head nursing

Philippine Rehabilitation Institute Foundation, INC.College of Nursing

RELATED LEARNING EXPERIENCELEADERSHIP AND MANAGEMENT

( Head Nursing )

Name: Section/ Group:Hospital: Date of Exposure:

DAILY REQUIREMENT CHECKLISTCRITERIA DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

I. ATTENDANCE/ Time of ArrivalII. PARAPHERNALIA

Bp ApparatusCalculatorThermometerBandage ScissorTourniquetTape MeasureCanister with dry cotton ballsCanister with cotton balls soaked in alcoholMedicine trayBlack/ red, green ball pens, pencilMicropore Small notebookPenlight with batteriesClip boardSignature of Student Head Nurse:Student Head Nurse:

Prepared by: Gian Arlo H. Castro Noted by: Jerry Manlapaz RN, MANStudent Head Nurse Clinical Instructor

Philippine Rehabilitation Institute Foundation, Inc

College Of Nursing

RLE LEADERSHIP AND MANAGEMENT(HEAD NURSING)

SCHEDULE OF ACTIVITIES

Date: February 19, 2013 Clinical Area: Children's Ward Census: 7

Time Activities 6:30-7:00 Opening prayer, checking of attendace, Pre-conference,

Checking of Praphernalias7:00-7:30 Short review on Planning7:30-8:00 Endorsement, Bedside Rounds8:00-9:30 V/S taking, Medicatuins, Morning Care, Chart Reading9:30-10:00 Break10:00-10:30 Quiz on Planning and Rationalization10:30-11:30 Documentation, NCP, Drug Study11:30-12:30 Afternoon V/S Taking, Medications12:30-1:00 Post-conference, Learning Insights



College Of Nursing

RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING)

DAILY PATIENT ASSIGNMENT SHEET


Name of Students Room&

Bed #

Name of Patient Age Diagnosis Doctor in Charge

Remarks

Vazquez, Khaycee Natividad, Elmo 5 Osteomyelitis Dr. BoylesLaxa, Raquel Siaboc, Ariana Mae 1 Pyomyositis L leg Dr. Tuliao

Fernandi, Haydielyn Rodriguez, Ryan Joel 5 Chronic Osteomyelitis Dr. V.A. LimAlfonso, Carmina Raganit, Christopher 4 Fx Open III B Proximal Dr. Simbulan

Amoyo, Mario Jose Solana, Mac Kenneth 3 T/C Pyomositis R arm Dr. V.A. LimVisitacion, Von

DarwinMirabite, Jaryl 5 Fx Cl. Comp. Disp.Subtero-

ChantericDr. Lim

Tanquintic, Michael Badillo, Elisa C. 6 Chronic Osteomyelitis L hip Dr. Boyles



College of Nursing

RLE LEADERSHIP AND MANAGEMENT(HEAD NURSING)

I & O SHEET

Date: Feb. 19, 2013 Clinical Area: Children's Ward Census: 7

Room & Bed No.

Name Of Patient Input Output

Oral IVF NGT ( OF )

Others Urine NGT CTT Others

Berdillo, Elis 500 30 - - 2 - - -Raganit, Christopher 400 50 - - 2 - - -Natividad, Elmo 200 100 - - 2 - - -Siaboc, Ariana Mae 230 50 - - 1 - - -Solana, Mac Kenneth 200 - - - 1 - - -Mirabite, Jaryl 600 - - - - - - -Rodriguez, Ryan Jay 500 - - - 2 - - -



College of Nursing

RLE LEADERSHIP AND MANAGEMENT( HEAD NURSING )

MEDICATION SHEET


Room & Bed #

Name of Patient Name of Drug Action Dosage Frequency Time of Administrati

on

Treatment

Raganit, Christopher

Cefazolin Antibiotic 400 mg q8 8am-4pm-12am

Gentamycin Antibiotic 30 mg q6 6am-12pm-6pm-12am

Paracetamol Analgesic/ Antipyretic

250 g/5 ml

q6 6am-12pm-6pm-12am

Solana, Mac Kenneth

Oxacillin Antibiotic 375mg q6 6am-12pm-6pm-12am

Rodriguez, Ryan Jay

Cefuroxime Antibiotic 750mg q6 6am-12pm-6pm-12am

Siaboc, Ariana Mae Oxacillin Antibiotic 100mg q6 6am-12pm-6pm-12am


250mg/5ml

TID 8am-12pm-5pm

Carbocisteine Mucolytic 1.5mg q6 x 5 days 6am-12pm-6pm-12am

Vit. C Vit. Supplement

1 ml OD 8am

Natividad, Elmo Ceftriaxone Antibiotic

Amikacin Antibacterial 60mg q8 8am-4pm-12am


250mg TID 8am-12pm-5pm

Mirabite, Jaryl Paractamol Analgesic/ Antipyretic

250mg Q4 PRN 12am-4am-8am-12pm-4pm-8pm

Badillo, Elisa Paracetamol Analgesic/ Antipyretic

300mg q4 RTC x 24 hours

12am-4am-8am-12pm-4pm-8pm

Metoclopramide Antiemetic 5mg q6 PRN 6am-12pm-6pm-12am

Ceftriaxone Antibiotic 500mg q12 8am-8pmAmikacin Antibacterial 60mg q8 8am-4pm-

12amIbuprofen Analgesic/

NSAID200mg Q4 PRN 12am-4am-

8am-12pm-4pm-8pm

FeS04 Supplement 5ml OD 8am



ENDORSEMENT SHEET

Date: Feb 19, 2013 Total Census: 7Student Head Nurse: Gian Arlo H. Castro

Name of Patient Age DIC Diagnosis Diet Procedures

Labs Medications V/S I and O Special Endorsement

U S


4 Dr. Simbulan

Fx Open III B

Proximal

DAT - - Cefazolin 400 mg IV q8 (-)

ANST,Gentamycin 30

mg IV q6 (-) ANST,

Paracetamol 250 g/5 ml q6

x24 days

2x - -

Solana, Mac Kenneth

3 Dr. V.A. Lim

T/C Pyomositis R arm

DAT - - Oxacillin 375mg IV Q6

1x - -

Rodriguez, Ryan Jay

5 Dr. V.A. Lim

Chronic Osteomye

litis Fibula

DAT - - Cefuroxime 750mg IV q6 (-)

ANST

2x - -

Siaboc, Ariana Mae

1 Dr. Tulia

o

Pyomyositis L leg

DAT - Oxacillin 100mg IV (-)ANST Q6,

Paracetamol 250mg/5ml 5ml

TID for pain only,

Carbocisteine

1x - -

drops 1.5mg q6 x 5days,

Vit. C drops 1ml OD

Natividad, Elmo

5 Dr. Boyl

es

Osteomyelitis

DAT - - Ceftriaxone,Paracetamol

250mg/5ml 5ml TID for pain

only,Amikacin 60mg

(-) ANST

2x - -

Mirabite, Jaryl

5 Dr. Lim

Fx. Cl. Comp. Disp.

Subterochanderic

DAT - - Paractamol 250mg/5ml q4 PRN for pain

2x - -

Badillo, Elisa 6 Dr. Boyl

es

Chronic osteomyelitis L hip

DAT - - Paracetamol 300mg IV q4

RTC x 24 hours,Metoclopramide 5mg IV q6 PRN,

Ceftriaxone 500mg (-) ANST

q12, Amikacin 60mg

(-) ANST,Ibuprofen

200mg/5ml q4 for pain 5ml,FeS04 syrup

5ml OD

2x - -


PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC.College of Nursing

RELATED LEARNING EXPERIENCELEADERSHIP AND MANAGEMENT

(Head Nursing)

Name: Gian Arlo Castro Section/Group: 3Hospital: Philippine Orthopedic Center Date of Exposure: February 19, 2013

VITAL SIGNS MONITORING SHEET

Room & Bed

No.

Name Of Patient

Time: 8:00 Time: 12:00

BP T P R Pain BP T P R Pain

Natividad, Elmo

100/60 36 108 36 - 100/70 35.8 110 37 -

Badillo, Elisa 100/70 36.3 98 39 - 100/60 36.2 100 40 -

Siaboc, Ariana Mae

- 36.5 120 40 - - 36.6 116 37 -


90/60 37.7 102 36 - 110/70 37.0 109 35 -

Solana, Mac Kenneth

100/60 36.3 110 36 - 100/60 36.5 109 37 -

Mirabite, Joryl 90/40 35.6 107 34 - 100/60 36 110 36 -

Rodriguez, Ryan Jay

100/60 36 100 40 - 100/70 36.4 104 38 -



DRUG STUDY

Name: Castro, Gian Arlo H. Area: POC-Children's Ward Date: Feb. 20, 2013 Score: 89Clinical Instructor: Jerry Manlapaz RN, MAN

NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS

NURSING CONSIDERATIO

NS

BRAND NAME:

Calpol

GENERIC NAME:Paracetamol

250 ml/5 mg

TID

Syrup

Analgesic

Muscle Relaxant

Decrease fever by inhibiting the effects of pyrogen on the hypothalamus heat regulating centers and by a hypothalamic action leading to sweating and vasodilation

Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti inflammatory action because of its minimal effect on peripheral prostaglandin synthesis

Stimulation, drowsiness, nausea, vomiting, abdominal pain, heap toxicity, hepatic seizure , leucopenia, neutropenia, haemolytic anemia, thrombocytopenia, pancytopenia, rash, urticarial, hypersensitivity, cyanosis, anemia, jaundice,

-none- Assess patient fever or pain, type of pain, location, intensity, duration, temperature and diaphoresis

Assess allergic reaction; rash, urtucuria, if these occur drug may have to be discontinued

Teach the patient to recognize signs of chronic overdose; bleeding, bruising, malaise, fever, sore throat.


DRUG STUDY


NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS

BRAND NAME:Oxacillin

GENERIC NAME:Oxacillin Sodium

100 mg IV q6 Antibiotic

antibacterialBactericidal: inhibits cell wall synthesis of sensitive organism causing cell death

CNS: Lethargy, Hallucination, seizuresGI: Glossitis, stomatitis, gastritis, sore mouth, vomiting, diarrhea, abdominal pain, bloody diarrhea, enterocolitis, pseudomembranous colitis, non specific hepatitisGU: nephritis, oliguria, proteinuria, hematuria, cast, azotemia, pyuriaHypersensitivity: rash, fever, wheezing

-none-Tell the patient that side effects maybe experienced such as; upset stomach, nausea, diarrhea,

Report difficulty of breathing, rashes, severe darrhea, severe pain at injection site, mouth sore.

Tell the patient to finish the entire course of therahy prescribed.


DRUG STUDY


NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS

BRAND NAME:

Aflem

GENERIC NAME:Carbocistein

1.5mg q6 x 5 days

Syrup

Mucolytic Reduces the viscosity of sputum and so can be used to help relieve the symptoms of chronic obstructive pulmonary disorder (COPD) and bronchiectasis by allowing the sufferer to bring up sputum more easily.

Bronchospasms, nausea, vomiting, stomatitis & rhinorrhea. Occasionally chills & fever.

-none- Should be taken in with food

Follow the doctors order

Carbocisteine should not be used with antitussives (cough suppressants) or medicines that dry up bronchial secretions.


DRUG STUDY


NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS

BRAND NAME:

Ceelin

GENERIC NAME:Ascorbic Acid

1.5mg q6 x 5 days

Syrup

Supplement Necessary for collagen formation and tissue repair. Involved in oxidation reduction reactions; tyrosine,folic acid, iron, and carbohydrate metabolism; lipid and protein synthesis, cellular respiration; and resisting infection.

CNS: fatigue,headache,insomnia,drowsinessGI: nausea,vomiting,heartburn, cramps,diarrheaGU: kidney stonesDERM: flushingHEMAT: deep veinthrombosis, sicklecell crisis,hemolysis (in G6PDdeficiency)

-none- Assess for signs of Vitamin C deficiency (faulty bone and tooth development, gingivitis, bleeding gums, loosened teeth) before and during therapy.Vitamin Cdeficiency is also called scurvy.

General:Often ordered as a part of multivitamin supplementation, because inadequate diet often results inmultiple-vitamin deficiency


DRUG STUDY

Name: Castro, Gian Arlo H. Area: POC-Children's Ward Date: March 4, 2013 Score: 90Clinical Instructor: Jerry Manlapaz RN, MAN

NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS

BRAND NAME:

Tiki-Tiki

GENERIC NAME:Multivitamins

1 tsp.OD

Syrup

Supplement Dietary supplements for the treatment and prevention of vitamin deficiencies. these vitamins are necessary for normal growth and development. Many acts s coenzymes or catalysts in numerous metabolic process

Urine discoloration, allergic reaction to preservatives, additives or colorants

-none- -none-


DRUG STUDY


NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS










DRUG STUDY


NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS

BRAND NAME:

Calpol


250mg/5ml(6ml)

q6 PRN for pain

Syrup

Analgesic

Muscle Relaxant








DRUG STUDY


NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS

BRAND NAME:

Calpol


250mg/5ml3ml

q4 PRN for pain

Syrup

Analgesic

Muscle Relaxant








DRUG STUDY


NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS

BRAND NAME:

Pharex Co-amoxiclav

GENERIC NAME:Co-amoxiclav

4mg/5ml

TID x 7 days

Syrup

Antibiotic Inhibits enzymes involved in formation of peptidoglycan layer of bacterial cell wallNo effect on human cell wallsBactericidal; only works on dividing bacteriaWell absorbed enterallyClavulanic acid inhibits bacterial ß-lactamase

Hepatitis, cholestatic jaundiceErythema multiforme (including Stevens-Johnson)Toxic epidermal necrolysis; exfoliative dermatitis

Diarrhea, vomitingRashesNeutropenia

-none- History of hypersensitivity

Renal impairment

Hepatic impairment - may cause cholestatic jaundice up to 6 weeks after cessation

May cause maculopapular rashes - almost always in presence of glandular fever


DRUG STUDY

Name: Castro, Gian Arlo H. Area: POC-Children's Ward Date: Mar. 14, 2013 Score: 89Clinical Instructor: Jerry Manlapaz RN, MAN

NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS










DRUG STUDY


NAME OF THE

DRUG

DOSAGEFREQUENCY

PREPARATION

CLASSIFICATION

MECHANISM OF ACTION

ADVERSE REACTIONS

ACTUAL ADVERSE

REACTIONS


NS

BRAND NAME:

Tiki-Tiki

GENERIC NAME:Multivitamins

1 tsp.OD

Syrup

Supplement Dietary supplements for the treatment and prevention of vitamin deficiencies. these vitamins are necessary for normal growth and development. Many acts s coenzymes or catalysts in numerous metabolic process

Urine discoloration, allergic reaction to preservatives, additives or colorants

-none- -none-


NURSING CARE PLANS (NCP)

Name: Area: Date: Score:Clinical instructor:

CUES NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION OF THE PROBLEM

PLANNING INTERVENTIONS

RATIONALE EVALUATION

head nursing

Documents

od syrup mechanism

jerry manlapaz

numerous metabolic

peripheral

specific hepatitis

nursing rle

anti inflammatory

hypothalamic