Hn Format 2

MEDICAL CENTER MANILA – (8th flr) 11 Nov 2009(1:00PM- 10:00PM) IV FLUID MONITORING SHEET RM No.

BOTTL E No.

IVF

HOURS TO RUN

RATE gtts/min

TIME STARTED

DUE TIME

AMOUNT RECEIVED FROM LAST SHIFT

IVF CHECK TIME

LEVEL ENDORSED TO NEXT SHIFT

Prepared by:

Noted by:

Chart Nurse

Vitug, Joan Student Head Nurse

AMOUNT INFUSED

MEDICAL CENTER MANILA – (8th flr) 11 Nov 2009(1:00PM- 10:00PM) STAFF ENDORSEMENT SHEET Room No.

:

Patient’s Initials: Age / Sex

:

Diagnosis

:

DOCTOR’S ORDER

Diet

:

Physician

:

NURSE’S NOTES D

IVF BOTTLE NO : SOLUTION : RATE

:

TIME STARTED : A

DUE TIME

:

AMOUNT RECEIVED : LEVEL ENDORSED TO NEXT SHIFT: MEDICATIONS / TREATMENT R

LABORATORY WORKS / DIAGNOSTIC PROCEDURES

Prepared by:

Noted by:

Staff Nurse

Vitug, Joan Student Head Nurse

MEDICAL CENTER MANILA – (8th flr) 11 Nov 2009(1:00PM- 10:00PM) MEDICATION SHEET Name of Drug

Action

Indication

Contraindication

Adverse Effects

Generic Name: Brand Name: Dosage: Frequency:

Classification:

Prepared By:

Noted by:

Medication Nurse

Vitug, Joan Student Head Nurse

Nursing Responsibilities

MEDICAL CENTER MANILA – (8th flr) 11 Nov 2009(1:00PM- 10:00PM) NURSING CARE PLAN Room No.

:

Patient’s Initials: Age / Sex

:

Diagnosis

:

ASSESSMENT

ANALYSIS

DIAGNOSIS

PLANNING

Diet

:

Physician

:

INTERVENTION

RATIONALE

Prepared by:

Noted by:

Staff Nurse

Vitug, Joan Student Head Nurse

EVALUATION

MEDICAL CENTER MANILA – (8th flr) 11 Nov 2009(1:00PM- 10:00PM) GENERAL APPEARANCE Student’s name Uniform Apron Cap Shoes Stockings/socks Name Plate I.D. Grooming Hair No Jewelry Fingernails Perfume Make-up

S1

S2

S3

S4

S5

S6

S7

Legend: (VG)-Very Good (F)- Fair (B)- Bad (N/A)- Not applicable Prepared by: Vitug, Joan Student Head Nurse

Noted by: Clinical Instructor

S8

Students Name

Prepared by: Noted by:

Vitug, Joan Student Head Nurse Clinical Instructor

Masks

Gloves

Tourniquet

Tape Measure

Drug Hand Book

NANDA

Micropore Tape

ballsWet & Dry Cotton

Clipboard

Penlight

Pen & Pencils

Digital Thermometer

Ruler

Med tray

Bandage scissor

Wrist Watch

Bp apparatus

MEDICAL CENTER MANILA – (Date) (Date(Shift))

PARAPHERNALIA CHECKLIST

MEDICAL CENTER MANILA – (Area) (Date(shift)) PERFORMANCE EVALUATION TOOL NAME___________________________ Staff Nurse Criteria I. Knowledge a. Assessed health conditions accurately. b. Identifies needs/problems of client before, during and after the procedures. c. Properly intervenes t the identified nursing problems by performance of independent and dependent nursing functions with minimum supervision. d. Explains the rationale for each intervention. e. Evaluates the effectiveness of nursing intervention. f. Assumes the independence and responsibility over assigned task. g. Needs the least supervision when doing assigned task. h. Document pertinent observation and cases. i. Gives appropriate health teaching instructions to clients according to needs. II. Skills a. Applies the principle of asepsis when preparing materials and equipment. b. Prepares and set up needed supplies and equipment. c. Uses/ operates tools for nursing intervention. d. Maintains the equipment and supplies used in good working condition and in order of care. e. Reports and records of data are completed and accurate. III. Attitude a. Established good interpersonal relationship with client’s family, co-worker, staff, leader, and CI b. Reports to duty in complete uniform with paraphernalia and properly groomed and on time. c. Has initiative, responsible and efficient. d. Shows respect to himself and others. e. Shows interest and enthusiasm in his work. f. Submits requirement on time. IV. Quizzes (20%) V. Attendance TOTAL 100%

Standard Grade 3 3 3 3 3 3 3 3 3 5 5 5 5 5 3 3 3 3 3 5 20 8 100

Actual Grade

MEDICAL CENTER MANILA – (8th flr) 11 Nov 2009(1:00PM- 10:00PM) ORGANIZATIONAL CHART

Clinical Instructor

Head Nurses

Medication Nurse

Chart Nurse

Staff Nurse

701 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

702 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

703-1 Name: Age/sex: Dr: Dx:

703-2 Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

704-1 Name: Age/sex: Dr: Dx:

704-2 Name: Age/sex: Dr: Dx:

705-2 Name: Age/sex: Dr: Dx:

706-1 Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

Dr’s order:

Dr’s order:

706-2 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

707 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

708 Name: Age/sex: Dr: Dx:

709 Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

710 Name: Age/sex: Dr: Dx:

712 Name: Age/sex: Dr: Dx:

714 Name: Age/sex: Dr: Dx:

715 Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

Dr’s order:

Dr’s order:

716 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

717 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

718 Name: Age/sex: Dr: Dx:

719-1 Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

719-2 Name: Age/sex: Dr: Dx:

720 Name: Age/sex: Dr: Dx:

721 Name: Age/sex: Dr: Dx:

722 Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

Dr’s order:

Dr’s order:

723 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

724-1 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

724-2 Name: Age/sex: Dr: Dx:

725-1 Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

725-2 Name: Age/sex: Dr: Dx:

726-1 Name: Age/sex: Dr: Dx:

726-2 Name: Age/sex: Dr: Dx:

727-1 Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

Dr’s order:

Dr’s order:

727-2 Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

Name: Age/sex: Dr: Dx: Diet: IV: Dr’s order:

Name: Age/sex: Dr: Dx:

Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

Name: Age/sex: Dr: Dx:

Name: Age/sex: Dr: Dx:

Name: Age/sex: Dr: Dx:

Name: Age/sex: Dr: Dx:

Diet: IV:

Diet: IV:

Diet: IV:

Diet: IV:

Dr’s order:

Dr’s order:

Dr’s order:

Dr’s order: