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Assessment Established Rapport: Done through making the patients feel comfortable and being as approachable as possible. Obtained Patient History: Through patient interaction, and interviews with the use of open ended and close ended questions that lead to vital information regarding the patients condition. Performed Physical Assessment: For daily patient assessment, a minimum of five minutes per patients was allotted to do a head to toe assessment to determine the immediate needs of the patients. Identified Subjective and Objective cues of the patient

II. Planning Prioritized patient needs and problems with the use of Abraham Maslows Hierarchy of Needs. Formulated short term nursing care plans that were designed to fit the 8 hour shift. III.Implementation Carried out the formulated nursing care plan and the physicians order efficiently Administered prescribed medications bearing in mind the 10 rights in giving the Medications Bedside Care Provided Health Teaching to patients and evaluated health teachings through simple questions that matched their level of understanding including demonstration and return demonstration of certain health teachings. Provided patients social, emotional, psychological and spiritual support while maintaining nurse-patient relationship. Provided patients a comfortable, safe and a therapeutic environment. IV.Evaluation Evaluated the effectiveness of rendered nursing care and nursing care plan through assessment of patients subjective and objective cues. Reported or notified immediate superiors for any untoward unusualities noted from patients.

V. Recording Applied proper documentation in patients chart and recorded promptly the necessary data based from assessments, interventions form the formulated nursing care plans.

Singed: Nia Fe Nuez, R.N. Meil, R.N. RN HEALS II Nurse Rosemarie Nurse Area Supervisor

Dr. Alma B. Ungab, R.N., M.N., DPA Chief Nurse

RN HEALS MONTHLY JOURNAL May 2012 Name: Nia Fe Nuez Cebu Area/Unit of Assignment: Ward II VSMMC I. Activities: Performed daily nursing duties in the unit. 1. Endorsement and nursing rounds every shift done. 2. Perineal Care 3. Bathing the Baby 4. Carrying out of doctors order done. 5. Documentation of nursing processes done. 6. Giving proper medications done. 7. Facilitating of laboratory exams done. 8. Providing safety to patient in the unit done. II. Learning Insights: This month of May is my last month of my exposure to OB Ward. I will surely miss the staff nurses/volunteer nurses there. I learned a lot through them. I was able to handle patients with confidence. Too bad, we just had our duty for approximately 3 months. Just when I was getting to love everything about the ward, we were rotated to another. III.Issues and Concerns: As of now I dont have any issues and concerns coz my concerns before was already given actions and I am happy for that.
IV. Recommendation:

Province: Hospital:

If possible I would like to recommend a Tv for the private room and refrigerator for the ward since there are some medication that needs to be refrigerate. Signed:

Nia Fe Nuez, R.N. R.N. RN HEALS II Nurse

Rosemarie Meil, Nurse Area Supervisor