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MEDICAL CENTER MANILA – (8th flr)

11 Nov 2009(1:00PM- 10:00PM)

IV FLUID MONITORING SHEET

AMOUNT
LEVEL
RM BOTTL HOURS RATE TIME DUE RECEIVED IVF AMOUNT
IVF ENDORSED TO
No. E No. TO RUN gtts/min STARTED TIME FROM LAST CHECK TIME INFUSED
NEXT SHIFT
SHIFT

Prepared by: Noted by:

Vitug, Joan
Chart Nurse Student Head Nurse
MEDICAL CENTER MANILA – (8th flr)

11 Nov 2009(1:00PM- 10:00PM)

STAFF ENDORSEMENT SHEET

Room No. : Diet :


Patient’s Initials: Physician :
Age / Sex :
Diagnosis :

DOCTOR’S ORDER NURSE’S NOTES IVF


BOTTLE NO :
D
SOLUTION :
RATE :
TIME STARTED :
A DUE TIME :
AMOUNT RECEIVED :
LEVEL ENDORSED TO NEXT SHIFT:
MEDICATIONS / TREATMENT

LABORATORY WORKS / DIAGNOSTIC PROCEDURES

Prepared by: Noted by:

Vitug, Joan
Staff Nurse Student Head Nurse
MEDICAL CENTER MANILA – (8th flr)

11 Nov 2009(1:00PM- 10:00PM)

MEDICATION SHEET

Nursing
Name of Drug Action Indication Contraindication Adverse Effects
Responsibilities
Generic Name:

Brand Name:

Dosage:

Frequency:

Classification:

Prepared By: Noted by:

Vitug, Joan
Medication Nurse Student Head Nurse
MEDICAL CENTER MANILA – (8th flr)

11 Nov 2009(1:00PM- 10:00PM)

NURSING CARE PLAN

Room No. : Diet :


Patient’s Initials: Physician :
Age / Sex :
Diagnosis :

ASSESSMENT ANALYSIS DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Prepared by: Noted by:

Vitug, Joan
Staff Nurse Student Head Nurse
MEDICAL CENTER MANILA – (8th flr)

11 Nov 2009(1:00PM- 10:00PM)

GENERAL APPEARANCE

Student’s name S1 S2 S3 S4 S5 S6 S7 S8
Uniform
Apron
Cap
Shoes
Stockings/socks
Name Plate
I.D.
Grooming
Hair
No Jewelry
Fingernails
Perfume
Make-up

Legend:

(VG)-Very Good
(F)- Fair
(B)- Bad
(N/A)- Not applicable

Prepared by: Noted by:

Vitug, Joan
Student Head Nurse Clinical Instructor
Vitug, Joan
Prepared by:

Student Head Nurse


Students Name

Bp apparatus

Wrist Watch

Bandage scissor

Med tray

Ruler

Digital Thermometer
(Date(Shift))

Pen & Pencils


PARAPHERNALIA CHECKLIST
MEDICAL CENTER MANILA – (Date)

Penlight
Noted by:

Clipboard
Clinical Instructor

ballsWet & Dry Cotton

Micropore Tape

NANDA

Drug Hand Book

Tape Measure

Tourniquet

Gloves

Masks
MEDICAL CENTER MANILA – (Area)

(Date(shift))

PERFORMANCE EVALUATION TOOL

NAME___________________________
Staff Nurse
Criteria Standard Actual
Grade Grade
I. Knowledge
a. Assessed health conditions accurately. 3
b. Identifies needs/problems of client before, during and after the procedures. 3
c. Properly intervenes t the identified nursing problems by performance of independent and 3
dependent nursing functions with minimum supervision.
d. Explains the rationale for each intervention. 3
e. Evaluates the effectiveness of nursing intervention. 3
f. Assumes the independence and responsibility over assigned task. 3
g. Needs the least supervision when doing assigned task. 3
h. Document pertinent observation and cases. 3
i. Gives appropriate health teaching instructions to clients according to needs. 3
II. Skills
a. Applies the principle of asepsis when preparing materials and equipment. 5
b. Prepares and set up needed supplies and equipment. 5
c. Uses/ operates tools for nursing intervention. 5
d. Maintains the equipment and supplies used in good working condition and in order of care. 5
e. Reports and records of data are completed and accurate. 5
III. Attitude
a. Established good interpersonal relationship with client’s family, co-worker, staff, leader, and CI 3
b. Reports to duty in complete uniform with paraphernalia and properly groomed and on time. 3
c. Has initiative, responsible and efficient. 3
d. Shows respect to himself and others. 3
e. Shows interest and enthusiasm in his work. 3
f. Submits requirement on time. 5
IV. Quizzes (20%) 20
V. Attendance 8
TOTAL 100% 100
MEDICAL CENTER MANILA – (8th flr)

11 Nov 2009(1:00PM- 10:00PM)

ORGANIZATIONAL CHART

Clinical Instructor

Head Nurses

Medication Nurse Chart Nurse Staff Nurse


701 702 703-1 703-2
Name: Name: Name:
Age/sex: Name: Age/sex: Age/sex:
Dr: Age/sex: Dr: Dr:
Dx: Dr: Dx: Dx:
Dx:
Diet: Diet: Diet:
IV: Diet: IV: IV:
IV:
Dr’s order: Dr’s order: Dr’s order:
Dr’s order:

704-1 704-2 705-2 706-1


Name: Name: Name: Name:
Age/sex: Age/sex: Age/sex: Age/sex:
Dr: Dr: Dr: Dr:
Dx: Dx: Dx: Dx:

Diet: Diet: Diet: Diet:


IV: IV: IV: IV:

Dr’s order: Dr’s order: Dr’s order: Dr’s order:


706-2 707 708 709
Name: Name: Name:
Age/sex: Name: Age/sex: Age/sex:
Dr: Age/sex: Dr: Dr:
Dx: Dr: Dx: Dx:
Dx:
Diet: Diet: Diet:
IV: Diet: IV: IV:
IV:
Dr’s order: Dr’s order: Dr’s order:
Dr’s order:

710 712 714 715


Name: Name: Name: Name:
Age/sex: Age/sex: Age/sex: Age/sex:
Dr: Dr: Dr: Dr:
Dx: Dx: Dx: Dx:

Diet: Diet: Diet: Diet:


IV: IV: IV: IV:

Dr’s order: Dr’s order: Dr’s order: Dr’s order:


716 717 718 719-1
Name: Name: Name:
Age/sex: Name: Age/sex: Age/sex:
Dr: Age/sex: Dr: Dr:
Dx: Dr: Dx: Dx:
Dx:
Diet: Diet: Diet:
IV: Diet: IV: IV:
IV:
Dr’s order: Dr’s order: Dr’s order:
Dr’s order:

719-2 720 721 722


Name: Name: Name: Name:
Age/sex: Age/sex: Age/sex: Age/sex:
Dr: Dr: Dr: Dr:
Dx: Dx: Dx: Dx:

Diet: Diet: Diet: Diet:


IV: IV: IV: IV:

Dr’s order: Dr’s order: Dr’s order: Dr’s order:


723 724-1 724-2 725-1
Name: Name: Name:
Age/sex: Name: Age/sex: Age/sex:
Dr: Age/sex: Dr: Dr:
Dx: Dr: Dx: Dx:
Dx:
Diet: Diet: Diet:
IV: Diet: IV: IV:
IV:
Dr’s order: Dr’s order: Dr’s order:
Dr’s order:

725-2 726-1 726-2 727-1


Name: Name: Name: Name:
Age/sex: Age/sex: Age/sex: Age/sex:
Dr: Dr: Dr: Dr:
Dx: Dx: Dx: Dx:

Diet: Diet: Diet: Diet:


IV: IV: IV: IV:

Dr’s order: Dr’s order: Dr’s order: Dr’s order:


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

Name: Name: Name: Name:


Age/sex: Age/sex: Age/sex: Age/sex:
Dr: Dr: Dr: Dr:
Dx: Dx: Dx: Dx:

Diet: Diet: Diet: Diet:


IV: IV: IV: IV:

Dr’s order: Dr’s order: Dr’s order: Dr’s order:

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