulating problem Use problem solving • Graded
headnurse solving process based process format: problem
will be able on the managerial 1. Statement of solving
to identify problems identified problems and process
26
problem cues using
solving 2. Analysis performance
process (scientific and evaluation
appropriat situational) tool, guided
e for the 3. Alternative by CI
area of courses of
exposure action
4. Rationale
5. Evaluation
Student Submit a training Formulating a • Ward class
staff nurse proposal with budget training plan: evaluation
will be able proposal 1. Choice of using PET,
to conduct topic guided by CI
a ward 2. General
class objective
3. Specific
objectives
4. Number of
hours
allocated
5. Participants
6. Health
teaching plan
a. Objecti
ves(SKA)
b. Learnin
g content
c. Method
ologies/stra
tegies
d. Learnin
g activities
e. Time
allotment
f. Resour
ces/instructi
onal
materials
g. Evaluat
ion
7. Working
committees
a. Over all
chair
27
b. Finance
c. Progra
m invitation
d. Registr
ation and
reception
e. Food/p
hysical
arrangeme
nt
f. Afterca
re
g. Secreta
rial/docume
ntation
8. Budget
proposal
Be familiar Proper procedure of Attend and observe • Properly
with the turning over the endorsement, receive
endorseme patient to the student headnurse patients and
nt incoming shift so as to will endorse to endorse
procedure maintain continuity of incoming shift patients,
care graded,
guided by CI
Supervise Assess patients Allow headnurses to Performance
student through: assign individual Evaluation tool,
staff • Interview patient baby chart, guided
nurses, • Observation Require student by CI
perform • Physical staff nurses to make
accurate assessment a baby chart and
nursing • Review of accomplish the
assessmen records following
t using the • Focused
following history taking
techniques • Nursing
: system review
• Inter chart
view • NCP
• Obs • Kardex
erva
tion
• Phys
ical
asse
28
ssm
ent
• Revi
ew
of
reco
rds
Require NCP using the Identify and Graded discussion
student following format: prioritize nursing on NCP details
staff nurse Assessment problems between student
to (Subjective/Objective) Make sample head nurse and
formulate Nursing Diagnosis charting student staff nurse
a nursing Background Develop (supervised by
care plan Knowledge individualized NCP clinical instructor.
using Nursing Objectives
standard Nursing Intervention
format Rationale
Evaluation
Require Reflect the time of Sign the medication Check
student drug administration sheet with the time accomplished form
staff nurse and sign the of administration (supervised by
to medication sheet accurately reflected Clinical Instructor)
accomplish accordingly
medication
sheet of
their
sample
chart
Facilitate Communication skills Interact with the Observe and guide
nurse- and techniques in patient, discuss students during
patient dealing with critically discharge plan with interaction
interaction ill patients the patient (supervised by
between clinical instructor)
student-
staff nurse
and
patient
Supervise • Color coding of Observe aseptic Graded drug study
student medication techniques in drug prior to
staff nurse cards preparation administration
in • Asepsis in Drug study (supervise by
preparing preparation of Observe 10 R’s in clinical instructor)
and medicines giving medications
administeri • Observance of Closely supervise
29
ng oral, the 10 R’s in students in drug
intramuscu giving administration
lar, medications
subcutane • Proper
ous, identification
intraderma and making of
l medication
medication cards according
s to agency policy
accurately on color codes
Supervise • Asepsis in Asepsis in Discussion,
student preparation of preparation of question and
staff nurse medicines medicines answer sessions,
in • Drug study Drug study compute dosage
preparing • Computation Observance of the Review on dosage
and • Observance of 10 R’s in giving IV and solutions,
administeri the 10 R’s in medications graded drug study
ng giving IV Compute dosage prior to supervised
parenteral medications administration
medicines (supervised by
clinical instructor
Supervise IV fluids administration Observe perform Observe and
student and blood transfusion and assist in the supervise students
staff nurse administration of IV in IV fluids
administer, fluids and blood administration and
check and transfusions blood transfusion
regulate IV (supervised by the
fluids and clinical instructor)
blood
transfusion
rate/flow
Supervise BASIC NURSING Observe, perform Observe, supervise
student PROCEDURES: and assist in the and evaluate
staff nurse • Vital signs following basic students in the
in taking and nursing procedures: performance of the
performing recording • Hygienic care basic nursing
basic • Hygienic care— —oral, skin, procedures---
nursing oral, skin, perineal graded
procedures perineal • Bed bath Debriefing and
accurately • Bed bath • Bed making sharing of
and • Bed making • TSB experiences during
efficiently post-conference
• TSB • Suctioning
(supervised by
• Suctioning • NGT insertion,
clinical instructor)
30
• NGT insertion, removal and
removal and feeding
feeding • Positioning
• Positioning • Assisting
• Assisting patients in his
patients in his daily needs
daily needs • Do back rub
• Do back rub • I&O
• I&O monitoring monitoring
• Indwelling foley • Indwelling
catheter foley catheter
Insertion and Insertion and
removal removal
• O2 • O2
administration administration
• Nebulizations • Nebulizations
• IV insertions • IV insertions
• Collection of • Collection of
specimen specimen
• Hot and cold • Hot and cold
compress compress
application application
• Wound dressing • Wound
• Post-mortem dressing
care • Post-mortem
• Carry out care
doctors order • Carry out
(with doctors order
supervision) (with
• Make lab supervision)
request • Make lab
request
Evaluate Formulate and develop
student a comprehensive case
staff nurse study using the
during following format:
comprehen TITLE PAGE
sive case TABLE OF CONTENTS
study/pres INTRODUCTION
entation • Background of
before the the study
end of the • Rationale for
rotation
31
choosing the
case
• Significance of
the study
CLINICAL SUMMARY
• General data
• Chief complaint
• HPI
• PMH
• FH
• PA
• Patterns of
functioning
• Laboratory and
diagnostic
examinations
a. Sate
ordered
b. Examinati
on ordered
c. Normal
value
d. Actual
value/result
e. Interpreta
tion
f. Analysis
• Impression/diag
nosis
• Course in the
ward (day to
day patient
progress report)
a. Assessme
nt
b. Nursing
interventions
c. Medical
and surgical
interventions
d. Clients
response
CLINICAL DISCUSSION
32
OF THE DISEASE
• Anatomy and
physiology
• Schematic
diagram of the
disease
• Drug study
a. Date
ordered
b. Generic
name
c. Brand
name
d. Dosage,
frequency
and route
e. Classificat
ion
f. Specific
indication
g. Action
h. Side
effects
i. Adverse
reactions
j. Nursing
consideration
s
NURSING CARE PLAN
• Problem list
a. Date
identified
b. Nursing
diagnosis
(PES format)
c. Degree of
priority
• Nursing care
plan
a. Cues
b. Nursing
diagnosis
c. Backgrou
33
nd
knowledge
(with
reference)
d. Nursing
goals and
objectives
e. Nursing
interventions
(independent
, dependent,
collaborative
or
development
al,
supplementa
l facilitative)
f. Rationale
(with
reference)
g. Evaluatio
n
• Discharge
planning
a. Medicines
b. Exercise/e
conomic
consideratio
n
c. Treatmen
t
d. Health
teachings
e. Outpatien
t follow-up
diet
f. Diet
spiritual
34
College of Nursing
(HEAD NURSING)
JOB DESCRIPTION
I. JOB IDENTIFICATION
Position title: Head Nurse

Department/Section: Nursing unit/ward
Supervisor’s Title: Nursing Supervisor
II. JOB SUMMARY
The head nurse is a professional nurse who assumes responsibility for

managing the human and material resources of a nursing unit to provide
quality patient care and an environment conducive to staff growth and
satisfaction.
III. QUALIFICATION REQUIREMENTS
Bachelors of Science in Nursing; Registered Nurse; at least one year of

clinical nursing experience; with Supervisory Development Training; 9 units of
Nursing Management and Supervision in the Graduate School as required by
RA 9173
IV. JOB RELATIONSHIP
Source of Workers- Nurse I/ Staff Nurse

Promotion to: Nurse III/ Supervising Nurse
Responsible to: Nurse III/ Supervising Nurse
Responsible for: Nurse I/ Staff Nurse; Nursing Attendants
V. FUNCTIONS
A. PATIENT CARE MANAGEMENT
• Participates in the development of nursing standards, policies, procedures

regarding patient care and updates these as necessary
• Promotes, utilizes quality assurance standards and programs in the unit
35
• Supervises and evaluates the quality of patient care through frequent
rounds
• Act as liason with the medical staff to coordinate medical and nursing
management of patient care
• Serves as a resource person to nursing personnel under him/ her in

assessing, planning, implementing and evaluating nursing care provided
• Assumes the role of patient advocate
• Coordinates patient care with other members of the health team, other
hospital units, services, and/or divisions.
• Serves as committee member within the department, hospital or

professional organization
• Keeps superior informed regarding problems/ issues in patient care within

the nursing unit
B. MANAGEMENT OF NURSING PERSONNEL
• Participates in the selection of nursing staff for the unit
• Schedules staff assignments considering experience, interest and training
• Adjust staffing levels/ ratio according to the severity of the patient illness,
the number of patients and number of nurses
• Advises and or inform staff regarding new or revised policies and

procedures
• Keep the Supervising Nurse informed of personnel activities and problems
• Present changes or innovations to staff in a positive manner
• Provides a conducive climate in which the staff will free to consult her/him
for problems or assistance
C. MANAGEMENT OF PATIENT CARE UNITS
• Provides safe, clean, secure environment for patients, visitor and

personnel
• Requisitions adequate supplies and equipment needed for patient care
• Monitors utilization of supplies and equipment through monthly audits and

inventories
36
• Prepare monthly, semi-annual, annual reports of achievements/ problems
• Maintains effective communication within unit/ departments and other

services through conferences/ meeting
D. EDUCATIONAL RESPONSIBILITIES
• Assist in the staff development in the unit:
 Coordinates with training staff in planning, implementing ad

evaluating orientation of new nursing personnel
• Assists Clinical Instructors of affiliating colleges of nursing or school of

midwifery in planning, implementing and evaluating the learning
experience of the students
• Assumes responsibility for own learning and development needs

College of Nursing
(HEAD NURSING)
JOB DESCRIPTION
VI. JOB IDENTIFICATION
Position title: Staff nurse
Department/Section: Nursing unit/ward
Division: Nursing Service
VII. ORGANIZATIONAL RELATIONSHIPS

Reports to: Charge Nurse, Head Nurse and Supervisor
Supervises: None
VIII. JOB SUMMARY

The staff nurse is responsible in undertaking a direct nursing care with
corresponding nursing interventions as indicated by patient needs. Through
time management, the nurse allocates the quality care to each patient.
IX. DUTIES AND RESPONSIBILITIES
37
• Executes the order of the doctor.
• Make rounds after endorsement to personally assess patient’s conditions.
• Performs hygienic care.
• Assist in any bedside procedures perform by the doctor.
• Administer oral and intravenous medication.
• Monitors and record intravenous fluid.
• Attends and answer patient/relative inquiry.
• Assist and position the client during physical examination.
• Relays any untoward signs and symptoms felt by every patient to be

charge nurse-on-duty.
• Provides comfort measures that enhance quality health care.
• Assists in performing passive range of motion and activity of daily living.
• Ensures safety of every patient.
• Documents medicines, procedures and all activities done.
• Observes isolation precaution.
• Conducts endorsement to the incoming shift.
• Assist in maintaining a comfortable, orderly, clean and safe environment

for patients and hospital staff in every shift.
• Request medicines and supplies to be used.
• Returns medicines and supply prior to discharging a patient.
• Checks the E-cart every shift and maintains its completeness.
• Tags the patient room in vacant ready.
• Conducts general inspection of the area.
• Establishes a good working relationship with the member of the health

team.
• Participates in CQI activities.
38
• Performs other functions that may be assigned from time to time.
X. JOB SPECIFICATION
EDUCATION
• Graduate of B.S. Nursing with updated professional license from PRC
(Professional Regulations Commission)
• Licensed IV therapist certified by the ANSAP (Association of Nursing

Service Administrators of the Philippines)
• Must have an updated Basic Life Support license or other lifesaving

license certified by the Philippine National Red Cross or other Nurses
Association.
WORK EXPERIENCE
• Preferred but not required
TRAININGS
• Completion of Skills Training Program for Healthcare Practitioners
• Basic infection control
• 5’S
• Customers Relations
• Employee’s Orientation
1.0 INTRODUCTION
1.1Nursing Service Department integrates all the hospital’s vital services tasked
with the responsibility of setting standards for safe nursing practice, providing
quality care to the patient and coordinating its services with the various
divisions, departments, services in the hospital and the community.
The Nursing Service Division is composed of a group of professional and trained

personnel committed to show compassion coupled with excellent nursing
practices within the hospital and the entire community.
It is the responsibility of the Nursing Service to provide quality patient care at all
times, for all patients regardless of race, ethical/ regional origin, social or
economic status and in so doing support the mission and vision of the hospital
2.0 OBJECTIVES
2.1 To establish, maintain and utilize standards of safe and ethical nursing practice.
2.2 To provide quality nursing care.
39
2.3 To establish and maintain acceptable standards of nursing care.
2.4 To provide an environment conducive for clinical related learning experiences of
nursing students.
2.5 To support the CQI program of the hospital
STAFFING FORMULA COMPUTATION
Total Census: Fourteen (14) patients in a Tertiary Hospital (CMC)
1. According to levels of care needed.
14 x 0.30 = 4.2
14 x 0.45 = 6.3
14 x 0.15 = 2.1
14 x 0.10 = 1.4
Total = 14
2. According to number of Nursing Care Hours (NCH)
4.2 x 1.5 = 6.3
40
6.3 x 3 = 18.9
2.1 x 4.5 = 9.45
1.4 x 6 = 8.4
Total = 43.05 NCH / day
3. Total NCH by 14 patients per year
43.05 x 365 days / year = 15,713.25 NCH / year
4. Actual working hours rendered by each nursing personnel per year
8 hrs / day x 143 working days / year = 1,704 working hrs /

year
5. Total number of personnel needed
a. Total NCH / yr 15,713.25 = 10
Total working hrs / yr 1,704

b. Relief of total Nursing personnel
10 x 0.15 = 1.5
c. Total Nursing personnel needed
10 + 2 = 12 personnel
6. Ratio of Professional to Non-professional
12 x 0.65 = 7 Professionals
12 x 0.35 = 4 Nursing Attendant
7. Distribution by Shift
Professionals:
41
7 x 0.45 = 3 (morning shift)
7 x 0.37 = 3 (afternoon shift)
7 x 0.18 = 1(graveyard shift)
Non – Professionals:
4 x 0.45 = 2 (morning shift)
4 x 0.37 = 1 (afternoon shift)
4 x 0.18 = 1 (graveyard shift)

College of Nursing
(HEAD NURSING)
42
MASTER ROTATION PLAN

College of Nursing
Tue Wed Thu Fri- Mon Tue Wed Thu Fri-Sun Mon
Sun
Tue Wed Thu Fri-Sun Mon Tue Wed Thu
Nov. 30 Dec. Dec. Dec. Dec. Dec. Dec. 08 Dec. Dec. Dec.
01 02 3- 5 06 07 09 10-12 13
Dec. 14 Dec. 15 Dec. 16 Dec. Dec. 20 Dec. 21 Dec. 22 Dec. 23
MANEBO,
17-19
Krisha
MANEBO, C C
Krisha
MAQUILING, C H
James H W R
H
MAQUILING,
James
G G
O E A O I R
MARASIGAN,
MARASIGAN
Lance
, Lance
E
N
E O C
K R
S I
T
S
MARAVILLAS E I D M
, MARAVILLA
Gershwin
S, Gershwin R
N
F N
G
F A T
SM
MARCAIDA,
MARCAIDA,
A E F C A
Romeo Jr. L OF P
Romeo Jr. L S
MARQUEZ,
MARQUEZ,
R
F R A F A
R
Donna Anne
Donna Anne
O
R
A F E
Q S
T
Y P
MATACUBO,
MATACUBO, U / A
Mary
MaryShane
Shane
I L
I
S E
E R
MATAS, R V
MATAS,
Mherjorie N E A T
Mherjorie D
T M L Y
MEDINA,
MEDINA, A E U
Carl
CarlAlvin
Alvin T U N A
MEDINA, T T
MEDINA, I
MeriGayle
Meri Gayle T S I
O O
MEGINO, N N
MEGINO,
Jenica Joy
Y
Jenica Joy
MENDOZA,
MENDOZA,
Ma.
Ma.Theresa
Theresa
43
(HEAD NURSING)
MASTER ROTATION PLAN
HEAD NURSING
(MEDICINE
WARD)
44
CAPITOL MEDICAL CENTER COLLEGES, INC.
#4 Sto. Domingo Avenue, Quezon City
(Head Nursing)
Area: 7A Date: Dec. 6,
2010
Student’s Name Time In Signature
Manebo, Krisha 4:55am
Matas, Mherjorie 5:30am
Marasigan, Lance 4:45am
Marcaida, Romeo Jr. 5:10am
Megino, Jenica Joy 6:10am
Medina, Carl Alvin 4:50am
45
PREPARED BY: NOTED BY:
STUDENT HEAD NURSE CLINICAL
INSTRUCTOR
46
College of Nursing

(Head Nursing)
DAILY REQUIREMENT CHECKLIST

Date: December 6, 2010 Clinical Area: 7A
Criteria Maneb Matas, Marcaid Megino Medina

o, Mherjori a, , Jenica , Carl
Krisha e Romeo Joy Alvin
Jr,
II.PARAPHERNALIA
BP Apparatus/stet
Calculator
Thermometer
Bandage Scissor
Tourniquet
Tape measure
Canister with dry
cotton balls
Canister with wet
cotton balls
Medicine tray
Black and red pen/
pencil
Micropore
Small Notebook
Small Alcohol
Penlight
Signature of
student Head Nurse
Clean Gloves
Sterile Gloves
Prepared By: _______________ Noted By:________________
STUDENT HEAD NURSE Clinical Instructor

College of Nursing
47
(HEAD NURSING)
SCHEDULE OF ACTIVITIES
Date: December 9, 2010 Clinical Area: CMC- 7A
Time Activities
5:30-6:00 Attendance, Checking if paraphernalia’s, Preconference
6:00-6:45 Endorsement and room assignment
6:45-7:00 Nursing rounds
7:00-7:30 Chart reading
7:30-9:00 Vital signs, giving medications and treatment, morning care and
Plotting of vital signs and signing of medications
9:00-9:45 Quiz
9:45-10:45 Break
10:45-11:45 Chart reading (Making of NCP’s, FDAR
11:45-1:00 Vital signs, giving medications, I&O recording
1:00-1:20 Endorsement to next group
1:20-1:45 Checking of patients Chart, Submission of NCP’s, FDAR
1:45-2:00 Post conference, End of duty
PREPARED BY: _______________________ NOTED BY:

______________________
Student headnurse Clinical instructor

48
(Head Nursing)
ENDORSEMENT SHEET
Date: Dec. 6, 2010 Clinical
Area: CMC 7th A
Census: 17
Room no: 745 - A (+) Low back pain
Patient’s Name: Increase oral fluid intake
Apolonio, Treatment: N/A NPO @ pm
Marcelino Still for stool
Attending IVF: D5NR1l x Reserve 6 “U” of blood
Physician: Dr. 80cc/ hr Repeat CBC @ 6am
Quiambao V/S q4°, I & O q shift°
Diagnosis: SV r/o
dengue
Diet: DAT, NDCF
Medication: Myonal
1 tab OD
Room no: 745 - C Still for stool
Patient’s Name: Ng, 02 gauge re,pved
Abner Treatment: N/A Keep Map 120 – 130
Attending For 2D echo
Physician: Dr. IVF: PNSS1L x V/S q4°, I & O q shift°
Aquino 80cc/hr
Diagnosis: CVA
infarct, HCVD N/F
Diet: Low Salt, Low
Fat
Medication:
Coversyl 5mg/tab
OD
Room no: 745 - D (+) Fever
Patient’s Name: Increase Oral Fluid Intake
Montarde, Leo Treatment: Blood Extracted
Attending
Placil for vomiting V/S q4°, I &
Physician: Dr.
Felipe IVF: D5NR 1L x O q shift°
Diagnosis: Dengue 80cc/ hr
Fever
Diet: DAT, NDCF
Medication:
Omeprazole
40mg/tab 1 tab OD
Isoket 10mg OD
Room no: 745 - E Increase Crea in CBC
49
Patient’s Name: 02 @ 3LPM
Miraran, Benito Treatment: For 2D Echo
Attending V/S q1°, I & O q shift°
Physician: Dr,
IVF: D5NR 1L x
Gonong
Diagnosis: CHF 2° 80cc/ hr
to NSTEMI
Diet: DM, Low Salt,
Low Fat
Medication: Isoket
5mg/tab OD
ASA 50mg 1 tab OD
Avamax 80mg 1 tab
OD
Azithromycin
500mg/tab 1 tab OD
Room no: 745 - G Increase Oral Fluid Intake
Patient’s Name: CBG @ 12nn
Gay, Dennis Treatment: 02 @ 3LPM
Attending Duabent neb q8° Para not indicated
Physician: Dr. V/S q4°, I & O q shift°
Atabug IVF: N/A
Diagnosis:
Complicated UTI
Diet: Mechanical,
Low Salt, Low Fat,
DM
Medication:
Iberet FA 1tab OD
Clopidogrel 75mg/ tab
OD
Aminovita 1tb OD
Furosemid 40mg OD
Omacor 1cap OD
Lantus 14 “U” SQ OD
Lipitor 20mg OD
Prozelax 1 tab OD
Omeprazole 20mg OD
Doxfilline 40mg 1 tab
OD
Room no: 746 - A Still for stool
Patient’s Name: Stool amoeba
Saturnina, Treatment: Watch out for hypotension,
Demetria tachycardia
Attending IVF: D5NSS 1L x V/S q4°, I & O q shift°
Physician: Dr. 12°
Garcia
50
Diagnosis: LSD
STGM, Kilip I
Diet: Low Salt, Low
Fat
Medication:
Omeprazole 40mg/
tab OD
Room no: 746 - B Still for stool
Patient’s Name: 02 @ 2LPM
Flores, Julieta Treatment: N/A For 2D Echo with Doppler
Physician: Dr. Jara IVF: N/A
Diagnosis: NSTE MI,
Kilip I
Diet: LSLF
Medication:
Lipitor 80mg/ tab 1
tab ODHS
Clopidogrel 1 tab OD
Diazepam 5mg 1 tab
BID
Room no:746 - D (+) Body Weakness
Patient’s Name: CBG @ midnight
Ferrer, Florecita Treatment: N/A Metformin Hold
Physician: Dr. R. IVF: N/A
Tan
Diagnosis:
Hypoglycemia
Diet: Regular Diet
Medication:
Aspirin EC 80mg/ tab
OD after Lunch
Valsartan 80mg/ tab
OD
Lanoxin 0.25mg/ tab
½ tab OD
Trimetazidine 45mg/
tab BID
Room no: 746 - F 02 prn
Patient’s Name: V/S q4°, I & O q shift°
Cortez, Nilda Treatment: N/A
Attending
Physician: Dr. IVF: N/A
Garcia
51
Diagnosis: LSD
STGM, Kilip I
Diet: LSLF
Medication:
Isoket 5mg/ tab BID
Furosemid 40mg/ tab
OD Amlodipine 5mg/
tab OD
Carvedilol 6.25mg/ tab
BID Captopril 25mg/ tab
½ tab BID
Iberet + FA 1 tab OD
Clopidogrel 75mg/ tab
OD
Room no: 746 - G For Hemodialysis consent
Patient’s Name: UTZ of KUB
Bernal, Josefina Flores Treatment: N/A Transfuse 1 “U” PRBC @ 7am,
Attending no pre - meds
Physician: Dr. J. IVF: D5NSS 1L x
Dalupang 100cc/ hr
Diagnosis: T/c
Glumerulonephritis
Diet: Regular Diet
Medication:
Eldicet TID
Felodipine OD
Prepared by: Lance Marasigan Noted by:
Student Head Nurse Clinical

Instructor
52

(Head Nursing)
DAILY PATIENT ASSIGNMENT SHEET
Date: Dec. 6, 2010 Clinical Area: CMC 7th A
Name of Student Room/Bed Name of Patient Diagnosis Remarks
Number
1.Marcaida, Romeo 745 - C Ng, Abner CVA infarct
Jr.
745 – A Apolonio, SV r/o dengue

Marcelino
2. Matas, Mherjorie 746 - A Demetria, Saturnina Gastrointestinal
Bleeding r/o Colonic
pathologic hemorrhoid
Grade III
746 - B Julieta, Flores NSTEM 1 HCVD MF
3. Megino, Jenica 746 - D Ferrer, Florecita Hypoglycemia 2nd

Joy Dagal degree poor oral hygiene
746 - F Cortez, Nilda ACS NSTEMI Killip 1

Cordero
746 - G Bernal, Josefina T/c Glomerulonephritis,

Flores hpn st. 2
4. Medina, Carl 745 - G Gay, Dennis Complicated UTI

Alvin
745 - D Montarde, Leo Dengue Fever
745 - E Miraran, Benito CHF 2° to NSTEMI
Student Head Nurse

Clinical Instructor
53
College of Nursing

(HEAD NURSING)
DAILY TASK SHEET
Name: Marcaida, Romeo Jr. Area: CMC-
7A
Section/ Group: IV – 5, Group 16 Date: December
6, 2010
Patients name: Ng, Abner Sample Charting:
Room / Bed no.: 745C
Diagnosis: CVA Infarct Focus : Hypertension
Attending Physician: Dr. Aquino
Data:
Vital Signs: q4
Intake and Output: q shift - Bp of 150/90
Diet: Low Salt, Low Fat - Headache
Activity: - Pain Scale: 5/10
Contraptions:
N/A Action:
IVF’s: - Encouraged patient to

N/A have adequate rest
- Advised to eat low salt
foods
Procedures / laboratory work up: Response:

N/A
- Patient’s BP was
lowered from 150/90 to
130/80
Medications: - Headache was relieved
Omeprazole 40mg 1 tab OD - Pain Scale lowered to
ASA (Aspilet) 80mg 2 tabs OD 2/10
Citicholine (Cholinerv) 1gm/ tab BID
Coversyl 5mg/tab 1 tab OD
Vital Signs: Intake:
8am Oral: 1000
RR: 24 PR: Parenteral: (-)
80 Total: 1000
TEMP: 36 0 c
BP: 150/90mmHg
12nn Output:
RR: 24 PR: Urine: 900
80 Drainage: ( - )
TEMP: 36 0 c BM: ( - )
BP: 150/100mmHg Total: 900
54
College of Nursing

(HEAD NURSING)
DAILY TASK SHEET
Name: Marcaida, Romeo Jr. Area: CMC-
7A
6, 2010
Patients name: Apolonio, Marcelino Sample Charting:
Room / Bed no.: 745 A
Diagnosis: SVI r/o dengue Focus : Acute pain
Attending Physician: Dr. Quiambao
Data:
Vital Signs: q4
Intake and Output: q shift - “Low Back Pain”, as
Diet: DAT, NDCF verbalized by the patient.
Activity: - Facial Grimace
Contraptions: - Pain Scale of 7/10
IV @ Left Hand
IVF’s: Action:
D5NR 1L x 160cc/ hr
- Provided comfort
measure to relieve pain
Procedures / laboratory work up: - Advised patient to have

N/A adequate rest to relieve
strain at the lower back
Response:
Medications:
Omeprazole (Omepron) 40mg/ tab 1 tab OD - Pain was lessen as
Myonal 1 tab TID verbalized by the patient
Vital Signs: Intake: - Pain Scale Lowered to

8am Oral: 1600 3/10
RR: 19 PR: Parenteral: 750
64 Total: 2350
TEMP: 36.4 0 c
BP: 110/ 80 mmHg
12nn Output:
65 Drainage: ( - )
TEMP: 36 0 c BM: ( - )
BP: 100/ 70 mmHg Total: 1000
55
College of Nursing

(HEAD NURSING)
DAILY TASK SHEET
Name: Matas, Mherjorie Area: CMC- 7A
6, 2010
Patients name: Demetria, Saturnina Sample Charting:
Room / Bed no.: 746 A
Diagnosis: Lower gastrointestinal Focus : Acute pain
bleeding r/o colonic pathology
Data:
haemorrhoid grade III
Attending Physician: Dr. M.R. Elgar - “Masakit po ang aking
Vital Signs: q4 ulo”, as verbalized by
Intake and Output: q shift the patient
Diet: Soft Diet - Pain Scale of 5/10
Activity: - Facial Grimace
Contraptions: - Irritable
- Guarding Behavior
Action:
IVF’s:
D5 NSS 1L x 12 hrs - Provided comfort
measures
Procedures / laboratory work up: (repositioning)
Still for Stool - Encouraged adequate
rest periods
- Instructed/ Encouraged
Medications: use of relaxation
Vit K. 20mg technique (TV/ radio)
- Encouraged deep
Omeprazole 40mg 1 tab OD
breathing exercises
Ciprofloxacin (Ciprobay) 200mg IV - Administered pain
Muronidazole 500mg IV reliever as prescribed
8am Oral: 300
RR: 22 Parenteral: 640 Response:
PR: 62 Total: 940
TEMP: 36 0 c - - Patient report pain is
BP: 120/ 80 mmHg relieved
12nn Output:
RR: 21 Urine: 400
PR: 66 Drainage: ( - )
TEMP: 36 0 c BM: ( - )
BP: 110/ 70 mmHg Total: 400
56
College of Nursing

(HEAD NURSING)
DAILY TASK SHEET
Name: Matas, Mherjorie Area: CMC- 7A
6, 2010
Patients name: Julieta, Flora Sample Charting:
Room / Bed no.: 746 B
Diagnosis: NSTEM 1 HCVD MF Focus : Acute pain
Attending Physician: Dr. R.D. Jarca
Data:
Vital Signs: q4
Intake and Output: q shift - “Medyo sumasakit pa din
Diet: Soft Diet ang dibdib ko”, as
Activity: verbalized by the patient
Contraptions: - Pain Scale 7/10
- Facial Grimace
- BP: 160/90
IVF’s: - RR:21
PNSS 1L x 40cc/ hr - PR:60
- Irritable
Procedures / laboratory work up:

Still for Stool Action:
- Provided comfort
Medications: measures (repositioning)
Lipitor 80mg/ tab 1 tab ODHS - Encouraged adequate
Clopidogrel 1 tab OD rest periods
Diazepam 5mg 1 tab BID - Instructed/ Encouraged
Vital Signs: Intake: use of relaxation
technique (TV/ radio)
8am Oral: 400
- Encouraged deep
RR: 21 PR: 60 Parenteral: 320 breathing exercises
TEMP: 36 0 c Total: 720 - Administered pain
BP: 160/90 mmHg reliever as prescribed
12nn Output:
63 Drainage: ( - ) Response:
TEMP: 36 0 c BM: ( - )
BP: 140/90 mmHg Total: 930 - - Patient report pain is
relieved

College of Nursing
57
(HEAD NURSING)
DAILY TASK SHEET
Name: Megino, Jenica Joy Area: CMC- 7A
6, 2010
Patients name: Ferrer, Florecita Dagal Sample Charting:
Room / Bed no.: 746 - D
Diagnosis: Hypoglycemia 2nd degree Focus : Activity
Intolerance
Attending Physician: Dr. R. Tan
Vital Signs: q4
Data:
Intake and Output: q shift
Diet: Renal Diet “Nanghihina pa rin siya”,
Activity: as verbalized by the
Contraptions: patient.
IVF Right Hand
Action:
IVF’s:
PNSS x 40cc/ hr - Monitored Vital Signs
- Positioned the patient
comfortably
- Instructed companion
Procedures / laboratory work up: to provide safety
N/A - Encouraged to increase
oral fluid intake
- Kept Rested
Medications:
Aspirin EC 80mg/ tab OD after Lunch Response:
Valsartan 80mg/ tab OD
Lanoxin 0.25mg/ tab ½ tab OD - Still weak but tolerated
small feeding
Trimetazidine 45mg/ tab BID
8am Oral: 420
68 Total: 600
TEMP: 36 0 c
BP: 150/90 mmHg
12nn Output:
100 Drainage: ( - )
TEMP: 36 0 c BM: ( - )
BP: 140/90 mmHg Total: 450

College of Nursing
58
(HEAD NURSING)
DAILY TASK SHEET
6, 2010
Patients name: Cortez, NIlda Cordero Sample Charting:
Room / Bed no.: 746 - F
Diagnosis: ACS NSTEMI Killip 1: Focus : Health Teachings
Hypokalemia 2nd degree, Acute
Data:
Gastroenteritis, anemia 2nd degree,
abnormal uterine bleeding - Conscious, coherent
Attending Physician: H.C. Garcia - With companion
Vital Signs: q4 around
Intake and Output: q shift -
Diet: Low Salt Low Fat Diet Action:
Activity:
Contraptions: - Assessed patient’s
condition and level of
IVF Left hand - Discontinued
understanding
IVF’s: - Encouraged to avoid
red meats; oily food
PNSS 1L x 10cc/ hr – Discontinued
- Instructed for home
Procedures / laboratory work up:
medications:
N/A
Medications: - Carvedilol 6.25mg/ tab
Isoket 5mg/ tab BID Furosemid 40mg/ tab OD BID
Amlodipine 5mg/ tab OD - Iberet + FA 1 tab OD
Carvedilol 6.25mg/ tab BID Captopril 25mg/ - Amlodipine 5mg/ tab
tab ½ tab BID OD
Iberet + FA 1 tab OD Clopidogrel 75mg/ tab - Captopril 75mg/ tab
OD
OD
- Simvastatin 40mg/tab
ODHS
8am Oral: 410 - Reminded Follow – up
RR: 18 PR: Parenteral: 20 Check up after 1 week
100 Total: 430 on Dr. Garcia’s Clinic
TEMP: 36 0 c Rm 310 M – W – F – Sat
BP: 130/90 mmHg 9 – 12 nn
12nn Output:
100 Drainage: ( - ) Response:
TEMP: 37.1 0 c BM: ( - )
BP: 130/90 mmHg Total: 400 - - Patient showed
understanding of
59
instructions

College of Nursing

(HEAD NURSING)
DAILY TASK SHEET
6, 2010
Patients name: Bernal, Josefina Flores Sample Charting:
Room / Bed no.: 746 - G
Diagnosis: T/c Glomerulonephritis, hpn Focus : Provision of Care
st. 2
Data:
Attending Physician: Dr. J.J. Dalupang
Vital Signs: q4 - Monitored Vital Signs
Intake and Output: q shift
Diet: Renal Diet (1.600 kcal/ day) Action:
Activity:
Contraptions: - Provided Care
IVF Left Hand - Kept rested and
Comfortable
IVF’s: - Instructed companion
to provide safety
D5NSS 1L x 100cc/ hr Response:
- Still weak and bothered

Procedures / laboratory work up: by the disease
Blood Transfusion
Medications:
Felodi[ine 5mg/ tab OD
Eldicet 1tab PO TID
8am Oral: 500
120 Total: 1110
TEMP: 36.8 0 c
BP: 160/100 mmHg
60
12nn Output:
104 Drainage: ( - )
TEMP: 36 0 c BM: 3
BP: 160/100mmHg Total: 830

College of Nursing

(HEAD NURSING)
DAILY TASK SHEET
Name: Medina, Carl Alvin Area: CMC- 7A
6, 2010
Patients name: Gay, Dennis Sample Charting:
Room / Bed no.: 745 - G
Diagnosis: Complicated UTI Focus : Hypertension
Attending Physician: Dr. Atabug
Data:
Vital Signs: q4
Intake and Output: q shift - Bp of 130/ 70
Diet: Mechanical Low Salt Low Fat DM
Activity: Action:
Contraptions:
Heplock - Encouraged patient to
have adequate rest
IVF’s:
N/A - Advised to eat low
Procedures / laboratory work up: Sodium foods and Low
N/A Fat Foods
Medications:
Response:
Iberet FA 1tab OD Clopidogrel - Patient’s BP was
75mg/ tab OD lowered to 120/ 70
Aminovita 1tb OD Furosemid
40mg OD
Omacor 1cap OD Lantus 14 “U”
SQ OD
Lipitor 20mg OD Prozelax 1 tab
OD
Omeprazole 20mg OD Doxfilline 40mg
1 tab OD
61
8am Oral: 250
64 Total: 250
TEMP: 36 0 c
BP: 130/90mmHg
12nn Output:
66 Drainage: ( - )
TEMP: 36.2 0 c BM: 1

College of Nursing

(HEAD NURSING)
DAILY TASK SHEET
Name:Medina, Carl Alvin Area: CMC- 7A
6, 2010
Patients name: Motarde, Leo Sample Charting:
Room / Bed no.: 745 - D
Diagnosis: Dengue Fever Focus : Hyperthermia
Attending Physician: Dr. Felipe
Data:
Vital Signs: q4
Intake and Output: q shift - T> 39.4
Diet: Diet As Tolerated, No Dark Colored - Flushed skin
Foods - Warm to touch
Activity:
Contraptions: Action:
N/A
- Anti – Pyretic Given
IVF’s: - Encouraged to increase
oral fluid intake
D5NR 1L x 100cc/ hr - Encouraged to wear
light clothing
- Instructed to take
Procedures / laboratory work up: adequate rest
N/A -
Response:
- Temperature lowered
Medications: to 38.3 0 c
Omeprazole 40mg /tab 1 tab OD
Isoket 10mg OD
62
8am Oral: 1000
100 Total: 1000
TEMP: 38.6 0 c
BP: 100/70 mmHg
12nn Output:
100 Drainage: ( - )
TEMP: 38.3 0 c BM: ( - )
63
College of Nursing

(HEAD NURSING)
MEDICATION SHEET
Room No. Patient’s Diagnosis Medications/ Dosage/ Frequency Due Time

Name
745 – A Apolonio, SV r/o dengue Myonal 1 tab TID 8am, 2pm
Maracelin
o
745 – A Ng, Abner CVA Infarct, HCVD N/F Coversyl 5mg/ tab 1 tab OD 8am
Omeprazole (Omepron) 40mg/tab 1 tab
OD 8am
745 – D Montarde, Dengue Fever Omeprazole (Risek) 40mg/ tab 1 tab OD 7am
Leo Jr. before breakfast
745 – E Miraran, CHF 2° to NSTEMI Isoket 10mg/tab 1 tab TID 8am, 2pm
Benito ASH 80mg/tab OD 8am
Azithromycin 500mg/ tab 1 tab OD 8am
Metoprolol 50mg ½ tab BID 8am
Risek 40mg 1 tab OD 8am
Furosemide 40mg 1 tab OD 8am
Clexane 0.4cc SQ BID 8am
Plogrel 75mg/tab 1 tab OD 8am
745 – G Gay, Complicated UTI Lantus 12 Units SQ OD 8am
Dennis Prozelac (Tamsulusin 1 tab OD 8am
Clopidogrel 75mg/tab 1 tab OD 8am
Omeprazole 20mg/tab 1 tab OD 8am
Furosemid 40mg/tab 1 tab OD 8am
Iberet FA 1 tab OD 8am
64
Aminovita 1 cap TID 8am, 2pm
746 – A Saturnina, Lower gastrointestinal Bisoprolol 5mg/tab OD 8am

Demetria bleeding r/o colonic Omacor 1 cap OD 8am
pathology haemorrhoid Omeprazole (Omepron) 40mg tab OD 8am
grade III
746 - B Flora, NSTEMI, Kilip I Clopidogrel 1 tab OD 8am
Julieta Diazepam 5mg 1 tab BID 8am
ASA 80mg/tab OD 8am
Isoket 10mg/ tab 1 tab TID 8am, 2pm
Omepron 20mg/tab 1 tab OD 8am
Aspirin 80mg 1 tab OD after meal 8am
746 – D Ferrer, Hypoglycemia Valsartan 80mg/tab 1 tab OD 8am
Florecita Lanoxin 0.25mg/ tab ½ tab OD 8am
Trimefazidine 25mg/tab 1 tab BID 8am
746 – F Cortez, CSD STGM, Kilip I ISDN (Isoket) 5mg/tab 1 tab BID 8am
Nilda Carvedilol 6.25mg/tab 1 tab BID 8am
Iberet + FA 1 tab OD 8am
Furosemide (Lasix) 40mg/tab 1 tab OD 8am
Amlodipine (Norvasc) 5mg/tab 1 tab OD 8am
Captopril 25mg/tab ½ tab BID 8am
Clopidogrel 75mg/tab 1 tab OD 8am
Eldicet 1 tab TID 8am
Felodipine 5mg/ tab 1 tab OD 8am

Instructor
65
College of Nursing

(HEAD NURSING)
VITAL SIGNS AND I&O SHEET
Room Name of Time: 8am Intake output

no. patient BP PR RR TEMP
745A Apolonio, 120/8 64 19 36.4C Oral: Urine:
Marcelino 0 IVF: Drainage:
BM:
745C Ng, Abner 150/9 80 24 36C Oral: Urine:
0 IVF: Drainage:
BM:
745D Montarde, 100/7 100 24 38.6C Oral: Urine:
Leo 0 IVF: Drainage:
BM:
745E Miraran, 150/7 60 20 36C Oral: Urine:
Benito 0 IVF: Drainage:
BM:
745G Gay, Dennis 130/9 64 32 36C Oral: Urine:
0 IVF: Drainage:
BM:
746A Saturnina, 120/8 62 22 36C Oral: Urine:
Demetria 0 IVF: Drainage:
BM:
746B Flores, Julieta 160/9 60 21 36C Oral: Urine:
0 IVF: Drainage:
BM:
746D Ferrer, 150/9 68 20 36C Oral: Urine:
Florecita 0 IVF: Drainage:
BM:
746F Cortez, Nilda 130/9 100 18 36C Oral: Urine:
0 IVF: Drainage:
BM:
746G Bernal, 160/1 120 20 36.8C Oral: Urine:
Josefina 00 IVF: Drainage:
BM:
66
College of Nursing

(HEAD NURSING)
VITAL SIGNS AND I&O SHEET
Room Name of Time: 12nn Intake output

745A Apolonio, 100/7 65 20 36C Oral: 1000 Urine:1600
Marcelino 0 IVF:750 Drainage: 0
BM: 0
745C Ng, Abner 150/1 80 24 36C Oral: 1000 Urine: 900
00 IVF: N/A Drainage: 0
BM: 0
745D Montarde, 100/7 100 24 38.3C Oral: 1300 Urine: 200
Leo 0 IVF: 640 Drainage: 0
BM: 0
745E Miraran, 160/8 58 20 36C Oral: 150 Urine: 300
Benito 0 IVF: 80 Drainage: 0
BM: 0
745G Gay, Dennis 120/7 66 26 36C Oral: 250 Urine: 300
0 IVF: N/A Drainage: 0
BM: 1
746A Saturnina, 110/7 66 21 36C Oral: 400 Urine: 400
Demetria 0 IVF: 640 Drainage: 0
BM: 0
746B Flores, Julieta 140/9 63 20 36 Oral: 1100 Urine: 930
0 IVF: 320 Drainage: 0
BM: 0
746D Ferrer, 140/9 100 20 36C Oral: 420 Urine: 450
Florecita 0 IVF: 180 Drainage: 0
BM: 0
746F Cortez, Nilda 130/7 100 20 36.4C Oral:500 Urine: 400
0 IVF: 20 Drainage: 0
BM: 0
746G Bernal, 160/1 104 20 37.1C Oral: 500 Urine: 830
Josefina 00 IVF: 610 Drainage: 0
BM: 3
Admissions:
67
Room Name of Time: 12nn Intake output
745B Romero, 100/7 80 20 36C Oral: Urine:
Teofilo 0 IVF: Drainage:
BM:
746 C Lau, Angelina 120/8 80 26 36C Oral: Urine:
0 IVF: Drainage:
BM:

Instructor

College of Nursing
68
(Head Nursing)
INTRAVENOUS FLUID SHEET
DATE: December 6, 2010 CLINICAL AREA: CMC- 7A
STUDENT ROOM PATIENT IVF MEDICIN AMOUNT TIME AMOUNT

NURSE NUMBE S NAME E ADDED RECEIVE CONSUME ENDORSE
R D D D
Marcaida, 745 - A Apolonio, D5NR N/A 650cc 11:00am 600cc
Romeo Jr. Marcelino 1l x
60cc/
hr
Medina, 745 - D Montarde D5NR N/A 300c 10:00am 700cc
Carl Alvin , Leo 1L x
100cc/
hr
745 - E Miraran, PNSS N/A 500cc N/A 420cc
Benito 1L x
10cc/
hr
Matas, 746 - A Saturnina D5NS N/A 400cc 12:00nn 850
Mherjorie , S 1L x
Demetria 12°
746 - B Flores, PNSS N/A 700cc N/A 400cc
Julieta 1L x
40cc/
hr
Megino, 746 - D Ferrer, PNSS N/A 200cc N/A Shifted to
Jenica Joy Florecita 1L x Heplock
40cc/
hr
746 - G Bernal, D5NS D5W250c 550cc N/A
Josefina S 1L x c + 60mL
Flores 100cc/ NaCHO3 x
hr 24°

STUDENT HEAD NURSE CLINICAL INSTRUCTOR
69
College of Nursing

(Head Nursing)
INTRAVENOUS MONITORING SHEET
DATE: December 6, 2010 CLINICAL AREA: CMC- 7A
STUDENT ROOM NAME OF IVF IVF LEVEL

NURSE NUMBER PATIENT RECEIVED ENDORSED
Marcaida, 745 - A Apolonio, D5NR1l x 650cc 600cc
Romeo Jr. Marcelino 60cc/ hr
Medina, Carl 745 - D Montarde, D5NR 1L x 300cc 700cc

Alvin Leo 100cc/ hr
745 - E Miraran, PNSS 1L x 500cc 420cc

Benito 10cc/ hr
Matas, 746 - A Saturnina, D5NSS 1L 400cc 850cc
Mherjorie Demetria x 12°
746 - B Flores, PNSS 1L x 700cc 400cc
Julieta 40cc/ hr
Megino, 746 - D Ferrer, PNSS 1L x 200cc Shifted to
Jenica Joy Florecita 40cc/ hr Heplock
746 - G Bernal, D5NSS 1L 550cc

Josefina x 100cc/ hr
Flores

STUDENT HEAD NURSE CLINICAL INSTRUCTOR
70
(HEAD NURSING)
NURSING CARE PLAN

Name of Patient: Ferrer, Florecita Dagal Area: CMC- 7A
Section/ Group: IV – 5, Group 16 Date: December 6, 2010
Cues Nursing Analysis Objective Intervention Rationale Evaluation

Diagnosis s
SUBJECTIVE: Deficient Hypoglycemia SHORT TERM: Determine To identify SHORT TERM:
“Hindi pa ba knowledge | After 2 hours Client’s most starting point After 2 hours
tatanggalin regarding Irritability of nursing urgent need of nursing
ang swere therapy/ self – | interventions, from both interventions,
ko?”, as care needs Confusion patient will be client’s and patient
verbalized by related to | able to nurse’s view wasable to
the patient misinterpretati Lack of verbalize point. verbalize
ons, evidenced Information understandin To meet learner’s understandin
OBJECTIVE: by statements | g of State needs g of
 Irritable of questions Deficient condition/ objectives condition/
 Difficult and knowledge disease clearly in disease
y of misinterpretati process and learner’s term To facilitate process and
understan ons treatment. learning treatment.
ding LONGTERM: Determine LONGTERM:
After 4 hours client’s After 4 hours
of nursing method of of nursing
interventions, accessing interventions,
patient will be information To clarify patient
able to expectations of wasable to
exhibit Provide teacher and exhibit
increase mutual goal learner increase
interest for setting and interest for
own learning learning Promotes sense own learning
and begin to contracts of control over and begin to
look for situation look for
information Provide active information
and ask role for client and ask
questions in learning questions
71
process.

(HEAD NURSING)
NURSING CARE PLAN

Name of Patient: Bernal, Josefina Flores Area: CMC- 7A
Diagnosis s
72
SUBJECTIVE: Anxiety related Disease SHORT TERM: Observe Can be a clue to SHORT TERM:
“Hindi halata to change in | After 2hours of behaviour the client’s level of After 2hours of
sa akin na health status, Slightly nursing indicative of anxiety nursing
may sakit nap stress threat to Irritable interventions, level of anxiety interventions,
patient will be patient was
ala akong self – concept |
able to Note use of able to
ganito?” as evidenced by Depressed verbalize drugs, insomnia Maybe behavioural verbalize
verbalized by expressed | awareness of or excessive indicators of use of awareness of
the patient. uncertainty, Anxiety feelings of sleeping, withdrawal to deal feelings of
anxious and anxiety. limited/ with problems anxiety.
ability to LONG TERM: avoidance of LONG TERM:
OBJECTIVE: problem - solve After 4 hours of inter – actions After 4 hours of
 Patient nursing with others. May interfere with nursing
crying interventions, ability to deal with interventions,
patient will Be aware of problem patient was
appear relaxed defence appear relaxed
 Slightly and report mechanisms and report
Anxious anxiety is being used. To determine those anxiety is
reduced to that might be reduced to
manageable Review coping helpful in current manageable
level. skills used in circumstances level.
past
(HEAD NURSING)
NURSING CARE PLAN
Name of Patient: Cortez, Nilda Cordero Area: CMC- 7A
Diagnosis s
73
Readiness for Physician SHORT TERM: Discuss present To note whether SHORT TERM:
enhanced | After 2hours of resources used changes can be After 2hours of
OBJECTIVE: therapeutic Home nursing by the client arranged nursing
regimen instructions interventions, interventions,
 Willingn
patient will be Identify steps To enhance patient was
ess to management |
able to assume necessary to commitment and able to assume
listen to Willingness responsibility reach desired the likelihood of responsibility
physician’ and for managing health goals achieving the goal for managing
s orders eagerness to treatment treatment
and listen regimen Promotes sense of regimen
instructio | LONG TERM: Accept client’s self – esteem to LONG TERM:
ns for Readiness for After 4 hours of evaluation of continue efforts After 4 hours of
discharge enhanced nursing own strengths/ nursing
therapeutic interventions, limitations interventions,
regimen patient will be while working patient was
able to together Provides positive able to
management
demonstrate reinforcement demonstrate
proactive Acknowledge proactive
management individual management
by anticipating efforts to by anticipating
and planning reinforce and planning
for movement for
eventualities of toward eventualities of
condition/ attainment of condition/
potential desired potential
complications outcomes complications

(HEAD NURSING)
NURSING CARE PLAN

Name of Patient: Flores, Julieta Area: CMC- 7A
74

Diagnosis s
SUBJECTIVE: Acute pain Unpleasant SHORT TERM: Note patient’s Serve as a SHORT TERM:
“Medyo related to sensory and After 1 hours vital signs baseline data After 1 hours
sumasakit pa ischemia of emotional of nursing of nursing
din ang dibdib myocardial arising from interventions, Note and To rule out interventions,
ko|, as tissue actual or the patient investigate worsening of the patient
verbalized by potential will be able to changes from underlying was able to
the patient tissue demonstrate previous condition demonstrate
damage. use of report use of
OBJECTIVE: relaxation relaxation
 Pain skills and Provide To promote non – skills and
Scale: diversional comfort pharmacological diversional
8/10 activities as measures pain activities as
indicated, for management indicated, for
 Facial individual individual
Grimace situation Encourage To prevent situation
adequate rest fatigue
periods
 BP: LONGTERM: LONGTERM:
160/90 After 1 day of Encourage After 1 day of
 RR: 21 nursing deep For relaxation nursing
interventions, breathing technique interventions,
 PR: 60
patient will exercise patient
report relief reported
 Irritable
of pain and Administer To maintain relief of pain
pain scale is pain reliever acceptable level and pain
0. as ordered of pain scale is 0.

(HEAD NURSING)
NURSING CARE PLAN
75
Name of Patient: Demetria, Saturnina Area: CMC- 7A

Diagnosis s
SUBJECTIVE: Acute Pain SHORT TERM: SHORT TERM:
“Masakit po related to Unpleasant After 1 hours Note patient’s Serve as a After 1 hours
ang ulo ko”, biological sensory and of nursing vital signs baseline data of nursing
as verbalized response emotional interventions, interventions,
by the patient arising from the patient Note and To rule out the patient
actual or will be able to investigate worsening of was able to
OBJECTIVE: potential demonstrate changes from underlying demonstrate
 Pain tissue use of previous condition use of
Scale of damage. relaxation report relaxation
5/10 skills and skills and
diversional Provide To promote non – diversional
 Facial activities as comfort pharmacological activities as
Grimace indicated, for measures pain indicated, for
individual management individual
situation situation
 Guardin Encourage To prevent
g adequate rest fatigue
Behavior LONGTERM: periods LONGTERM:
After 1 day of After 1 day of
 Irritable nursing Encourage nursing
interventions, deep For relaxation interventions,
patient will breathing technique patient
report relief exercise reported
of pain and relief of pain
pain scale is Administer To maintain and pain
0. pain reliever acceptable level scale is 0.
as ordered of pain

(HEAD NURSING)
76
NURSING CARE PLAN
Name of Patient: Apolonio, Marcelino Area: CMC- 7A

Diagnosis s
SUBJECTIVE: Fatigue related Fatigue SHORT TERM: Assist patient To achieve SHORT TERM:
“Hindi ako to sleep | After 8 hours with self care normal self care After 8 hours
nkatulog ng deprivation Sleep of nursing needs need of nursing
maaayos”, as Deprivation interventions, interventions,
verbalized by patient will be Provide patient was
the patient able to adequate rest To decrease able to
verbalize gain body’s metabolic verbalize gain
OBJECTIVE: of his Limit demand of his
 Lack of strength back exposure to strength back
Energy temperature To avoid negative
and humidity impact in energy
 Disinter extremes
est
Determine
 Always degree of To organize plan
sleeping sleep of care
disturbance

(HEAD NURSING)
NURSING CARE PLAN

77
Name of Patient:Ng, Abner Area: CMC- 7A

Diagnosis s
SUBJECTIVE: Deficient Hospital SHORT TERM: Provide To prevent SHORT TERM:
“Para saan ba knowledge Apparatus After 8 hours information information After 8 hours
‘tong mga regarding | of nursing relevant only overload of nursing
gamit ko?”, as therapeutic Irritability interventions, to the interventions,
verbalized by regimen | patient will be situation patient was
the patient related to lack Confusion able to Can encourage to able to
of information | understand Provide continuation of understand
OBJECTIVE: Lack of what are his positive efforts what are his
 Asks Information therapeutic reinforcement therapeutic
questions | regimen To avoid regimen
frequently Deficient Use short, misunderstanding
knowledge simple
sentences and
concepts To provide an
overview of the
Repeat and information
summarize as
needed To gain
knowledge
Provide
access
information
for contact
person

(HEAD NURSING)
78
NURSING CARE PLAN
Name of Patient: Montarde, Leo Area: CMC- 7A

Diagnosis s
SUBJECTIVE: Hyperthermia Body SHORT TERM: Monitor Vital To have data SHORT TERM:
“Ang lamig, related to Temperature After 4 hours Signs base After 4 hours
giniginaw illness elevated of nursing of nursing
ako”, as above normal interventions, Note interventions,
verbalized by range patient’s chronological Children are more patient’s
the patient body and prone to heat body
temperature developmenta temperature
OBJECTIVE: will decrease. l age of the was
 T= patient decreased.
39.4°c To cool the
Perform TSB body’s surface
To lower body
Give anti – temp
pyretic as
prescribed
79
(HEAD NURSING)
NURSING CARE PLAN

Name of Patient: Gay, Dennis Area: CMC- 7A

Diagnosis s
SUBJECTIVE: Risk for Doesn’t want SHORT TERM: Determine Patient or Family SHORT TERM:
“I want Milo”, unstable blood to cooperate After 8 hours individual history may After 8 hours
as verbalized glucose related to the of nursing factors that affect one’s blood of nursing
by the patient to dietary prescribed interventions, may glucose interventions,
intake diet there will be contribute to there was no
OBJECTIVE: | no noted unstable noted
 Blood Risk for increase in glucose increase in
Glucose – unstable blood glucose Multiple factors blood glucose
8.3g/dL blood glucose level Record affect blood level
patient’s glucose level
common
situations
which
contribute to
unstable To promote
glucose client’s
participation
Provide
information on
balancing food
intake
80
QUIZZES
AND
EVALUATION
TOOL
81
College of Nursing
Name: _____________________________________________ Date: ___________

Year and Section: _________ Group
No.:_______
I. Put the letter of your answer on the space provided.
____1.) Is primarily a thinking act and the process of designing the machine
a.) Directing c.) Organization
b.) Planning d.) none of the above
____ 2.) Is a line drawing that shows how the parts of the organization are
linked?
a.) Organizational Chart c.) Gantt Chart
b.) Flow Chart d.) Chart Carron
____ 3.) It means responsible to only one supervisor.

a.) Unity of Direction c.) Unity of the Heart
b.) Unity of Command d.) none of the above
____ 4.) The oldest and simplest form of organization.

a.) Old Organization c.) New Organization
b.) Simple Organization d.) Hierarchical Organization
____ 5.) Assists the line accomplishing the primary objectives of the unit.
a.)Hierarchical Organization c.) Free – Form/ Matrix
b.) Staff Organization d.) Line Authority
____ 6.) Nurse Schwarzengger is taking care of his patient who can take a
bath on his own, feed himself, and perform ADLS. How many nursing care
hours should he render to the patient?
a.) 1.5 hours c.) 3 hours
b.) 4.5 hours d.) 24 hours
82
____ 7.) Sulakiki Hospital is a newly established hospital that needs a total of
228 nursing personnel. How many nursing professionals should they hire?
a.) 148 c.) 80
b.) 69 d.) 88
____ 8.) How many nursing attendants should Sulakiki Hospital hire?
a.) 148 c.) 80
b.) 69 d.) 88
____ 9.) Nurse El mudo Chacarron is a nurse that possess a heart of an ox,
brain of a t – rex, and an eye of a tiger, is working for 8 hours/ day for 5 days
a week. What is his total working hours/ yr?
a.) 1,704 c.) 1,805
b.) 1,708 d.) 1,6988
____ 10.) Nurse Neri gave birth to his hermaphrodite sibling and she needs to
use his maternity leave. How many months can nurse Neri use her maternity
leave?
a.) 2 months c.) 4 months
b.) 3 months d.) 5 months
____ 11.) Nurse supervisor Mr. Sigarilyas is the one who arranged the
schedule of his staff. This type of Scheduling is called?
a.) Centralized Scheduling c.) Decentralized Scheduling

b.) It’s Complicated d.) This is an English speaking zone
____ 12.) Nurse Schwazengger’s wife just gave birth to their son and needs to
use his Paternity Leave. How many days can he use his paternity leave?
a.) 5 days c.) 6 days
b.) 7 days d.) 8 days
____ 13.) Nurse Canturay is absent because of his inflamed gluteus maximus.
The one that takes the duty of an absent nurse is called?
a.) Drowner c.) Floater
b.) Believer d.) Summoner
____ 14.) Nurse Testosterone is taking care of a patient who needs assistance
in bathing, feeding, or ambulating for shorts periods of time. This patient is
categorized as?
a.) LEVEL 1 – MINIMAL CARE c.) LEVEL 3 – INTENSTIVE CARE
b.) LEVEL 2 – INTERMEDIATE CARE d.) LEVEL 4 - HIGHLY SPECIALIZED
CARE
83
____ 15.) Is the right to act or make decisions with out the approval of higher
administration?
a.) Authority c.) Power
b.) Accountability d.) Status
____ 16.) Is the obligation to perform the assigned task?

b.) Accountability d.) Responsibility
____ 17.) Is the ability to influence another to behave in accordance with ones
wishes?
____ 18.) Is the transmission of information between persons?

a.) Authority c.) Communication
____ 19.) What is the mode of transmission for Pneumonia?

a.) Sexual Intercourse c.) Airborne
b.) Bite of an infected animal d.) Direct Contact
____ 20.) Nurse Bolangtsaw is working at a hospital in Czechoslovakia and his

patient is suffering
from a high – grade fever. The medication that Nurse bolangtsaw is expected
to order is?
a.) Neozep c.) Solucortef
b.) Viagra d.) Aeknil
84
College of Nursing

(HEAD NURSING)
CLINICAL PERFORMANCE EVALUATION TOOL

(Student staff nurse to student head nurse)
Name: Manebo, Krisha Dates of exposure:

December 6, 2010
Year/section: IV - 5 Clinical area: CMC -7A
Direction: Rate the students on the following competencies using a 5-point

scale as follows:
Rating Quantitative Description

5 Outstanding Able to function independently and
correctly observes principles
4 Very satisfactory Able to function with less supervision from
the instructor & observes principles,
theories of nursing most of the time
3 Satisfactory Able to function but requires close
supervision from the instructor and
observes principles and theories of nursing
sometimes
2 Needs improvement Able to function but requires close
occasionally applies principles and theories
of nursing
1 Unsatisfactory Unable to function and has not applied nor
observed underlying principles and
theories of nursing
85
PERFORMANCE RATING
I. ESTABLISHMENT OF WORKING RELATIONSHIP
1. Establishes rapport with subordinates 4
2. Gains trust and confidence of subordinates 4
3. Able to mediate between subordinates and patients 5
4. Able to maintain stability under pressure 5
II. ASSESSMENT/PLANNING
1. Utilizes appropriate resources for ward assessment 4
2. Utilizes different techniques in gathering data (interview, 4
observation, records review, reports)
3. Gathers data on: 5
Nursing service history
Physical set-up
Organizational chart
Ongoing appraisal evaluation
Ward rules and regulations and SOP’s
Channel of communication
Records and reports
4. Analyze data gathered based on scientific concepts and 4
principles
5. Briefs student staff nurses on data gathered 4
6. Identifies and prioritizes problems based on data gathered 5
according to the urgency of the problem, availability of
resources (manpower, materials, money/budget)
III. PROBLEM SOLVING PROCESS
a. Involves the staff, other members of the health team and 4
administrative units in identifying problems in the unit
b. Generates suggestions and recommendations for the 4
resolution of identifies problems
c. Analyze the existence of the problem 4
d. Identifies specific and appropriate strategies to attain 4
objectives
e. Develops alternative course of action 4
f. Implements plan of action 4
g. Sets criteria for evaluation using the different 4
parameters of evaluation
IV. LEADERSHIP
a) Conducts a pre-conference with his/her staff to discuss 4
the objectives and activities for the day, helps
subordinates formulate strategies in accomplishing
assigned tasks, address questions pertaining to
accomplishment of tasks
b) Prepares and briefs subordinates on the learning 4
objectives for the day
c) Distributes patient assignment evenly 5
d) Delegates tasks to student staff nurses 4
e) Prepares and brief subordinates on the daily plan of 4
activities
f) Evaluates if the objectives are met 4
86
g) Identifies constraints for non-attainment of objectives 5
and activities
h) Come up with resolutions to address constraints 4
i) Supervise his/her staff during procedures and other 4
assigned tasks
j) Manages tasks using the principles of time management 4
k) Coordinates and collaborates with other members of the 4
health team and other administrative units in the
attainment of objectives
l) Evaluates performance of staff and the unit as a whole 4
through the use of reports, records, observations,
interviews and conferences
m) Troubleshoots as necessity arise 4
n) Conducts post conference at the end of the shift, 4
resolves issues and concerns and conducts debriefing as
necessary
o) Require incident reports as necessary, keeps the clinical 4
instructor informed and updated
p) Utilizes the existing chain of command in implementing 4
activities
REMARKS:
EVALUATED BY:_________________________
Student staff nurse
CONFORME:___________________________
Student head nurse
NOTED:________________________________
Clinical instructor
Actual score X 100

Total score
135 X 100 = 81.8%

165
87
College of Nursing

(HEAD NURSING)

Name: Marcaida, Romeo Jr. Dates of exposure:

December 6, 2010

scale as follows:

sometimes
88
of nursing
theories of nursing
PERFORMANCE RATING
V. ESTABLISHMENT OF WORKING RELATIONSHIP
6. Gains trust and confidence of subordinates 4
7. Able to mediate between subordinates and patients 4
8. Able to maintain stability under pressure 4
VI. ASSESSMENT/PLANNING
7. Utilizes appropriate resources for ward assessment 4
8. Utilizes different techniques in gathering data (interview, 4
9. Gathers data on: 4
Physical set-up
Records and reports
10.Analyze data gathered based on scientific concepts and 4
principles
11.Briefs student staff nurses on data gathered 4
12.Identifies and prioritizes problems based on data gathered 4
VII. PROBLEM SOLVING PROCESS
h. Involves the staff, other members of the health team and 4
i. Generates suggestions and recommendations for the 4
j. Analyze the existence of the problem 4
k. Identifies specific and appropriate strategies to attain 4
objectives
l. Develops alternative course of action 4
m. Implements plan of action 4
n. Sets criteria for evaluation using the different 4
89
VIII. LEADERSHIP
q) Conducts a pre-conference with his/her staff to discuss 4
the objectives and activities for the day, helps
r) Prepares and briefs subordinates on the learning 5
s) Distributes patient assignment evenly 4
t) Delegates tasks to student staff nurses 4
u) Prepares and brief subordinates on the daily plan of 4
activities
v) Evaluates if the objectives are met 4
w) Identifies constraints for non-attainment of objectives 5
and activities
x) Come up with resolutions to address constraints 4
y) Supervise his/her staff during procedures and other 4
assigned tasks
z) Manages tasks using the principles of time management 4
aa)Coordinates and collaborates with other members of the 4
health team and other administrative units in the
bb) Evaluates performance of staff and the unit as a 5
whole through the use of reports, records, observations,
cc) Troubleshoots as necessity arise 5
dd) Conducts post conference at the end of the shift, 4
necessary
ee)Require incident reports as necessary, keeps the clinical 5
instructor informed and updated
ff) Utilizes the existing chain of command in implementing 5
activities
REMARKS:
EVALUATED BY:_________________________
Student staff nurse
CONFORME:___________________________
Student head nurse
NOTED:________________________________
Clinical instructor
90
Actual score X 100
Total score
139 X 100 = 84.2%

165

College of Nursing

(HEAD NURSING)

Name: Matas, Mherjorie Dates of exposure: December

6, 2010

scale as follows:
91
sometimes
of nursing
theories of nursing
PERFORMANCE RATING
IX. ESTABLISHMENT OF WORKING RELATIONSHIP
10.Gains trust and confidence of subordinates 5
11.Able to mediate between subordinates and patients 4
12.Able to maintain stability under pressure 4
X. ASSESSMENT/PLANNING
13.Utilizes appropriate resources for ward assessment 4
14.Utilizes different techniques in gathering data (interview, 4
15.Gathers data on: 4
Physical set-up
Records and reports
principles
XI. PROBLEM SOLVING PROCESS
o. Involves the staff, other members of the health team and 4
p. Generates suggestions and recommendations for the 4
92
q. Analyze the existence of the problem 4
r.Identifies specific and appropriate strategies to attain 4
objectives
s. Develops alternative course of action 5
t. Implements plan of action 5
u. Sets criteria for evaluation using the different 4
XII. LEADERSHIP
gg) Conducts a pre-conference with his/her staff to 4
discuss the objectives and activities for the day, helps
hh) Prepares and briefs subordinates on the learning 5
ii) Distributes patient assignment evenly 4
jj) Delegates tasks to student staff nurses 4
kk)Prepares and brief subordinates on the daily plan of 4
activities
ll) Evaluates if the objectives are met 4
mm) Identifies constraints for non-attainment of 5
objectives and activities
nn) Come up with resolutions to address constraints 4
oo)Supervise his/her staff during procedures and other 5
assigned tasks
pp) Manages tasks using the principles of time 5
management
qq) Coordinates and collaborates with other members of 4
the health team and other administrative units in the
rr) Evaluates performance of staff and the unit as a whole 4
through the use of reports, records, observations,
ss) Troubleshoots as necessity arise 4
tt) Conducts post conference at the end of the shift, 4
necessary
uu) Require incident reports as necessary, keeps the 4
clinical instructor informed and updated
vv)Utilizes the existing chain of command in implementing 5
activities
REMARKS:
EVALUATED BY:_________________________
Student staff nurse
93
CONFORME:___________________________
Student head nurse
NOTED:________________________________
Clinical instructor
Actual score X 100

Total score
140 X 100 = 84.8%

165

College of Nursing

(HEAD NURSING)

94
Name: Megino, Jenica Joy Dates of exposure: December
6, 2010

scale as follows:

sometimes
of nursing
theories of nursing
PERFORMANCE RATING
XIII. ESTABLISHMENT OF WORKING RELATIONSHIP
13.Establishes rapport with subordinates 5
XIV. ASSESSMENT/PLANNING
Physical set-up
Records and reports
95
principles
XV. PROBLEM SOLVING PROCESS
v. Involves the staff, other members of the health team and 4
w. Generates suggestions and recommendations for the 4
x. Analyze the existence of the problem 4
y. Identifies specific and appropriate strategies to attain 4
objectives
z. Develops alternative course of action 4
aa. Implements plan of action 4
bb.Sets criteria for evaluation using the different 4
XVI. LEADERSHIP
ww) Conducts a pre-conference with his/her staff to 4
xx)Prepares and briefs subordinates on the learning 5
yy)Distributes patient assignment evenly 5
zz) Delegates tasks to student staff nurses 4
aaa) Prepares and brief subordinates on the daily plan of 4
activities
bbb) Evaluates if the objectives are met 4
ccc) Identifies constraints for non-attainment of 4
ddd) Come up with resolutions to address constraints 4
eee) Supervise his/her staff during procedures and other 4
assigned tasks
fff) Manages tasks using the principles of time management 4
ggg) Coordinates and collaborates with other members of 4
hhh) Evaluates performance of staff and the unit as a 5
iii) Troubleshoots as necessity arise 4
jjj) Conducts post conference at the end of the shift, 4
necessary
kkk) Require incident reports as necessary, keeps the 4
lll) Utilizes the existing chain of command in implementing 4
96
activities
REMARKS:
EVALUATED BY:_________________________
Student staff nurse
CONFORME:___________________________
Student head nurse
NOTED:________________________________
Clinical instructor
Actual score X 100

Total score
138 X 100 = 83.6%

165

College of Nursing
97
(HEAD NURSING)

Name: Medina, Carl Alvin Dates of exposure: December

14, 2009

scale as follows:

sometimes
of nursing
theories of nursing
PERFORMANCE RATING
XVII. ESTABLISHMENT OF WORKING RELATIONSHIP
17.Establishes rapport with subordinates 5
XVIII. ASSESSMENT/PLANNING
98
Physical set-up
Records and reports
principles
XIX. PROBLEM SOLVING PROCESS
cc. Involves the staff, other members of the health team and 4
dd.Generates suggestions and recommendations for the 4
ee.Analyze the existence of the problem 5
ff. Identifies specific and appropriate strategies to attain 4
objectives
gg.Develops alternative course of action 4
hh.Implements plan of action 4
ii. Sets criteria for evaluation using the different 4
XX. LEADERSHIP
mmm) Conducts a pre-conference with his/her staff to 5
nnn) Prepares and briefs subordinates on the learning 4
ooo) Distributes patient assignment evenly 4
ppp) Delegates tasks to student staff nurses 4
qqq) Prepares and brief subordinates on the daily plan of 4
activities
rrr)Evaluates if the objectives are met 4
sss) Identifies constraints for non-attainment of 4
ttt)Come up with resolutions to address constraints 4
uuu) Supervise his/her staff during procedures and other 4
assigned tasks
vvv) Manages tasks using the principles of time 4
management
99
www) Coordinates and collaborates with other members of 5
xxx) Evaluates performance of staff and the unit as a 4
yyy) Troubleshoots as necessity arise 4
zzz) Conducts post conference at the end of the shift, 4
necessary
aaaa) Require incident reports as necessary, keeps the 5
bbbb) Utilizes the existing chain of command in 5
implementing activities
REMARKS:
EVALUATED BY:_________________________
Student staff nurse
CONFORME:___________________________
Student head nurse
NOTED:________________________________
Clinical instructor
Actual score X 100

Total score
140 X 100 = 84.8%

165
100
College of Nursing
(HEAD NURSING)
(Student head nurse to student staff nurse)
Name: Manebo, Krisha Dates of

exposure: December 16, 2010 Year/section: Year 4 Section 5
group: 16 clinical area: CMC -7A

scale as follows:

sometimes
of nursing
theories of nursing
PERFORMANCE RATING
XXI. ESTABLISHMENT OF WORKING RELATIONSHIP
21.Establishes rapport with patients 5
22.Able to involve patients in plan of care 5
23.Punctual and prompt in all activities 5
101
24.Able to maintain stability in all activities 5
25.Gathers data using interview, observation, records review 4
and reports
26.Formulates appropriate nursing care plan 4
27.Wear complete prescribed RLE uniform 5
XXII. IMPLEMENTATION
a. Carries out assigned tasks based on the criteria of 5
distribution of assignments
b. Follows principles of time management 5
c. Equipped with the required paraphernalia for RLE 4
d. Observes proper channels of communication 4

e. Carries out plan of care including: 5
• Bedside care
• Administration of medications
• Administration of treatments (CPT, Nebulization,
IVF)
f. Shows initiative in performing tasks 5

g. Accomplishes delegated tasks within prescribed time 5
frame
h. Provides psychological and spiritual support to patients 5
i. Accepts supervision and criticisms 5
j. Conducts appropriate health teachings 4
XXIII. EVALUATION
a. Notifies immediate supervisor about untoward situations 5
or conditions related to patient care in the area
b. Makes revisions in the plan of care as necessary 5
c. Evaluates nursing care rendered 4
XXIV. ETHICO LEGAL CONSIDERATIONS
a. Demonstrates honesty at all times 5
b. Conducts self in a tactful manner 5
c. Keeps confidential patient information 5
d. Observes the PNA Code of Ethics 4
e. Guided by RA 9173 4
f. Observes the 11 Core Competency Guidelines 5
REMARKS:
EVALUATED BY:
Student Head Nurse
CONFORME:
Student Staff Nurse
102
Noted by:
Clinical instructor
Actual Score (120) x 100 = 92 x .80 = 73.84
Total Score (130)
Quiz Grade 94 x .20 = 18.8

Total Grade = 92.64%

College of Nursing
(HEAD NURSING)
Name: Marcaida, Romeo Jr. Dates of


scale as follows:

sometimes
of nursing
theories of nursing
PERFORMANCE RATING
1. Establishes rapport with patients 5
103
2. Able to involve patients in plan of care 5
3. Punctual and prompt in all activities 4
4. Able to maintain stability in all activities 4
5. Gathers data using interview, observation, records review 5
and reports
6. Formulates appropriate nursing care plan 5
7. Wear complete prescribed RLE uniform 5
II. IMPLEMENTATION

• Bedside care
IVF)

frame
III. EVALUATION
IV. ETHICO LEGAL CONSIDERATIONS
REMARKS:
EVALUATED BY:
Student Head Nurse
CONFORME:
Student Staff Nurse
104
Noted by:
Clinical instructor
Actual Score (120) x 100 = 92 x .80 = 73.84
Total Score (130)
Quiz Grade 88 x .20 = 18.8


College of Nursing
(HEAD NURSING)
Name: Matas, Mherjorie Dates of


scale as follows:

sometimes
of nursing
theories of nursing
PERFORMANCE RATING
105
and reports
II. IMPLEMENTATION

• Bedside care
IVF)

frame
III. EVALUATION
REMARKS:
EVALUATED BY:
Student Head Nurse
106
CONFORME:
Student Staff Nurse
Noted by:
Clinical instructor
Actual Score (120) x 100 = 92 x .80 = 73.84
Total Score (130)
Quiz Grade 91 x .20 = 18.2


College of Nursing
(HEAD NURSING)
Name: Megino, Jenica Joy H. Dates of


scale as follows:

sometimes
of nursing
theories of nursing
PERFORMANCE RATING
107
and reports
II. IMPLEMENTATION

• Bedside care
IVF)

frame
III. EVALUATION
REMARKS:
EVALUATED BY:
Student Head Nurse
108
CONFORME:
Student Staff Nurse
Noted by:
Clinical instructor
Actual Score (120x 100 = 92 x .80 = 73.84
Total Score (130)
Quiz Grade 85 x .20 = 17


College of Nursing
(HEAD NURSING)
Name: Medina, Carl Alvin Dates of exposure:

December 16, 2010 Year/section: Year 4 Section 5

scale as follows:

sometimes
of nursing
theories of nursing
109
PERFORMANCE RATING
V. ESTABLISHMENT OF WORKING RELATIONSHIP
10.Punctual and prompt in all activities 4
11.Able to maintain stability in all activities 5
12.Gathers data using interview, observation, records review 5
and reports
13.Formulates appropriate nursing care plan 4
14.Wear complete prescribed RLE uniform 4
VI. IMPLEMENTATION
k. Carries out assigned tasks based on the criteria of 5
l. Follows principles of time management 5
m. Equipped with the required paraphernalia for RLE 4
n. Observes proper channels of communication 4

o. Carries out plan of care including: 5
• Bedside care
IVF)
p. Shows initiative in performing tasks 5

q. Accomplishes delegated tasks within prescribed time 5
frame
r. Provides psychological and spiritual support to patients 5
s. Accepts supervision and criticisms 4
t. Conducts appropriate health teachings 4
VII. EVALUATION
d. Notifies immediate supervisor about untoward situations 5
e. Makes revisions in the plan of care as necessary 5
f. Evaluates nursing care rendered 4
VIII. ETHICO LEGAL CONSIDERATIONS
g. Demonstrates honesty at all times 4
h. Conducts self in a tactful manner 5
i. Keeps confidential patient information 5
j. Observes the PNA Code of Ethics 5
k. Guided by RA 9173 5
l. Observes the 11 Core Competency Guidelines 5
REMARKS:
110
EVALUATED BY:
Student Head Nurse
CONFORME:
Student Staff Nurse
Noted by:
Clinical instructor
Actual Score (120)x 100 = 92 x .80 = 73.84
Total Score (130)
Quiz Grade 88 x .20 = 17.6

Introduction
Gastroenteritis
Gastroenteritis (also known as gastric flu or stomach flu, although unrelated to influenza) is
inflammation of the gastrointestinal tract, involving both the stomach and the small intestine and
resulting in acute diarrhea. It can be transferred by contact with contaminated food and water.
The inflammation is caused most often by an infection from certain viruses or less often
by bacteria, their toxins, parasites, or an adverse reaction to something in the diet or medication.
Current death rates have come down significantly to approximately 1.5 million deaths annually in
the year 2000, largely due to the global introduction of oral rehydration therapy[1] and is a leading
cause of death among infants and children under 5.
At least 50% of cases of gastroenteritis due to foodborne illness are caused by norovirus. Another
20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant
viral agents include adenovirus[4] and astrovirus.
Different species of bacteria can cause gastroenteritis,

including Salmonella, Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia
coli, Yersinia,Vibrio cholerae, and others. Some sources of the infection are improperly prepared
food, reheated meat dishes, seafood, dairy, and bakery products. Each organism causes slightly
111
different symptoms but all result in diarrhea. Colitis, inflammation of the large intestine, may also
be present.
Risk factors include consumption of improperly prepared foods or contaminated water and travel
or residence in areas of poor sanitation. It is also common for river swimmers to become infected
during times of rain as a result of contaminated runoff water.
Significance of the Study

The study emphasizes the right assessments for Acute Gastroenteritis. This
may also help other individual to know the right pattern of interventions for
clients that have Acute Gastroenteritis. This is also for the awareness of
many about what are the preventions that we may do to avoid the increasing
population of Gastoenteritis. After this research the people may know the dos
and don’ts on having Gastroenteritis.
Objectives
General Objective
Acute Gastroenteritis as a case study will provide people with
knowledge and deeper understanding of underlying causes of disease and
different exogenous and endogenous factors that increases the risk of
developing this disease. It will also serve as an opportunity for nurses to
recognize the required nursing care for clients and serve as a lead as they
provide health teaching and present instructional materials focusing on the
prevention of disease.
Specific Objective
- Know the cause of the disease and how does it affect the patient’s
health status.
- Interpret and analyze the results of laboratory tests the patient

underwent.
112
GORDON’S PATTERNS OF FUNCTIONING
Patterns of Before During Interpretation

Functioning Hospitalization Hospitalization
Patient is always Patient The patient

Health brought to the cooperates to the depends on the
Perception hospital by his procedures being physician’s
parents when advised by the advice for his
every time she physician. health care.
feels sick.
The patient The patient is He is not picky

Nutrition – doesn’t have any advised to have a when it comes to
Metabolic favorite food and low fat diet. food and doesn’t
Pattern he is also being have any know
bottle – fed by a allergies to food,
milk formula but in the
(Progress Gold) hospital, they
and doesn’t have served her
any allergies nutritious food to
when it comes to contribute to her
food, as fast recovery.
verbalized by his
mother.
113
Episodes of There were noted The patient
Elimination vomiting and progress. depends on the
Pattern watery stools Vomiting physician’s
were noted, subsided and advise for his
urination is stool becomes health care.
normal. soft, urination is
still normal.
Consumes almost
3 – 4 diapers a Consumes almost
day. 2 – 3 diapers a
day.
GORDON’S PATTERN OF FUNCTIONING

Activity – He is being He became less The patient

Exercise played by her active and became less
Pattern mother and their usually just lying active during
other relatives. in the bed, as hospitalization
He is active and verbalized by the because of his
plays a lot, as mother. condition.
verbalized by the
patient’s mother.
114
Sleep – Rest He doesn’t sleep She usually The frequency of
Pattern. that much sleeps for 8 – 10 his sleep has
because of his hrs because he increased
condition, as became less because he
verbalized by the active. became less
mother. active.
He doesn’t have Cognitive pattern The patient’s

Cognitive any problems in of functioning is cognitive pattern
Pattern his cognitive still normal. of functioning is
pattern of still normal.
functioning for his
age.
GORDON’S PATTERN OF FUNCTIONING

The patient is The patient had There is a change

Self – always smiling decreased energy in the patient’s
Perception and is very and always lies in self – perception
Pattern playful, as the bed and pattern.
verbalized by the crying most of
mother. the time.
115
The patient is the He is being He has a very
Role – first baby in his visited by his supportive and
Relationship family. father after work. loving family.
Pattern
He is always
being played by
his father, mother
and other
relatives.
Patient Nothing changed Patient is already

Sexuality – undergone in his sexuality – circumcised.
Reproductive circumcision last reproductive
Pattern march 2010. pattern.
GORDON’S PATTERNS OF FUNCTIONING

The patient cries The patient cries The patient cries

Coping – Stress whenever he whenever he see whenever he
Pattern sees a stranger, a nurse/ doctor. feels scared/
as verbalized by stressed.
the mother.
116
The patient is a There is no There is no
Value – Belief roman catholic change in his change in his
Pattern and always value – belief value – belief
brought to the pattern. pattern.
church by his
parents.
Patient’s Profile
Name: Arizapa, Chris
Birthday: September 19, 2009
Birthplace: Quezon City
Age: 1 year old
Sex: Male
Address: 0726 DAFADIL St. PIT 5, Green Land Subd.
117
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Hospital Number: 304757
Date of Admission: December 13, 2010
Attending Physician: Dr. Sung - Mallorca
Admitting Diagnosis: Acute Gastroenteritis with some dehydration
Patient’s History
History of Present Illness:
- 3 days prior to admission patient started to have fever (38 - 39°c) with
accompanying 1 episode of vomiting, no consult was done.
- 1 day prior to admission still with fever now with 1 episode of watery stool
with particles, foul smelling, non – mucosa, non – bloody.
- At day of admission, there was no fever but with 3 episodes of watery stools
with particle, decrease in oral intake. This prompted consult with the
attending physician and was subsequently admitted.
118
Past: Medical History
- Undergone hernioraphy bilateral with circumcision, march 2010.

- (-) Allergies
- (-) Measles
- (-) Chickenpox
Environmental History:
- Only child, lives in cainta, drinks progress gold and mineral water.
Immunization History:
- Complete for Age
Birth History:
Date of Birth: September 19, 2009

Gestational Age: Preterm
Type of Delivery: NSD
Indication|: Prom
Neonatal Complications: None
Feeding History:
Formula: Progress Gold
Developmental History:
Regard – 1month
Social Smile – 2months
Turned Abdomen – 3 months
Crept – 7 months
Sat Aided – 3 months
Sat Alone – 6 months
Stood Aided – 9 months
Stood Alone – 10 months
First Step – 10 months
Walked – 10 months
Said Words – 8 months
119
DIAGNOSTIC PROCEDURE
Fecalysis
Date: December 13, 2010
Interpretation:
- Color Yellow
- (+) Bacteria
PHYSICAL ASSESSMENT
A. ASSESSING APPEARANCE AND MENTAL STATUS
NORMAL ACTUAL INTERPRETATIO
ASSESSMENT
FINDINGS FINDINGS N
Vital Signs Temp: 36-37’C Temp: 36.7’C The patient is
RR: 30-40 RR: 48 difficulty in
PR: 120-140bpm PR: 147bpm. breathing.
1. Client posture -relaxed, erect -patient can’t -the patient is
and gait, posture, stand on his own. dependent
standing, sitting coordinated
and walking movement
2. Observe The client is The client is -normal
overall hygiene clean and neat. clean and neat.
3. Body and - No body and - No body and - normal
breath odor breath odor. breath odor.
120
4. Distress in -no distress -no distress -normal
posture noted noted
5. Clients -cooperative - Cooperative to -normal
attitude follow
instructions
6. Client’s Appropriate Client’s Normal
cognitive status client’s responses are
responses, appropriate and
logical sense of understandable
reality,
understandable
B. ASSESSING THE SKIN

ASSESSMENT NORMAL ACTUAL INTERPRETATIO
FINDINGS FINDINGS N
1.Inspect the skin -varies from light -fair complexion - normal
color to deep brown
2.Assess edema No edema No edema - normal
3. Inspect and -no abrasions , no -no abrasions , no -normal
palpate skin other lesions other lesions
lesion
4.observe and -moisture in skin - moisture in skin -normal
palpate the skin and the axillae and the axillae
moisture
5. Palpate skin -with in normal With in normal -normal
temperature range range
temperature. temperature.
6.skin turgor -when pinched -when pinched normal
skin spring back the skin springs
to previous state. back slowly to its
previous state.
C. ASSESSING THE HAIR

FINDINGS FINDINGS N
1. Inspect the -Evenly -hair is evenly -normal
evenness of hair distributed hair distributed.
121
growth over the
scalp.
2.Hair thickness -thick hair -thick hair -normal
and thinness -oily, resilient - oily hair
,texture and hair
oiliness
3.Presence of -no infection -no infection -normal
infection
D. ASSESSING THE SKULL AND FACE

FINDINGS FINDINGS N
1. Inspect the -rounded; smooth - rounded; -normal
skull, shape and skull contour. smooth skull
symmetry. contour.
2. Palpate the -smooth; uniform - smooth; uniform -normal
skull for nodules, consistency and consistency and
masses and absence of absence of
depression. nodules and nodules and
masses. masses.
3. Inspect facial -symmetric facial -symmetrical -normal
features features facial features
4.inspect the -non edematous - Not edematous -normal
eyes for edema eyes and no eyes and no
and hollowness presence of presence of
hollow eyes. hollow eyes.
5. Note -symmetric facial -symmetric facial -normal
symmetry of movements movements
facial movements
E. ASSESSING THE EYES

ASSESMENT NORMAL ACTUAL INTERPRETATIO
FINDINGS FINDINGS N
1.Inspect the -hair evenly -hair evenly -normal
eyebrows distributed distributed
(distribution, -skin intact -skin intact
alignment and -eyebrows -eyebrows
122
skin quality and symmetrically symmetrically
movements) aligned aligned
-equal movements -equal
movements
2.inspect for - equally -equally -normal
eyelashes distributed distributed
-curled slightly -curled slightly
outward outward
3. inspect the -skin intact -no discharges in -normal
eyelids for -no discharges the eyelids
surface -no discoloration
characteristics -lids are
symmetrically
aligned.
4. inspect the -transparent Transparent -normal
bulbor
conjunctiva
5. Inspect the Pinkish Pinkish -normal
Palpebral
Conjunctiva
F. ASSESING THE EARS

1. Inspect the -Color is the -Color is the -normal
Auricles for odor, same as facial same as Facial
symmetry of size skin. skin.
and position. - Symmetrically - Symmetrically
proportional. proportion.
2. Palpate the - Mobile, Firm and - Mobile, Firm and -normal
Auricles for not tender. not
texture, elasticity
and areas of
tenderness.
G. ASSESING THE NOSE AND SINUSES

1. Inspect the -No discharge, -No discharge, -normal
external nose for symmetric and symmetric and
123
shape, size or straight, uniform straight, uniform
color and in color. in color.
discharge from
nares.
2. Palpate the -No tenderness -No tenderness -normal
nose for
tenderness.
3. Determine -air moves freely -(+) nasal -due to colds
patency of both as client breaths disharge
nasal cavities through the
nares.
H. ASSESSING THE LIPS AND BUCCAL MUCOSA

FINDINGS FINDINGS N
1. Inspect the -soft moist and -soft moist and -normal
outer lips for smooth texture smooth texture
symmetry of
contour, color
and texture.
I. ASSESSING THE TEETH, GUMS AND MOUTH

ASSESSMENT NORMAL ACTUAL INTERPRETAION
FINDINGS FINDINGS
1.Inspect the -pink gums -pink gums -normal for
teeth and gum -moist ,firm -moist, firm gums patients age
texture gums -8 teeths
-32 teeths
2. inspect the -central position - central position -normal
position of the
tongue
3. inspect the -moves freely, no -moves freely, no -normal
tongue tenderness tenderness
movement
J. ASSESING THE NECK
124
ASSESSMENT NORMAL ACTUAL INTERPRETAIO
FINDINGS FINDINGS N
1.Inspect the -muscles and - muscles and -normal
neck muscles equally in size equally in size
(sternocleidomast -Head centered
iod and trapezius)
2. observe head -coordinated -coordinated -normal
movements movements with movements with
no discomforts. no discomforts.
K. ASSESSING THE THORAX AND THE LUNGS

FINDINGS FINDINGS N
1.Inspect the -chest is -chest is -normal
shape and symmetrically symmetrically
symmetry of the proportion proportion
thorax
2.Inspect spinal -spine is -spine is -normal
alignment vertically aligned vertically aligned
3.palpate the -skin intact and -skin intact and -normal
posterior thorax uniform uniform
temperature temperature
4.Inspect the -quiet, rhythmic -(+) crackles and - due to
breathing and effortless shallow subcostal pneumonia
patterns respiration retractions
L. ASSESSING THE HEART

FINDINGS FINDINGS
1.assessing the 120-140 bpm -137 -normal
heart rate and Heart sounds bpm
heart sounds clear - clear heart
sounds
M. ASSESSING THE PERIPHERAL PULSES

FINDINGS FINDINGS
125
1. Palpate the -symmetric -symmetric -normal
peripheral pulses pulses volume pulses volume
-full pulsation -full pulsation
N. ASSESSING THE BREAST AND AXILLAE

FINDINGS FINDINGS N
1.inspect the -round and -round and -normal
areola bilaterally same bilaterally same
-light pink in color -brow in color
O. ASSESSING THE ABDOMEN

FINDINGS FINDINGS
1.Inspect the -unblemished -blemished -client undergone
integrity of the -uniform in color -uniform in color surgery in the
abdomen -no tenderness -with tenderness lower abdomen
and lesions
2.inspect the -flat -flabby -normal
abdomen for -no evidence of
contour and enlargement of
symmetry abdominal organs
-no mass or
lesion
P. ASSESSING THE UPPER AND LOWER EXTREMITIES

FINDINGS FINDINGS N
1. Assessing the No severe No severe -normal
Upper and lower varicosities, varicosities,
Extremities deformities, deformities,
126
swelling or swelling or
severe pain on severe pain on
legs legs
2.Assessing the - D5NM 1L x
IVF solution on 100cc/hr
the right
metacarpal vein
3. Nails Pink and clean Pink and clean Normal
Q. ASSESSING THE MUSCULOSKELETAL SYSTEM

ASSESSMENT NORMAL ACTUAL INTEPRATATION
FINDINGS FINDINGS
1.Inspect the -equal size on the -equal size on the -normal
muscle for size both sides of the both sides of the
body body
2.inspect the -no contractures No contractures -normal

muscle and
tendons for
contractions
3.inspect the -no deformities No deformities -normal
skeleton for
normal structure
and deformities
4.inspect joint for -no swelling -no swelling -normal
swelling
ANATOMY AND PHYSIOLOGY
127
Gastrointestinal Tract
Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of cells, called
epithelium. The contents of the tube are considered external to the body and are in
continuity with the outside world at the mouth and the anus. Although each section
of the tract has specialised functions, the entire tract has a similar basic structure
with regional variations.
The wall is divided into four layers as follows:
Mucosa
The innermost layer of the digestive tract has specialised epithelial cells supported
by an underlying connective tissue layer called the lamina propria. The lamina
propria contains blood vessels, nerves, lymphoid tissue and glands that support the
mucosa. Depending on its function, the epithelium may be simple (a single layer) or
stratified (multiple layers).
128
Areas such as the mouth and oesophagus are covered by a stratified squamous (flat)
epithelium so they can survive the wear and tear of passing food. Simple columnar
(tall) or glandular epithelium lines the stomach and intestines to aid secretion and
absorption. The inner lining is constantly shed and replaced, making it one of the
most rapidly dividing areas of the body! Beneath the lamina propria is the muscularis
mucosa. This comprises layers of smooth muscle which can contract to change the
shape of the lumen.
Submucosa
The submucosa surrounds the muscularis mucosa and consists of fat, fibrous
connective tissue and larger vessels and nerves. At its outer margin there is a
specialized nerve plexus called the submucosal plexus or Meissner plexus. This
supplies the mucosa and submucosa.
Muscularis externa
This smooth muscle layer has inner circular and outer longitudinal layers of muscle
fibres separated by the myenteric plexus or Auerbach plexus. Neural innervations
control the contraction of these muscles and hence the mechanical breakdown and
peristalsis of the food within the lumen.
Serosa/mesentery
The outer layer of the GIT is formed by fat and another layer of epithelial cells called
mesothelium.
Individual components of the gastrointestinal

system
Oral cavity
The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified
squamous oral mucosa with keratin covering those areas subject to significant
abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to
the mechanical breakdown of food by chewing and chopping actions of the teeth. The
tongue, a strong muscular organ, manipulates the food bolus to come in contact with
the teeth. It is also the sensing organ of the mouth for touch, temperature and taste
using its specialised sensors known as papillae.
Insalivation refers to the mixing of the oral cavity contents with salivary gland
secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity
129
also plays a limited role in the digestion of carbohydrates. The enzyme serum
amylase, a component of saliva, starts the process of digestion of complex
carbohydrates. The final function of the oral cavity is absorption of small molecules
such as glucose and water, across the mucosa. From the mouth, food passes through
the pharynx and oesophagus via the action of swallowing.
Salivary glands
Three pairs of salivary glands communicate with the oral cavity. Each is a complex
gland with numerous acini lined by secretory epithelium. The acini secrete their
contents into specialised ducts. Each gland is divided into smaller segments called
lobes. Salivation occurs in response to the taste, smell or even appearance of food.
This occurs due to nerve signals that tell the salivary glands to secrete saliva to
prepare and moisten the mouth. Each pair of salivary glands secretes saliva with
slightly different compositions.
Parotids
The parotid glands are large, irregular shaped glands located under the skin on the
side of the face. They secrete 25% of saliva. They are situated below the zygomatic
arch (cheekbone) and cover part of the mandible (lower jaw bone). An enlarged
parotid gland can be easier felt when one clenches their teeth. The parotids produce
a watery secretion which is also rich in proteins. Immunoglobins are secreted help to
fight microorganisms and a-amylase proteins start to break down complex
carbohydrates.
Submandibular
The submandibular glands secrete 70% of the saliva in the mouth. They are found in
the floor of the mouth, in a groove along the inner surface of the mandible. These
glands produce a more viscid (thick) secretion, rich in mucin and with a smaller
amount of protein. Mucin is a glycoprotein that acts as a lubricant.
Sublingual
The sublinguals are the smallest salivary glands, covered by a thin layer of tissue at
the floor of the mouth. They produce approximately 5% of the saliva and their
secretions are very sticky due to the large concentration of mucin. The main
functions are to provide buffers and lubrication.
Oesophagus
130
The oesophagus is a muscular tube of approximately 25cm in length and 2cm in
diameter. It extends from the pharynx to the stomach after passing through an
opening in the diaphragm. The wall of the oesophagus is made up of inner circular
and outer longitudinal layers of muscle that are supplied by the oesophageal nerve
plexus. This nerve plexus surrounds the lower portion of the oesophagus. The
oesophagus functions primarily as a transport medium between compartments.
Stomach
The stomach is a J shaped expanded bag, located just left of the midline between the
oesophagus and small intestine. It is divided into four main regions and has two
borders called the greater and lesser curvatures. The first section is the cardia which
surrounds the cardial orifice where the oesophagus enters the stomach. The fundus
is the superior, dilated portion of the stomach that has contact with the left dome of
the diaphragm. The body is the largest section between the fundus and the curved
portion of the J.
This is where most gastric glands are located and where most mixing of the food
occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are
expelled into the proximal duodenum via the pyloric sphincter. The inner surface of
the stomach is contracted into numerous longitudinal folds called rugae. These allow
the stomach to stretch and expand when food enters. The stomach can hold up to
1.5 litres of material. The functions of the stomach include:
1. The short-term storage of ingested food.
2. Mechanical breakdown of food by churning and mixing motions.
3. Chemical digestion of proteins by acids and enzymes.
4. Stomach acid kills bugs and germs.
5. Some absorption of substances such as alcohol.

Most of these functions are achieved by the secretion of stomach juices by gastric
glands in the body and fundus. Some cells are responsible for secreting acid and
others secrete enzymes to break down proteins.
Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It averages
approximately 6m in length, extending from the pyloric sphincter of the stomach to
the ileo-caecal valve separating the ileum from the caecum. The small intestine is
compressed into numerous folds and occupies a large proportion of the abdominal
cavity.
131
The duodenum is the proximal C-shaped section that curves around the head of the
pancreas. The duodenum serves a mixing function as it combines digestive
secretions from the pancreas and liver with the contents expelled from the stomach.
The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is
in the jejunum where the majority of digestion and absorption occurs. The final
portion, the ileum, is the longest segment and empties into the caecum at the
ileocaecal junction.
The small intestine performs the majority of digestion and absorption of nutrients.
Partly digested food from the stomach is further broken down by enzymes from the
pancreas and bile salts from the liver and gallbladder. These secretions enter the
duodenum at the Ampulla of Vater. After further digestion, food constituents such as
proteins, fats, and carbohydrates are broken down to small building blocks and
absorbed into the body's blood stream.
The lining of the small intestine is made up of numerous permanent folds called
plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is
covered by epithelium with projecting microvilli (brush border). This increases the
surface area for absorption by a factor of several hundred. The mucosa of the small
intestine contains several specialised cells. Some are responsible for absorption,
whilst others secrete digestive enzymes and mucous to protect the intestinal lining
from digestive actions.
Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like
a frame. It consists of the appendix, caecum, ascending, transverse, descending and
sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of
7.5cm.
The caecum is the expanded pouch that receives material from the ileum and starts
to compress food products into faecal material. Food then travels along the colon.
The wall of the colon is made up of several pouches (haustra) that are held under
tension by three thick bands of muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold faecal matter
before it passes through the anorectal canal to the anus. Thick bands of muscle,
known as sphincters, control the passage of faeces.
The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal
surface is flat with several deep intestinal glands. Numerous goblet cells line the
132
glands that secrete mucous to lubricate faecal matter as it solidifies. The functions of
the large intestine can be summarised as:
1. The accumulation of unabsorbed material to form faeces.
2. Some digestion by bacteria. The bacteria are responsible for the formation of
intestinal gas.
3. Reabsorption of water, salts, sugar and vitamins.
Liver
The liver is a large, reddish-brown organ situated in the right upper quadrant of the
abdomen. It is surrounded by a strong capsule and divided into four lobes namely the
right, left, caudate and quadrate lobes. The liver has several important functions. It
acts as a mechanical filter by filtering blood that travels from the intestinal system. It
detoxifies several metabolites including the breakdown of bilirubin and oestrogen. In
addition, the liver has synthetic functions, producing albumin and blood clotting
factors. However, its main roles in digestion are in the production of bile and
metabolism of nutrients. All nutrients absorbed by the intestines pass through the
liver and are processed before traveling to the rest of the body. The bile produced by
cells of the liver, enters the intestines at the duodenum. Here, bile salts break down
lipids into smaller particles so there is a greater surface area for digestive enzymes
to act.
Gall bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on the
posterior surface of the liver's right lobe. It consists of a fundus, body and neck. It
empties via the cystic duct into the biliary duct system. The main functions of the gall
bladder are storage and concentration of bile. Bile is a thick fluid that contains
enzymes to help dissolve fat in the intestines. Bile is produced by the liver but stored
in the gallbladder until it is needed. Bile is released from the gall bladder by
contraction of its muscular walls in response to hormone signals from the duodenum
in the presence of food.
Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its
head communicates with the duodenum and its tail extends to the spleen. The organ
is approximately 15cm in length with a long, slender body connecting the head and
tail segments. The pancreas has both exocrine and endocrine functions. Endocrine
133
refers to production of hormones which occurs in the Islets of Langerhans. The Islets
produce insulin, glucagon and other substances and these are the areas damaged in
diabetes mellitus. The exocrine (secretrory) portion makes up 80-85% of the
pancreas and is the area relevant to the gastrointestinal tract.
It is made up of numerous acini (small glands) that secrete contents into ducts which
eventually lead to the duodenum. The pancreas secretes fluid rich in carbohydrates
and inactive enzymes. Secretion is triggered by the hormones released by the
duodenum in the presence of food. Pancreatic enzymes include carbohydrases,
lipases, nucleases and proteolytic enzymes that can break down different
components of food. These are secreted in an inactive form to prevent digestion of
the pancreas itself. The enzymes become active once they reach the duodenum.

(HEAD NURSING)
NURSING CARE PLAN

Name of Patient: Arizapa, Chris
Area: CMC- 7A
134
Section/ Group: IV – 5, Group 16
Cues Nursin Scientifi Objectiv Interventi Ration Evaluati

g c e ons ale on
Diagno Interfere
sis nce
SUBJECTI Fluid Introducti SHORT Instruct To SHORT
VE: Volume on of TERM: the mother avoid TERM:
“Nanunu Deficit Bacteria After 4 to increase dehydr After 4
yo iyong Related to the GI hours of oral fluid ation hours of
labi to Tract nursing given to nursing
niya”, as illness | intervent the patient intervent
verbalize as Body’s ions, ions,
d by the manifes immune patient’s Monitor patient’s
patient’s ted by response episodes Vital Signs episodes
mother dry lips triggered of To of watery
and | watery Monitor serve stools
OBJECTIV episode The body stools I&O as a was be
E: s of tries to will be Accurately baselin lessen
 Dr watery expel the lessen e data
y Lips stools. foreign LONGTE
 Epi bacteria LONGTE Give To note RM:
sodes | RM: Xylogel as any After 3
of Episodes After 3 prescribed deviatio days of
water of watery days of ns in nursing
y stools nursing Give eliminat intervent
stool intervent Intravenou ion ions,
s ions, s Fluids as there
there will Prescribed To was
be prevent absence
absence further of
of dryness episodes
episodes of the of watery
of lips stool and
watery lips will
stool and To return to
lips will provide normal.
return to adequa
normal. te fluid
intake
DRUG STUDY
GENE MECHANISM INDICATI CONTRAINDICA SIDE NURSING
RIC OF ACTION ONS TIONS EFFECTS RESPONSIBI
NAME LITIES
/
BRAN
D
135
NAME
Zinc
Zinbe Improves Deficien Diarrhe Monitor V/S
e appetite, wt cy a
gain, height Monitor
increase, vomitin patient’s
resistance to g response to
infection by medication
letharg
increasing
y
zinc level
viral
Gastr Stimulates diarrhe Itching Monitor V/S
o gut immune as ,
Flora function, antibioti Swelling Monitor
down c patient’s
regulate associat Fever response to
ed
allergic and medication
diarrhe
inflammatory as and
reactions commu
and provides nity
gut barrier acquire
d
diarrhe
as.
Works by Allergie
Xyzal blocking hist s sleepin Monitor V/S
amine ess,
receptors. It Monitor
does not headac patient’s
prevent the he, response to
actual medication
mouth
release of dryness
histamine
from mast
cells, but
prevents it
binding to its
receptors
Pathophysiology
Predisposing Precipitating
factors: factors:
Gender: Male 136 Lifestyle
Age: 1 y/o
Affected Part: Gastrointestinal Tract
Introduction of bacteria
Bacteria invades the

digestive system
Bacteria penetrates trough

the Gastrointestinal Tract
Body’s immune system

responds
Inflammation of the
Gastrointestinal Tract
Signs and Symptoms
- Diarrhea
- Vomiting
- Fever
- Loss of Apetite
137
Acute Gastroenteritis
Untreated Treated
- Severe - Relief of the

Diarrhea following signs and
symptoms
- Colitis
DISCHARGE PLANNING
Medications:
- Zinbee 2.5mL daily

- GI Flora to consume
138
- Xyzal Oral drops 2x a day for 5 days
Exercise:
- Avoid strenuous activities until fully recovered
Treatment:
- Xylogel to gums every 4 hours as needed
Health Teachings:
- Instruct to increase oral fluid intake
Out Patient:
- Next clinic visit is on December 20, 2010
Spiritual:
- Always think positive and always ask guidance to the lord almighty

(HEAD NURSING)
139
Clinical Area: 7A Semester: 2nd
semester
Inclusive Dates: November 29 to December 23 Level: IV
Clinical Instructor: Mrs. Dela Torre Group: 16
Name of Student Grade Remarks

Manebo, Krisha 92.64%
Matas, Mher 92.04%
Marcaida, Romeo Jr. 91.44%
Megino, Jenica Joy 90.84%
Medina, Carl Alvin 91.44%

INSTRUCTOR

College of Nursing

(Head Nursing)
140
PROBLEM SOLVING PROCESS
DATE:_________________ CLINICAL AREA: CMC-7A

GENERAL OBJECTIVE:
STATEM ANALYS ALTERNA IMPLEMENTA RATIONAL EVALUATI

ENT OF IS TIVE TION E ON
PROBLE COURSE
M AND OF
CUES ACTION
Problem: Risk for After RLE Gathering of To replace After the

IVF medicati exposure, new materials the old one RLE
medicatio on error the IVF such as exposure,
n board is related medication illustration the IVF
already to chart will board, colored medicatio
old ineffecti be able to papers, n chart
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board as new numbers and replaced
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Cues: ed by misplacem one. With
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the signs. replacing it to medication
plastic the medication error by
cover room providing a
therapeuti
- The c / more
color of eye
the board pleasant IV
is already board
faded

INSTRUCTOR

College of Nursing
141
(Head Nursing)
Budgetting:
Item(s) Unit Price

½ illustration board 1 Php 25.00
Colored Papers 12 pcs Php 18.00
Tape 1 Php 6.50
Plastic Cover 1 Yard Php 24.00
Bond Paper 4 pcs Php 3.00
Total: Php 67.50

College of Nursing

(Head Nursing)
142

GENERAL OBJECTIVE:
STATEME ANALYSI ALTERNA IMPLEMENT RATIONA EVALUAT

NT OF S TIVE ATION LE ION
PROBLEM COURSE
AND OF
CUES ACTION
Absence Organizati Provision Using the This will The group

of onal chart of hard illustration be the was able
Organizati is an copy of board to be main to provide
onal Chart Organizati the
structure the hard source of
in 7A. onal chart organizati
that in 7A. portion of the the copy onal chart
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ultimate copy of the onal chart
source of staff and
authority other
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one who 7A. This will
manage provide
goals and long time
protection
policies for Addition of
.
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board.
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And this
structure
will
greatly
help other
colleagues
and
researcher
s to have
the
informatio
n of
organizati
onal chart
of 7A.
143

INSTRUCTOR
Budgeting for the Organizational Chart
Item Price Total

Illustration Board 15pesos 15
Colored Paper 20pesos 20
Plastic cover 15pesos 15
= 50 pesos al
Budgeting for the Wall clock
Item Price Total

Wall clock 150pesos 150
=150 pesos all

College of Nursing
# 4 Sto. Domingo Ave., Quezon City

(HEAD NURSING)
Problem Solving Process (PSP)
Area: Capitol Medical Center 7thA Date: Dec
20, 2010
General Objective: Kardex for the staff in 7thA.
144
STATEME ALTERNAT
NT OF IVE
IMPLEMENTA RATIONA EVALUATI
PROBLE ANALYSIS COURSE
TION LE ON
M AND OF
CUES ACTION
The need KARDEX is Kardex Using different This will The group
to replace very essential make-over sheets of make the was able to
the old especially in colored paper, kardex successfull
Kardex the ward. It is we changed presentab y replace
where vital everything in le in the the old
Not instructions to the kardex eyes of kardex
presentab be done for except for the nurses with a new
le and the patients old frame. and more presentabl
disorganiz are written. It organized e and
ed kardex is also being After changing . organized
in the used as a the pages, we kardex. 
area. reference immediately
during placed the
endorsement kardex sheet to
to the charge each page and
nurse of the fixed
next shift. everything on
Having it it.
organized,
neat and
presentable
may help the
nurses
become
comfortable
while
endorsing with
one another.

BUDGETING
MATERIALS NUMBER OF ITEMS PRICE
USED
Specialty paper 10 pcs. 37.50 php
Plastic folder (pink and 7 pcs 80.00 php
orange)
Double-sided tape 1 pc. 52.50 php
Adhesive tape 1 pc. 25 php
TOTAL: 195php
Prepared by:
MARAVILLAS, Gershwin B.
MEGINO, Jenica Joy H.
MENDOZA, Ma. Theresa D.
Noted by:
Mrs. Mary Grace E. Dela Torre RN, MAN
Clinical Instructor
145
College of Nursing

(Head Nursing)

GENERAL OBJECTIVE:
STATEME ANALYSIS ALTERNA IMPLEMENT RATION EVALUA

NT OF TIVE ATION ALE TION
PROBLEM COURSE
AND CUES OF
ACTION
Unrecogniz
Unrecogniz able labels After 4  Assess the  To After 4
able labels of chart hours of chart rack provid hours of
of charts rack nursing of the e clinical
rack. interventi ward guidel rotation
related to
ines
old and on, the the
on
Objective shattered labels of how, patient
Cues: chart the charts when charts
 No numbers. rack will and rack has
Labels . be able to where already
on recognize the clear and
some further. newly readable
 Room print
labels are
number labels
will be placed in
marking
s of the set. proper
 Make print locations.
chart is
and
uneasy  For
readable
to read. easy
labels.
visuali
zation
.
 Place the
new and
readable
chart  To
labels to recog
146
their nize
proper the
places chart
numb
ers as
well
as to
promo
te
accur
acy in
Cover it with giving
plastic care
to a
right
patien
t.
 To
preve
nt the
labels
from
breaki
ng.
Budgeting
Item Amount
6.00
Colored Papers
Printing 5.00
Double -sided tape 12.75
Plastic Cover
Thumb tucks
TOTAL Php.
Prepared by: _____________________ Noted by:

_____________________
Student Head Nurse Clinical Instructor
147
I thoroughly listen to my student head nurse as she is being mentored by the
staff head nurse.
As we prepare for the upcoming challenges that we are about to face in head
nursing.
148
We gathered on the student’s area to make our ncps and fdars.
We are taking the quiz with honesty and respect to our student head nurse
149
As we seriously pose for the documentation of our head nursing duty.
The determination on our face as the end of the shift is near.
150
Me as a head nurse being mentored by the staff head nurse.
As I seriously and whole heartedly called the dietary.
151
As I carry out doctor’s order with thoroughness and charm.
Me as a medication nurse.
152
As I check the drugs with all of my heart.
Me, as an IV Nurse. As I seriously check the due time of my patients IV.
153
As I check the IVs.
The result of our hard work and careful assessment, our PSP.
154
Our low budgeted, simple but very useful PSP
As we prepare for the ward class.
155
I seriously surfed the net to gather ideas for the betterment of our ward class.
We took a break after the long preparation for our ward class.
156
The time of the ward class has started.
We seriously gathered to talk about the plans on our ward class.
157
After the hardships and trials that we faced during our head nursing duty, it is
now the time to relax and chill for a moment as we are about to be separated
from our beloved Clinical Instructor, Ma`am Dela Torre. We surely had a fun
and knowledgeable experience during our Head Nursing Duty.
158
College of Nursing

(HEAD NURSING)
Learning Insights
There are many things that I’ve learned during our duty in 7A, not
just in the field of nursing but also lessons in life. As a nurse you
should be well – rounded, you should be equipped with knowledge,
skills, patience, good time - management and a characteristic of a
good leader. A wise man once said, “The leader is the one who
shows the way, leads the way, and knows the way”. In a span of one
month I can say that my skills as a leader has somehow improve and
I’ve become more mature not just physically, but also emotionally
and intellectually.
159
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CAPITOL MEDICAL CENTER COLLEGES

RELATED LEARNING EXPERIENCE

In partial fulfillment of the requirements needed

After learning the different theories and concepts in nursing, each

My experience in head nursing gave me a chance to lead a group, to

I would like to express my graceful appreciation to the following special

Capitol Medical Center envisions itself to be globally recognized health care

Capitol Medical Center continually strives to be a role model in the delivery

CMCC PHILOSOPHY AND OBJECTIVES

Capitol Medical Center Colleges of Nursing believes that quality nursing

IV. 7th A Floor Ward

V. DUTIES AND RESPONSIBILITIES OF STUDENT HEAD NURSE

STUDENT HEAD NURSE

STUDENT STAFF NURSE

Good Morning! Please be reminded on our New SOP on Midnight Snacks

To All Night Duty Employees:

In our desire to be of environmental friendly, we discouraged the usage of

Please refer below for the procedure:

For your strict compliance. Thank you.

Note: This will be implemented on April 24, 26 and 29, 2008.

DATE : 14 July 2008

Your cooperation and support will be highly appreciated.

a. Code 70 is sounded whenever a patient in any part of the hospital

2. SERVICE RESIDENT ON DUTY

5. NURSE RECORDER / MICU NURSE

7. MICU ORDERLY / FLOOR ORDERLY

8. FLOOR HEAD NURSE / CHARGE NURSE

Subject: NOD ENHANCEMENTON PF PORTION

2. A written consent must be signed by at least two immediate relatives of legal

3. The Attending Physician and a Pulmonologist must be involved in all cases of

a. The patient has a terminal condition

b. The patient has irreversible brain damage

c. The continuation of ventilator support would be futile

6. Continued respectful comfort is provided until peaceful death

7. A DNR / NHM is effective upon its issuance

POLICIES AND PROCEDURES

• SURROGATE – The person selected to make a decision regarding

• MEDICALLY FUTILE – Cardiopulmonary resuscitation (CPR) will be

• ADVANCE DIRECTIVES – means that a patient’s wishes regarding life

Signatures Revision History

Capitol Medical Center

GUIDELINES FOR DISCHARGING PATIENT

1. Order for Discharge of Patients

No patient shall be discharged without the written order of the

1.2.1 if patient is insisting to be discharged without the approval of

1.2.3 Discharge order through telephone shall be written by Resident-

• It is suggested that doctors talk with their patients regarding their

2.1professional Fee through telephone shall be countersigned by the

3. Doctor’s secretary may be allowed to collect the professional fee of the

5. If a doctor desires to have his professional fee collected by the Business

• Professional fees collected at the Business office are automatically deducted

2. The charge nurse on duty to notify the infection control nurse.

6. The ER nurse to make the laboratory request and to administer the

7. All charge tickets should be tagged with ECC by the ER Clerk.

The charge nurse is responsible in informing the attending physician,

CAPITOL MEDICAL CENTER COLLEGES INC.

RLE ON LEADERSHIP AND MANAGEMENT

IV. CLINICAL FOCUS

SPECIFIC CONTENT ACTIVITIES EVALUATION

Position title: Head Nurse

II. JOB SUMMARY

The head nurse is a professional nurse who assumes responsibility for