Philippine Rehabilitation Institute Foundation Inc College Of Nursing RLE LEADERSHIP AND MANAGEMENT ( HEAD NURSING ) ACHIEVEMENT EVALUTION

REPORT (HEAD NURSE TO STAFF NURSE) Area: Children's Ward Inclusive Date: February 19, 2013 Clinical Instructor: Jerry Manlapaz RN, MAN Name of Students Grades Amoyo, Mario Jose 94.6 Alfonso, Carmina 90.8 Fernando, Haydielyn 94.6 Laxa, Raquel 96.9 Tanquintic, Michael 90 Vasquez, Khaycee 95.3 Visitacion, Von Darwin 92.3 Semester: 2nd Level: NCM 205 Sec/ Group: Remarks

Date: Submitted By: Signature Over Printed Name

Philippine Rehabilitation Institute Foundation, Inc. College Of Nursing Daily TASK SHEET Name: Gian Arlo H. Castro Section/Group: Patients Name: Balbuena, Ariane Room/Bed #: Diagnosis: Fx open IIIB comp. Disp. D3rd femur R Fx close inc D3rd fibula R S/P Spanning External Fixator Attending Physician: Dr. Cuevedo Vital Signs:q8 I & O: Diet: DAT Activity: Contraption: Spanning E.F. IVFs: Procedure/ Laboratory Work Up: X-ray Medication: Oxacillin 100mg IV ANST (-) q6 Paracetamol 250mg/5ml 5ml TID for pain Carbocistein drops 1.5mg q6 x 5 days Vit. C drops 1ml OD Area:Children's Ward Date: Feb. 20, 2013 >received px awake, alert & coherent sitting on wheelchair and wants to go outside asking her mom >px is bored and wants to do other things >took the V/S as follos BP: 80/40 T:35.1 P:82 R:32 >TSB given by mother and px shown signs of relief >I & O as follows Oral: 150ml Urine: 2 diapers Stool: 0 >took the patients incident history CASTRO,Gian Arlo H. SN =================================

Vital Signs: BP: 80/40 T: 35.1 P: 82 R: 32

I: Oral = 150ml Parenteral = n/a Output: Urine= 2 Drainage= n/a BM=0

Philippine Rehabilitation Institute Foundation, Inc. College Of Nursing Daily TASK SHEET Name: Gian Arlo H. Castro Section/Group: Patients Name: Balbuena, Ariane Room/Bed #: Cubicle I Diagnosis: Fx open IIIB comp. Disp. D3rd femur R Fx close inc D3rd fibula R S/P Spanning External Fixator Attending Physician: Dr. Cuevedo Vital Signs:q8 I & O: Diet: DAT Activity: Contraption: Spanning E.F. IVFs: Procedure/ Laboratory Work Up: X-ray Medication: Ceftazidime 250mg/IV q8 (-)ANST Paracetamol 250mg/5ml 6ml q6 PRN for pain Multivitamins + FeSO4 1 tsp OD Area:Children's Ward Date: Mar. 4, 2013 >received px awake, active and coherent lying on a different bed. >px has no IVF but has Spanning EF >on DAT >took the V/S as follos BP: 80/60 T:36.3 P:10 R:34 >arranged and groomed the bed >I & O as follows Oral: 80ml Urine: 1 diapers Stool: 0 >endorsed CASTRO,Gian Arlo H. SN =================================

Vital Signs: BP: 80/60 T: 36.3 P: 110 R: 34

I: Oral = 80ml Parenteral = n/a Output: Urine= 1 Drainage= n/a BM=0

Philippine Rehabilitation Institute Foundation, Inc. College Of Nursing Daily TASK SHEET Name: Gian Arlo H. Castro Section/Group: Patients Name: Cabanes. Phillip Joshua Room/Bed #: Diagnosis: Cl. Comp. Disp. Subtrochanderic Femur L Attending Physician: Dr. Cueveda Vital Signs:q4 I & O: Diet: DAT Activity: Contraption: Steinmann Pin Insertion 90-90 BST IVFs: Procedure/ Laboratory Work Up: X-ray, Ultrasound, Blood exam, Medication: Co-amoxiclav 4mg/5ml TID x 7 days Paracetamol 250mg/5ml 3ml q4 PRN for pain Area:Children's Ward Date: Mar. 5, 2013 >received pax awake, alert & coherent sitting on wheelchair and wants to go outside asking her mom >px is bored and wants to do other things >took the V/S as follos BP: 80/40 T:35.1 P:82 R:323 >TSB given by mother and px shown signs of relief >I & O as follows Oral: 150ml Urine: 2 diapers Stool: 0 >took the patients incident history CASTRO,Gian Arlo H. SN =================================

Vital Signs: BP: 90/60 T: 37.9 P: 92 R: 42

I: Oral = 100ml Parenteral = n/a Output: Urine= 1 Drainage= n/a BM=0

Philippine Rehabilitation Institute Foundation, Inc. College Of Nursing Daily TASK SHEET Name: Gian Arlo H. Castro Section/Group: Patients Name: Balbuena, Ariane Room/Bed #: Diagnosis: Fx open IIIB comp. Disp. D3rd femur R Fx close inc D3rd fibula R S/P Spanning External Fixator Attending Physician: Dr. Cuevedo Vital Signs: I & O: Diet: DAT Activity: Contraption: Spanning E.F. IVFs: Procedure/ Laboratory Work Up: X-ray Medication: Oxacillin 100mg IV ANST (-) q6 Multivitamins + FeSO4 1 tsp OD Vital Signs: BP: 80/60 T: 36.3 P: 110 R: 34 I: Oral = 2000ml Parenteral = n/a Output: Urine= 1 Drainage= n/a BM=0 Area:Children's Ward Date: Mar. 14, 2013 >received pax awake, alert & coherent lying on a different bed playing with her >px is playful and is stll on Spanning E.F. On >took the V/S as follos BP: 80/60 T:36.3 P:110 R:34 >TSB given by mother and px shown signs of relief >I & O as follows Oral: 200ml Urine: 1 diapers Stool: 0 >played with the px to lessen the uneasiness of the patient CASTRO,Gian Arlo H. SN =================================

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing # 56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Head Nurse to Student Staff Nurse) Name: Mario Jose Amoyo Year/ Section: Group: 3 Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward

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 ad observes principles theories of nursing most of the time 3 Satisfactory Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes 2 Needs Improvement Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing 1 Unsatisfactory Unable to function and has not applied nor observed underlying principles at theories of nursing

I. 1. 2. 3. 4. 5. 6. 7. II. a. b. c. d.

Performance Assessment/ Planning Establishes rapport with patients Able to involve patients in plan of care Punctual and prompt in all activities Able to maintain stability under pressure Gathers data using interview, observation, records review and reports Formulates appropriate nursing care plan Wears complete prescribed RLE uniform Assessment/ Planning Carriers out assigned tasks based on the criteria of distribution of assignments Follows principles of time management Equipped with the required paraphernalia for RLE Observes proper channels of communication

Rating 5 5 4 5 4 5 4 5 5 4 5

e. Carriers out plan of care, including: Bedside care Administration of Medications Administration of treatment ( CPT, Nebulization, IVF ) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III.Evaluation a. Notifies immediate supervisor about untoward situations or conditions related to patient care in the area b. Makes revision in the plan of care as necessary c. Evaluates nursing care rendered IV. Ethico Considerations a. Demonstrates honesty at all times b. Conducts self in a tactful manner c. Keeps confidential information d. Observes the PNA Code of Ethics e. Guided by RA 9173 f. Observes the 11 Core Competency Guidelines REMARKS:

4 5 4 5 5 5 4 5 5 5 5 5 5 5

EVALUATED BY: CONFORME: NOTED: Actual Score x 100 Total Score

Gian Arlo H. Castro Student Head Nurse Gian Arlo H. Castro Student Staff Nurse Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing # 56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Head Nurse to Student Staff Nurse) Name: Michael Tanquintic Year/ Section: Group: 3 Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward

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 ad observes principles theories of nursing most of the time 3 Satisfactory Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes 2 Needs Improvement Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing 1 Unsatisfactory Unable to function and has not applied nor observed underlying principles at theories of nursing

I. 1. 2. 3. 4. 5. 6. 7. II. a. b. c. d.

Performance Assessment/ Planning Establishes rapport with patients Able to involve patients in plan of care Punctual and prompt in all activities Able to maintain stability under pressure Gathers data using interview, observation, records review and reports Formulates appropriate nursing care plan Wears complete prescribed RLE uniform Assessment/ Planning Carriers out assigned tasks based on the criteria of distribution of assignments Follows principles of time management Equipped with the required paraphernalia for RLE Observes proper channels of communication

Rating 4 4 5 4 4 5 4 5 5 4 4

e. Carriers out plan of care, including: Bedside care Administration of Medications Administration of treatment ( CPT, Nebulization, IVF ) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III.Evaluation a. Notifies immediate supervisor about untoward situations or conditions related to patient care in the area b. Makes revision in the plan of care as necessary c. Evaluates nursing care rendered IV. Ethico Considerations a. Demonstrates honesty at all times b. Conducts self in a tactful manner c. Keeps confidential information d. Observes the PNA Code of Ethics e. Guided by RA 9173 f. Observes the 11 Core Competency Guidelines REMARKS:

4 5 5 4 5 4 4 5 5 5 5 5 5 5

EVALUATED BY: CONFORME: NOTED: Actual Score x 100 Total Score

Gian Arlo H. Castro Student Head Nurse Gian Arlo H. Castro Student Staff Nurse Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing # 56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Head Nurse to Student Staff Nurse) Name: Carmina Alfonso Year/ Section: Group: 3 Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward

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 ad observes principles theories of nursing most of the time 3 Satisfactory Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes 2 Needs Improvement Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing 1 Unsatisfactory Unable to function and has not applied nor observed underlying principles at theories of nursing

I. 1. 2. 3. 4. 5. 6. 7. II. a. b. c. d.

Performance Assessment/ Planning Establishes rapport with patients Able to involve patients in plan of care Punctual and prompt in all activities Able to maintain stability under pressure Gathers data using interview, observation, records review and reports Formulates appropriate nursing care plan Wears complete prescribed RLE uniform Assessment/ Planning Carriers out assigned tasks based on the criteria of distribution of assignments Follows principles of time management Equipped with the required paraphernalia for RLE Observes proper channels of communication

Rating 5 5 4 5 4 4 5 5 5 5 4

e. Carriers out plan of care, including: Bedside care Administration of Medications Administration of treatment ( CPT, Nebulization, IVF ) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III.Evaluation a. Notifies immediate supervisor about untoward situations or conditions related to patient care in the area b. Makes revision in the plan of care as necessary c. Evaluates nursing care rendered IV. Ethico Considerations a. Demonstrates honesty at all times b. Conducts self in a tactful manner c. Keeps confidential information d. Observes the PNA Code of Ethics e. Guided by RA 9173 f. Observes the 11 Core Competency Guidelines REMARKS:

5 5 4 5 5 4 5 4 4 5 5 3 4 4

EVALUATED BY: CONFORME: NOTED: Actual Score x 100 Total Score

Gian Arlo H. Castro Student Head Nurse Gian Arlo H. Castro Student Staff Nurse Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing # 56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Head Nurse to Student Staff Nurse) Name:Von Darwin Visitacion Year/ Section: Group: 3 Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward

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 ad observes principles theories of nursing most of the time 3 Satisfactory Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes 2 Needs Improvement Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing 1 Unsatisfactory Unable to function and has not applied nor observed underlying principles at theories of nursing

I. 1. 2. 3. 4. 5. 6. 7. II. a. b. c. d.

Performance Assessment/ Planning Establishes rapport with patients Able to involve patients in plan of care Punctual and prompt in all activities Able to maintain stability under pressure Gathers data using interview, observation, records review and reports Formulates appropriate nursing care plan Wears complete prescribed RLE uniform Assessment/ Planning Carriers out assigned tasks based on the criteria of distribution of assignments Follows principles of time management Equipped with the required paraphernalia for RLE Observes proper channels of communication

Rating 4 4 4 4 5 5 5 5 5 4 5

e. Carriers out plan of care, including: Bedside care Administration of Medications Administration of treatment ( CPT, Nebulization, IVF ) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III.Evaluation a. Notifies immediate supervisor about untoward situations or conditions related to patient care in the area b. Makes revision in the plan of care as necessary c. Evaluates nursing care rendered IV. Ethico Considerations a. Demonstrates honesty at all times b. Conducts self in a tactful manner c. Keeps confidential information d. Observes the PNA Code of Ethics e. Guided by RA 9173 f. Observes the 11 Core Competency Guidelines REMARKS:

4 4 5 5 5 5 4 4 4 5 5 5 5 5

EVALUATED BY: CONFORME: NOTED: Actual Score x 100 Total Score

Gian Arlo H. Castro Student Head Nurse Gian Arlo H. Castro Student Staff Nurse Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing # 56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Head Nurse to Student Staff Nurse) Name: Khaycee Vasquez Year/ Section: Group: 3 Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward

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 ad observes principles theories of nursing most of the time 3 Satisfactory Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes 2 Needs Improvement Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing 1 Unsatisfactory Unable to function and has not applied nor observed underlying principles at theories of nursing

I. 1. 2. 3. 4. 5. 6. 7. II. a. b. c. d.

Performance Assessment/ Planning Establishes rapport with patients Able to involve patients in plan of care Punctual and prompt in all activities Able to maintain stability under pressure Gathers data using interview, observation, records review and reports Formulates appropriate nursing care plan Wears complete prescribed RLE uniform Assessment/ Planning Carriers out assigned tasks based on the criteria of distribution of assignments Follows principles of time management Equipped with the required paraphernalia for RLE Observes proper channels of communication

Rating 5 5 5 5 5 5 5 5 5 5 5

e. Carriers out plan of care, including: Bedside care Administration of Medications Administration of treatment ( CPT, Nebulization, IVF ) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III.Evaluation a. Notifies immediate supervisor about untoward situations or conditions related to patient care in the area b. Makes revision in the plan of care as necessary c. Evaluates nursing care rendered IV. Ethico Considerations a. Demonstrates honesty at all times b. Conducts self in a tactful manner c. Keeps confidential information d. Observes the PNA Code of Ethics e. Guided by RA 9173 f. Observes the 11 Core Competency Guidelines REMARKS:

4 4 5 5 5 5 4 5 5 4 4 5 5 5

EVALUATED BY: CONFORME: NOTED: Actual Score x 100 Total Score

Gian Arlo H. Castro Student Head Nurse Gian Arlo H. Castro Student Staff Nurse Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing # 56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Head Nurse to Student Staff Nurse) Name:Raquel Laxa Year/ Section: Group: 3 Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward

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 ad observes principles theories of nursing most of the time 3 Satisfactory Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes 2 Needs Improvement Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing 1 Unsatisfactory Unable to function and has not applied nor observed underlying principles at theories of nursing

I. 1. 2. 3. 4. 5. 6. 7. II. a. b. c. d.

Performance Assessment/ Planning Establishes rapport with patients Able to involve patients in plan of care Punctual and prompt in all activities Able to maintain stability under pressure Gathers data using interview, observation, records review and reports Formulates appropriate nursing care plan Wears complete prescribed RLE uniform Assessment/ Planning Carriers out assigned tasks based on the criteria of distribution of assignments Follows principles of time management Equipped with the required paraphernalia for RLE Observes proper channels of communication

Rating 5 5 5 5 5 5 4 5 5 5 5

e. Carriers out plan of care, including: Bedside care Administration of Medications Administration of treatment ( CPT, Nebulization, IVF ) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III.Evaluation a. Notifies immediate supervisor about untoward situations or conditions related to patient care in the area b. Makes revision in the plan of care as necessary c. Evaluates nursing care rendered IV. Ethico Considerations a. Demonstrates honesty at all times b. Conducts self in a tactful manner c. Keeps confidential information d. Observes the PNA Code of Ethics e. Guided by RA 9173 f. Observes the 11 Core Competency Guidelines REMARKS:

5 5 5 5 4 4 5 5 5 5 5 5 5 5

EVALUATED BY: CONFORME: NOTED: Actual Score x 100 Total Score

Gian Arlo H. Castro Student Head Nurse Gian Arlo H. Castro Student Staff Nurse Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing # 56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Head Nurse to Student Staff Nurse) Name:Von Darwin Visitacion Year/ Section: Group: 3 Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward

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 ad observes principles theories of nursing most of the time 3 Satisfactory Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes 2 Needs Improvement Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing 1 Unsatisfactory Unable to function and has not applied nor observed underlying principles at theories of nursing

I. 1. 2. 3. 4. 5. 6. 7. II. a. b. c. d.

Performance Assessment/ Planning Establishes rapport with patients Able to involve patients in plan of care Punctual and prompt in all activities Able to maintain stability under pressure Gathers data using interview, observation, records review and reports Formulates appropriate nursing care plan Wears complete prescribed RLE uniform Assessment/ Planning Carriers out assigned tasks based on the criteria of distribution of assignments Follows principles of time management Equipped with the required paraphernalia for RLE Observes proper channels of communication

Rating 5 5 5 5 5 4 4 4 4 5 5

e. Carriers out plan of care, including: Bedside care Administration of Medications Administration of treatment ( CPT, Nebulization, IVF ) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III.Evaluation a. Notifies immediate supervisor about untoward situations or conditions related to patient care in the area b. Makes revision in the plan of care as necessary c. Evaluates nursing care rendered IV. Ethico Considerations a. Demonstrates honesty at all times b. Conducts self in a tactful manner c. Keeps confidential information d. Observes the PNA Code of Ethics e. Guided by RA 9173 f. Observes the 11 Core Competency Guidelines REMARKS:

5 5 5 5 4 5 5 5 5 4 5 5 5 5

EVALUATED BY: CONFORME: NOTED: Actual Score x 100 Total Score

Gian Arlo H. Castro Student Head Nurse Gian Arlo H. Castro Student Staff Nurse Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing #56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Staff Nurse to Student Head Nurse)

Name: Gian Arlo Castro Year/ Section: Rating 5 4 3 2 1

Group:

Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward Description Able to function independently and correctly Observes principles Able to function with less supervision from the instructor and observes principles theories of nursing most of the time Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing Unable to function and has not applied nor observed underlying principles at theories of nursing

Quantitative Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Performance I.ESTABLISHMENT OF WORKING RELATIONSHIP 1. Establishes rapport with subordinates 2. Gains trust and confidence of subordinates 3. Able to mediate between subordinates and patients 4. Able to maintain stability under pressure II. ASSESSMENT/ PLANNING 1. Utilizes appropriate resources for ward assessment 2. Utilizes different techniques in gathering data ( interview, observation, records review, reports) 3. Gathers data on:

Rating 5 5 5 5 5 5 5

Nursing service history Physical set up Organization chart Ongoing appraisal evaluation Ward rules and regulation at SOPS Channel of communication Records and Reports 4. Analyze data gathered based on scientific concepts and principles 5. Briefs students staff nurses on data gathered 6. Identifies and priorities problems based on data gathered according to the urgency of the availability of resources ( man power, materials, money/ budget) III. PROBLEM SOLVING PROCESS a. Involves the staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identifies problems c. Analyze the existence of the problem d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative course of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation V. LEADERSHIP a. Conduct a pre conference with his/her staff to discuss the objectives and activities for the day, helps subordinates, formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of task b. Prepares and brief subordinates on the learning objectives for the day c. Distribute patient assignment evenly d. Delegates tasks to student staff nurse e. Prepares and brief subordinates on the daily plan activities f. Evaluates if the objective are met g. Come up with resolutions to address constraints h. Supervise his/her staff during procedures and other assigned tasks i. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives j. Evaluates performance of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences 5 5 5

5 5 5 5 5 5 4

4 4 4 4 5 5 5 5 5

k. Troubleshoot as necessity arise l. Conducts post conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary m. Requires incident reports as necessary, keeps the clinical instructor informed and updated n. Utilizes the existing chain of command in implementing activities REMARKS:

5 5 5 5

EVALUATED BY: CONFORME:

Von Darwin Visitacion Student staff Nurse Student Staff Nurse

NOTED:

Jerry Manlapaz RN MAN Clinical Instructor

Actual Score x 100 Total Score

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing #56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Staff Nurse to Student Head Nurse)

Name: Gian Arlo Castro Year/ Section: Rating 5 4 3 2 1

Group:

Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward Description Able to function independently and correctly Observes principles Able to function with less supervision from the instructor and observes principles theories of nursing most of the time Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing Unable to function and has not applied nor observed underlying principles at theories of nursing

Quantitative Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Performance I.ESTABLISHMENT OF WORKING RELATIONSHIP 1. Establishes rapport with subordinates 2. Gains trust and confidence of subordinates 3. Able to mediate between subordinates and patients 4. Able to maintain stability under pressure II. ASSESSMENT/ PLANNING 1. Utilizes appropriate resources for ward assessment 2. Utilizes different techniques in gathering data ( interview, observation, records review, reports) 3. Gathers data on:

Rating 5 5 5 5 4 4 4

Nursing service history Physical set up Organization chart Ongoing appraisal evaluation Ward rules and regulation at SOPS Channel of communication Records and Reports 4. Analyze data gathered based on scientific concepts and principles 5. Briefs students staff nurses on data gathered 6. Identifies and priorities problems based on data gathered according to the urgency of the availability of resources ( man power, materials, money/ budget) III. PROBLEM SOLVING PROCESS a. Involves the staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identifies problems c. Analyze the existence of the problem d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative course of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation VI. LEADERSHIP a. Conduct a pre conference with his/her staff to discuss the objectives and activities for the day, helps subordinates, formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of task b. Prepares and brief subordinates on the learning objectives for the day c. Distribute patient assignment evenly d. Delegates tasks to student staff nurse e. Prepares and brief subordinates on the daily plan activities f. Evaluates if the objective are met g. Come up with resolutions to address constraints h. Supervise his/her staff during procedures and other assigned tasks i. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives j. Evaluates performance of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences 4 4 4

4 4 4 4 4 5 5 5

5 5 5 5 5 5 5 4 4

k. Troubleshoot as necessity arise l. Conducts post conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary m. Requires incident reports as necessary, keeps the clinical instructor informed and updated n. Utilizes the existing chain of command in implementing activities REMARKS:

4 5 5 5

EVALUATED BY: CONFORME:

Haydielyn Fernando Student staff Nurse Student Staff Nurse

NOTED:

Jerry Manlapaz RN MAN Clinical Instructor

Actual Score x 10 Total Score

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing #56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Staff Nurse to Student Head Nurse)

Name: Gian Arlo Castro Year/ Section: Rating 5 4 3 2 1

Group:

Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward Description Able to function independently and correctly Observes principles Able to function with less supervision from the instructor and observes principles theories of nursing most of the time Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing Unable to function and has not applied nor observed underlying principles at theories of nursing

Quantitative Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Performance I.ESTABLISHMENT OF WORKING RELATIONSHIP 1. Establishes rapport with subordinates 2. Gains trust and confidence of subordinates 3. Able to mediate between subordinates and patients 4. Able to maintain stability under pressure II. ASSESSMENT/ PLANNING 1. Utilizes appropriate resources for ward assessment 2. Utilizes different techniques in gathering data ( interview, observation, records review, reports) 3. Gathers data on:

Rating 5 5 5 5 4 4 4

Nursing service history Physical set up Organization chart Ongoing appraisal evaluation Ward rules and regulation at SOPS Channel of communication Records and Reports 4. Analyze data gathered based on scientific concepts and principles 5. Briefs students staff nurses on data gathered 6. Identifies and priorities problems based on data gathered according to the urgency of the availability of resources ( man power, materials, money/ budget) III. PROBLEM SOLVING PROCESS a. Involves the staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identifies problems c. Analyze the existence of the problem d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative course of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation VII. LEADERSHIP a. Conduct a pre conference with his/her staff to discuss the objectives and activities for the day, helps subordinates, formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of task b. Prepares and brief subordinates on the learning objectives for the day c. Distribute patient assignment evenly d. Delegates tasks to student staff nurse e. Prepares and brief subordinates on the daily plan activities f. Evaluates if the objective are met g. Come up with resolutions to address constraints h. Supervise his/her staff during procedures and other assigned tasks i. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives j. Evaluates performance of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences 4 4 4

5 4 4 5 4 5 5 5

5 5 5 5 5 5 4 4 4

k. Troubleshoot as necessity arise l. Conducts post conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary m. Requires incident reports as necessary, keeps the clinical instructor informed and updated n. Utilizes the existing chain of command in implementing activities REMARKS:

4 5 4 5

EVALUATED BY: CONFORME:

Raquel Laxa Student staff Nurse Student Staff Nurse

NOTED:

Jerry Manlapaz RN MAN Clinical Instructor

Actual Score x 100 Total Score

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing #56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Staff Nurse to Student Head Nurse)

Name: Gian Arlo Castro Year/ Section: Rating 5 4 3 2 1

Group:

Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward Description Able to function independently and correctly Observes principles Able to function with less supervision from the instructor and observes principles theories of nursing most of the time Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing Unable to function and has not applied nor observed underlying principles at theories of nursing

Quantitative Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Performance I.ESTABLISHMENT OF WORKING RELATIONSHIP 1. Establishes rapport with subordinates 2. Gains trust and confidence of subordinates 3. Able to mediate between subordinates and patients 4. Able to maintain stability under pressure II. ASSESSMENT/ PLANNING 1. Utilizes appropriate resources for ward assessment 2. Utilizes different techniques in gathering data ( interview, observation, records review, reports) 3. Gathers data on:

Rating 5 5 5 4 5 4 4

Nursing service history Physical set up Organization chart Ongoing appraisal evaluation Ward rules and regulation at SOPS Channel of communication Records and Reports 4. Analyze data gathered based on scientific concepts and principles 5. Briefs students staff nurses on data gathered 6. Identifies and priorities problems based on data gathered according to the urgency of the availability of resources ( man power, materials, money/ budget) III. PROBLEM SOLVING PROCESS a. Involves the staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identifies problems c. Analyze the existence of the problem d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative course of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation VIII. LEADERSHIP a. Conduct a pre conference with his/her staff to discuss the objectives and activities for the day, helps subordinates, formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of task b. Prepares and brief subordinates on the learning objectives for the day c. Distribute patient assignment evenly d. Delegates tasks to student staff nurse e. Prepares and brief subordinates on the daily plan activities f. Evaluates if the objective are met g. Come up with resolutions to address constraints h. Supervise his/her staff during procedures and other assigned tasks i. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives j. Evaluates performance of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences 5 4 4

4 5 5 5 5 4 4 5

5 5 4 4 4 4 4 5 5

k. Troubleshoot as necessity arise l. Conducts post conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary m. Requires incident reports as necessary, keeps the clinical instructor informed and updated n. Utilizes the existing chain of command in implementing activities REMARKS:

5 5 5 5

EVALUATED BY: CONFORME:

Mario Jose Amoyo Student staff Nurse Student Staff Nurse

NOTED:

Jerry Manlapaz RN MAN Clinical Instructor

Actual Score x 100 Total Score

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing #56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Staff Nurse to Student Head Nurse)

Name: Gian Arlo Castro Year/ Section: Rating 5 4 3 2 1

Group:

Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward Description Able to function independently and correctly Observes principles Able to function with less supervision from the instructor and observes principles theories of nursing most of the time Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing Unable to function and has not applied nor observed underlying principles at theories of nursing

Quantitative Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Performance I.ESTABLISHMENT OF WORKING RELATIONSHIP 1. Establishes rapport with subordinates 2. Gains trust and confidence of subordinates 3. Able to mediate between subordinates and patients 4. Able to maintain stability under pressure II. ASSESSMENT/ PLANNING 1. Utilizes appropriate resources for ward assessment 2. Utilizes different techniques in gathering data ( interview, observation, records review, reports)

Rating 5 5 5 5 5 4

3. Gathers data on: Nursing service history Physical set up Organization chart Ongoing appraisal evaluation Ward rules and regulation at SOPS Channel of communication Records and Reports 4. Analyze data gathered based on scientific concepts and principles 5. Briefs students staff nurses on data gathered 6. Identifies and priorities problems based on data gathered according to the urgency of the availability of resources ( man power, materials, money/ budget) III. PROBLEM SOLVING PROCESS a. Involves the staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identifies problems c. Analyze the existence of the problem d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative course of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation IX. LEADERSHIP a. Conduct a pre conference with his/her staff to discuss the objectives and activities for the day, helps subordinates, formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of task b. Prepares and brief subordinates on the learning objectives for the day c. Distribute patient assignment evenly d. Delegates tasks to student staff nurse e. Prepares and brief subordinates on the daily plan activities f. Evaluates if the objective are met g. Come up with resolutions to address constraints h. Supervise his/her staff during procedures and other assigned tasks i. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives j. Evaluates performance of staff and the unit as a whole through the use of reports, records, observations, interviews,

5 5 4

5 5 5 5 5 4 4 5

5 5 4 5 3 5 5 5 5

k. l. m. n.

and conferences Troubleshoot as necessity arise Conducts post conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary Requires incident reports as necessary, keeps the clinical instructor informed and updated Utilizes the existing chain of command in implementing activities

5 5 5 5

REMARKS:

EVALUATED BY: CONFORME:

Carmina Alfonso Student staff Nurse Student Staff Nurse

NOTED:

Jerry Manlapaz RN MAN Clinical Instructor

Actual Score x 100 Total Score

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing #56 Banawe Street, Quezon City RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) CLINICAL PERFORMANCE EVALUATION TOOL (Student Staff Nurse to Student Head Nurse)

Name: Gian Arlo Castro Year/ Section: Rating 5 4 3 2 1

Group:

Date of Exposure: Feb. 19, 2013 Clinical Area: Children's Ward Description Able to function independently and correctly Observes principles Able to function with less supervision from the instructor and observes principles theories of nursing most of the time Able to function but requires close supervision from the instructor and observes principles at theories of nursing sometimes Able to function but requires close supervision from the instructor and occasionally applies principles and theories of nursing Unable to function and has not applied nor observed underlying principles at theories of nursing

Quantitative Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Performance I.ESTABLISHMENT OF WORKING RELATIONSHIP 1. Establishes rapport with subordinates 2. Gains trust and confidence of subordinates 3. Able to mediate between subordinates and patients 4. Able to maintain stability under pressure II. ASSESSMENT/ PLANNING 1. Utilizes appropriate resources for ward assessment 2. Utilizes different techniques in gathering data ( interview, observation, records review, reports)

Rating 5 5 4 5 4 4

3. Gathers data on: Nursing service history Physical set up Organization chart Ongoing appraisal evaluation Ward rules and regulation at SOPS Channel of communication Records and Reports 4. Analyze data gathered based on scientific concepts and principles 5. Briefs students staff nurses on data gathered 6. Identifies and priorities problems based on data gathered according to the urgency of the availability of resources ( man power, materials, money/ budget) III. PROBLEM SOLVING PROCESS a. Involves the staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identifies problems c. Analyze the existence of the problem d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative course of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation X. LEADERSHIP a. Conduct a pre conference with his/her staff to discuss the objectives and activities for the day, helps subordinates, formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of task b. Prepares and brief subordinates on the learning objectives for the day c. Distribute patient assignment evenly d. Delegates tasks to student staff nurse e. Prepares and brief subordinates on the daily plan activities f. Evaluates if the objective are met g. Come up with resolutions to address constraints h. Supervise his/her staff during procedures and other assigned tasks i. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives j. Evaluates performance of staff and the unit as a whole through the use of reports, records, observations, interviews,

5 5 4

4 5 4 4 5 5 4 4 5

5 5 4 4 5 4 4 5 4

k. l. m. n.

and conferences Troubleshoot as necessity arise Conducts post conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary Requires incident reports as necessary, keeps the clinical instructor informed and updated Utilizes the existing chain of command in implementing activities

5 5 5 5

REMARKS:

EVALUATED BY: CONFORME:

Khaycee Vasquez Student staff Nurse Student Staff Nurse

NOTED:

Jerry Manlapaz RN MAN Clinical Instructor

Actual Score x 100 Total Score

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College Of Nursing Name: Carmina Alfonso Section/Group: Group 3 Hospital: Philippine Orthopedic Center Date of Exposure: Feb. 19, 2013 DAILY REQUIREMENT CHECKLIST CRITERIA I. ATTENDANCE /Time of arrival II. PARAPHERNALIA PRI bag NANDA Book Drug Handbook ID/ Nameplate Complete Uniform Shoes Nursing Cap/ Undershirt Wrist Watch Notebook/ Ticklers Thermometer Oral Rectal Axilla BP Apparatus Stethoscope Canister w/ Dry cotton balls Cotton balls with alcohol Ballpen Red Black Green Pencil Eraser Ruler Micropore tape Tape measure Penlight with battery Face mask 02/19/13 06:30A M

Bandage scissor Tourniquet Clean gloves Sterile gloves Soap Alcohol Betadine Tongue depressor Cotton buds Medicine tray Medicine cup Kidney basin Clip board Syringe 10 cc 5cc 3cc Tuberculin syringe Insulin syringe PATIENTS KIT Face towel Tooth brush Toothpaste Comb Nail cutter Soap Shampoo Prepared by: Gian Arlo H. Castro Student Head Nurse

Noted by: Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College Of Nursing Name: Mario Jose Amoyo Section/Group: Group 3 Hospital: Philippine Orthopedic Center Date of Exposure: Feb. 19, 2013 DAILY REQUIREMENT CHECKLIST CRITERIA I. ATTENDANCE /Time of arrival II. PARAPHERNALIA PRI bag NANDA Book Drug Handbook ID/ Nameplate Complete Uniform Shoes Nursing Cap/ Undershirt Wrist Watch Notebook/ Ticklers Thermometer Oral Rectal Axilla BP Apparatus Stethoscope Canister w/ Dry cotton balls Cotton balls with alcohol Ballpen Red Black Green Pencil Eraser Ruler Micropore tape 02/19/13 06:30A M

Tape measure Penlight with battery Face mask Bandage scissor Tourniquet Clean gloves Sterile gloves Soap Alcohol Betadine Tongue depressor Cotton buds Medicine tray Medicine cup Kidney basin Clip board Syringe 10 cc 5cc 3cc Tuberculin syringe Insulin syringe PATIENTS KIT Face towel Tooth brush Toothpaste Comb Nail cutter Soap Shampoo Prepared by: Gian Arlo H. Castro Student Head Nurse

Noted by: Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College Of Nursing Name: Hydielyn Fernando Section/Group: Group 3 Hospital: Philippine Orthopedic Center Date of Exposure: Feb. 19, 2013 DAILY REQUIREMENT CHECKLIST CRITERIA I. ATTENDANCE /Time of arrival II. PARAPHERNALIA PRI bag NANDA Book Drug Handbook ID/ Nameplate Complete Uniform Shoes Nursing Cap/ Undershirt Wrist Watch Notebook/ Ticklers Thermometer Oral Rectal Axilla BP Apparatus Stethoscope Canister w/ Dry cotton balls Cotton balls with alcohol Ballpen Red Black Green Pencil 02/19/13 06:30A M

Eraser Ruler Micropore tape Tape measure Penlight with battery Face mask Bandage scissor Tourniquet Clean gloves Sterile gloves Soap Alcohol Betadine Tongue depressor Cotton buds Medicine tray Medicine cup Kidney basin Clip board Syringe 10 cc 5cc 3cc Tuberculin syringe Insulin syringe PATIENTS KIT Face towel Tooth brush Toothpaste Comb Nail cutter Soap Shampoo Prepared by: Gian Arlo H. Castro Student Head Nurse

Noted by: Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College Of Nursing Name: Khaycee Vasquez Section/Group: Group 3 Hospital: Philippine Orthopedic Center Date of Exposure: Feb. 19, 2013 DAILY REQUIREMENT CHECKLIST CRITERIA I. ATTENDANCE /Time of arrival II. PARAPHERNALIA PRI bag NANDA Book Drug Handbook ID/ Nameplate Complete Uniform Shoes Nursing Cap/ Undershirt Wrist Watch Notebook/ Ticklers Thermometer Oral Rectal Axilla BP Apparatus Stethoscope Canister w/ Dry cotton balls Cotton balls with alcohol Ballpen Red 02/19/13 06:30A M

 Black Green Pencil Eraser Ruler Micropore tape Tape measure Penlight with battery Face mask Bandage scissor Tourniquet Clean gloves Sterile gloves Soap Alcohol Betadine Tongue depressor Cotton buds Medicine tray Medicine cup Kidney basin Clip board Syringe 10 cc 5cc 3cc Tuberculin syringe Insulin syringe PATIENTS KIT Face towel Tooth brush Toothpaste Comb Nail cutter Soap Shampoo Prepared by: Gian Arlo H. Castro Student Head Nurse

Noted by: Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College Of Nursing Name: Michael Tanquintic Section/Group: Group 3 Hospital: Philippine Orthopedic Center Date of Exposure: Feb. 19, 2013 DAILY REQUIREMENT CHECKLIST CRITERIA I. ATTENDANCE /Time of arrival II. PARAPHERNALIA PRI bag NANDA Book Drug Handbook ID/ Nameplate Complete Uniform Shoes Nursing Cap/ Undershirt Wrist Watch Notebook/ Ticklers Thermometer Oral Rectal Axilla BP Apparatus Stethoscope Canister w/ Dry cotton balls Cotton balls with 02/19/13 06:30A M

alcohol Ballpen Red Black Green Pencil Eraser Ruler Micropore tape Tape measure Penlight with battery Face mask Bandage scissor Tourniquet Clean gloves Sterile gloves Soap Alcohol Betadine Tongue depressor Cotton buds Medicine tray Medicine cup Kidney basin Clip board Syringe 10 cc 5cc 3cc Tuberculin syringe Insulin syringe PATIENTS KIT Face towel Tooth brush Toothpaste Comb Nail cutter Soap Shampoo Prepared by: Gian Arlo H. Castro

Noted by: Jerry Manlapaz RN, MAN

Student Head Nurse

Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College Of Nursing Name: Raquel Laxa Section/Group: Group 3 Hospital: Philippine Orthopedic Center Date of Exposure: Feb. 19, 2013 DAILY REQUIREMENT CHECKLIST CRITERIA I. ATTENDANCE /Time of arrival II. PARAPHERNALIA PRI bag NANDA Book Drug Handbook ID/ Nameplate Complete Uniform Shoes Nursing Cap/ Undershirt Wrist Watch Notebook/ Ticklers Thermometer Oral Rectal Axilla BP Apparatus Stethoscope 02/19/13 06:30A M

Canister w/ Dry cotton balls Cotton balls with alcohol Ballpen Red Black Green Pencil Eraser Ruler Micropore tape Tape measure Penlight with battery Face mask Bandage scissor Tourniquet Clean gloves Sterile gloves Soap Alcohol Betadine Tongue depressor Cotton buds Medicine tray Medicine cup Kidney basin Clip board Syringe 10 cc 5cc 3cc Tuberculin syringe Insulin syringe PATIENTS KIT Face towel Tooth brush Toothpaste Comb Nail cutter Soap Shampoo

Prepared by: Gian Arlo H. Castro Student Head Nurse

Noted by: Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College Of Nursing Name: Von Darwin Visitacion Section/Group: Group 3 Hospital: Philippine Orthopedic Center Date of Exposure: Feb. 19, 2013 DAILY REQUIREMENT CHECKLIST CRITERIA I. ATTENDANCE /Time of arrival II. PARAPHERNALIA PRI bag NANDA Book Drug Handbook ID/ Nameplate Complete Uniform Shoes Nursing Cap/ Undershirt Wrist Watch Notebook/ Ticklers Thermometer Oral Rectal 02/19/13 06:30A M

 Axilla BP Apparatus Stethoscope Canister w/ Dry cotton balls Cotton balls with alcohol Ballpen Red Black Green Pencil Eraser Ruler Micropore tape Tape measure Penlight with battery Face mask Bandage scissor Tourniquet Clean gloves Sterile gloves Soap Alcohol Betadine Tongue depressor Cotton buds Medicine tray Medicine cup Kidney basin Clip board Syringe 10 cc 5cc 3cc Tuberculin syringe Insulin syringe PATIENTS KIT Face towel Tooth brush Toothpaste Comb

Nail cutter Soap Shampoo Prepared by: Gian Arlo H. Castro Student Head Nurse

Noted by: Jerry Manlapaz RN, MAN Clinical Instructor