You are on page 1of 22

Philippine Rehabilitation Institute Foundation, INC.

College of Nursing RELATED LEARNING EXPERIENCE LEADERSHIP AND MANAGEMENT ( Head Nursing ) Name: Hospital: CRITERIA I. ATTENDANCE/ Time of Arrival II. PARAPHERNALIA Bp Apparatus Calculator Thermometer Bandage Scissor Tourniquet Tape Measure Canister with dry cotton balls Canister with cotton balls soaked in alcohol Medicine tray Black/ red, green ball pens, pencil Micropore Small notebook Penlight with batteries Clip board Signature of Student Head Nurse: Student Head Nurse: Prepared by: Gian Arlo H. Castro Student Head Nurse DAILY REQUIREMENT CHECKLIST DAY 1 DAY 2 Section/ Group: Date of Exposure: DAY 3 DAY 4 DAY 5

Noted by: Jerry Manlapaz RN, MAN Clinical Instructor

Philippine Rehabilitation Institute Foundation, Inc College Of Nursing RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) SCHEDULE OF ACTIVITIES Date: February 19, 2013 Time 6:30-7:00 7:00-7:30 7:30-8:00 8:00-9:30 9:30-10:00 10:00-10:30 10:30-11:30 11:30-12:30 12:30-1:00 Clinical Area: Children's Ward Census: 7

Activities Opening prayer, checking of attendace, Pre-conference, Checking of Praphernalias Short review on Planning Endorsement, Bedside Rounds V/S taking, Medicatuins, Morning Care, Chart Reading Break Quiz on Planning and Rationalization Documentation, NCP, Drug Study Afternoon V/S Taking, Medications Post-conference, Learning Insights

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 RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) DAILY PATIENT ASSIGNMENT SHEET Date: February 19, 2013 Name of Students Roo m & Bed # Clinical Area: Children's Ward Name of Patient Age Diagnosis Doctor in Charge Dr. Boyles Dr. Tuliao Dr. V.A. Lim Dr. Simbulan Dr. V.A. Lim Dr. Lim Dr. Boyles Census: 7 Remarks

Vazquez, Khaycee Laxa, Raquel Fernandi, Haydielyn Alfonso, Carmina Amoyo, Mario Jose Visitacion, Von Darwin Tanquintic, Michael

Natividad, Elmo Siaboc, Ariana Mae Rodriguez, Ryan Joel Raganit, Christopher Solana, Mac Kenneth Mirabite, Jaryl Badillo, Elisa C.

5 1 5 4 3 5 6

Osteomyelitis Pyomyositis L leg Chronic Osteomyelitis Fx Open III B Proximal T/C Pyomositis R arm Fx Cl. Comp. Disp.SubteroChanteric Chronic Osteomyelitis L hip

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 RLE LEADERSHIP AND MANAGEMENT (HEAD NURSING) I & O SHEET Date: Feb. 19, 2013 Room & Bed No. Name Of Patient Oral Berdillo, Elis Raganit, Christopher Natividad, Elmo Siaboc, Ariana Mae Solana, Mac Kenneth Mirabite, Jaryl Rodriguez, Ryan Jay 500 400 200 230 200 600 500 IVF 30 50 100 50 Clinical Area: Children's Ward Input NGT ( OF ) Others Urine 2 2 2 1 1 2 Output NGT CTT Others Census: 7

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 RLE LEADERSHIP AND MANAGEMENT ( HEAD NURSING ) MEDICATION SHEET Date: February 19, 2013 Room & Bed # Name of Patient Raganit, Christopher Clinical Area: Children's Ward Name of Drug Cefazolin Gentamycin Paracetamol Solana, Mac Kenneth Rodriguez, Ryan Jay Siaboc, Ariana Mae Oxacillin Cefuroxime Oxacillin Paracetamol Carbocisteine Vit. C Action Antibiotic Antibiotic Analgesic/ Antipyretic Antibiotic Antibiotic Antibiotic Analgesic/ Antipyretic Mucolytic Vit. Supplement Dosage 400 mg 30 mg 250 g/5 ml 375mg 750mg 100mg 250mg/5 ml 1.5mg 1 ml Frequency q8 q6 q6 q6 q6 q6 TID q6 x 5 days OD Census: 7 Time of Administrati on 8am-4pm12am 6am-12pm6pm-12am 6am-12pm6pm-12am 6am-12pm6pm-12am 6am-12pm6pm-12am 6am-12pm6pm-12am 8am-12pm5pm 6am-12pm6pm-12am 8am Treatment

Natividad, Elmo

Ceftriaxone Amikacin Paracetamol

Antibiotic Antibacterial Analgesic/ Antipyretic Analgesic/ Antipyretic Analgesic/ Antipyretic Antiemetic Antibiotic Antibacterial Analgesic/ NSAID Supplement 60mg 250mg 250mg 300mg 5mg 500mg 60mg 200mg 5ml q8 TID Q4 PRN q4 RTC x 24 hours q6 PRN q12 q8 Q4 PRN OD 8am-4pm12am 8am-12pm5pm 12am-4am8am-12pm4pm-8pm 12am-4am8am-12pm4pm-8pm 6am-12pm6pm-12am 8am-8pm 8am-4pm12am 12am-4am8am-12pm4pm-8pm 8am

Mirabite, Jaryl Badillo, Elisa

Paractamol Paracetamol Metoclopramide Ceftriaxone Amikacin Ibuprofen FeS04

Prepared by: Gian Arlo H. Castro Student Head Nurse

Noted by: Jerry Manlapaz RN, MAN Clinical Instructor

Philippine Rehabilitation Institute Foundation, Inc ENDORSEMENT SHEET Date: Feb 19, 2013 Student Head Nurse: Gian Arlo H. Castro Name of Patient Age DIC Diagnosis Diet Procedure Labs s Medications V/S I and O S Total Census: 7 Special Endorsement -

Raganit, Christopher

Dr. Simb ulan

Fx Open III B Proximal

DAT

Solana, Mac Kenneth Rodriguez, Ryan Jay Siaboc, Ariana Mae

3 5

Dr. V.A. Lim Dr. V.A. Lim Dr. Tulia o

T/C Pyomositi s R arm Chronic Osteomye litis Fibula Pyomyosit is L leg

DAT DAT

Cefazolin 400 mg IV q8 (-) ANST, Gentamycin 30 mg IV q6 (-) ANST, Paracetamol 250 g/5 ml q6 x24 days Oxacillin 375mg IV Q6 Cefuroxime 750mg IV q6 (-) ANST Oxacillin 100mg IV (-)ANST Q6, Paracetamol 250mg/5ml 5ml TID for pain only, Carbocisteine

U 2x

1x 2x

DAT

1x

Natividad, Elmo

Dr. Boyl es

Osteomye litis

DAT

Mirabite, Jaryl

Dr. Lim

Badillo, Elisa

Dr. Boyl es

Fx. Cl. Comp. Disp. Subteroch anderic Chronic osteomyel itis L hip

DAT

drops 1.5mg q6 x 5days, Vit. C drops 1ml OD Ceftriaxone, Paracetamol 250mg/5ml 5ml TID for pain only, Amikacin 60mg (-) ANST Paractamol 250mg/5ml q4 PRN for pain

2x

2x

DAT

Prepared by: Gian Arlo H. Castro Student Head Nurse

Paracetamol 2x 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 Noted by: Jerry Manlapaz RN, MAN Clinical Instructor

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing RELATED LEARNING EXPERIENCE LEADERSHIP AND MANAGEMENT (Head Nursing) Name: Gian Arlo Castro Hospital: Philippine Orthopedic Center Section/Group: 3 Date of Exposure: February 19, 2013 VITAL SIGNS MONITORING SHEET Room & Bed No. Name Of Patient BP Natividad, Elmo Badillo, Elisa Siaboc, Ariana Mae Raganit, Christopher Solana, Mac Kenneth Mirabite, Joryl 100/60 100/70 90/60 100/60 90/40 T 36 36.3 36.5 37.7 36.3 35.6 36 Time: 8:00 P 108 98 120 102 110 107 100 R 36 39 40 36 36 34 40 Pain BP 100/70 100/60 110/70 100/60 100/60 100/70 T 35.8 36.2 36.6 37.0 36.5 36 36.4 Time: 12:00 P 110 100 116 109 109 110 104 R 37 40 37 35 37 36 38 Pain -

Rodriguez, 100/60 Ryan Jay 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 DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Calpol Syrup DOSAGE FREQUENCY PREPARATION 250 ml/5 mg TID Muscle Relaxant CLASSIFIC ATION Analgesic MECHANISM OF ACTION
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

Date: Feb. 20, 2013 ADVERSE REACTIONS


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

Score: 89 NURSING CONSIDERATIO NS


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.

ACTUAL ADVERSE REACTIONS -none-

GENERIC NAME: Paracetamol

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Oxacillin DOSAGE FREQUENCY PREPARATION 100 mg IV q6 CLASSIFIC ATION Antibiotic antibacterial MECHANISM OF ACTION Date: Feb. 20, 2013 ADVERSE REACTIONS
CNS: Lethargy, Hallucination, seizures GI: Glossitis, stomatitis, gastritis, sore mouth, vomiting, diarrhea, abdominal pain, bloody diarrhea, enterocolitis, pseudomembranous colitis, non specific hepatitis GU: nephritis, oliguria, proteinuria, hematuria, cast, azotemia, pyuria Hypersensitivity: rash, fever, wheezing

Score: 89 NURSING CONSIDERATIO NS 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.

ACTUAL ADVERSE REACTIONS -none-

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

GENERIC NAME: Oxacillin Sodium

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Aflem DOSAGE FREQUENCY PREPARATION CLASSIFIC ATION Mucolytic 1.5mg q6 x 5 days Syrup MECHANISM OF ACTION
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.

Date: Feb. 20, 2013 ADVERSE REACTIONS


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

Score: 89 NURSING CONSIDERATIO NS


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.

ACTUAL ADVERSE REACTIONS -none-

GENERIC NAME: Carbocistei n

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Ceelin DOSAGE FREQUENCY PREPARATION CLASSIFIC ATION Supplement 1.5mg q6 x 5 days Syrup MECHANISM OF ACTION
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.

Date: Feb. 20, 2013 ADVERSE REACTIONS


CNS: fatigue,headache,ins omnia,drowsiness GI: nausea,vomiting,he artburn, cramps,diarrhea GU: kidney stones DERM: flushing HEMAT: deep veinthrombosis, sicklecell crisis,hemolysis (in G6PDdeficiency)

Score: 89 NURSING CONSIDERATIO NS


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

ACTUAL ADVERSE REACTIONS -none-

GENERIC NAME: Ascorbic Acid

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Tiki-Tiki DOSAGE FREQUENCY PREPARATION CLASSIFIC ATION Supplement 1 tsp. OD Syrup MECHANISM OF ACTION
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

Date: March 4, 2013 ADVERSE REACTIONS


Urine discoloration, allergic reaction to preservatives, additives or colorants

Score: 90 NURSING CONSIDERATIO NS


-none-

ACTUAL ADVERSE REACTIONS -none-

GENERIC NAME: Multivitami ns

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Oxacillin DOSAGE FREQUENCY PREPARATION 100 mg IV q6 CLASSIFIC ATION Antibiotic antibacterial MECHANISM OF ACTION Date: March 4, 2013 ADVERSE REACTIONS
CNS: Lethargy, Hallucination, seizures GI: Glossitis, stomatitis, gastritis, sore mouth, vomiting, diarrhea, abdominal pain, bloody diarrhea, enterocolitis, pseudomembranous colitis, non specific hepatitis GU: nephritis, oliguria, proteinuria, hematuria, cast, azotemia, pyuria Hypersensitivity: rash, fever, wheezing

Score: 90 NURSING CONSIDERATIO NS 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.

ACTUAL ADVERSE REACTIONS -none-

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

GENERIC NAME: Oxacillin Sodium

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Calpol DOSAGE FREQUENCY PREPARATION 250mg/5ml (6ml) q6 PRN for pain Syrup GENERIC NAME: Paracetamol CLASSIFIC ATION Analgesic Muscle Relaxant MECHANISM OF ACTION
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

Date: March 4, 2013 ADVERSE REACTIONS


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

Score: 90 NURSING CONSIDERATIO NS


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.

ACTUAL ADVERSE REACTIONS -none-

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Calpol DOSAGE FREQUENCY PREPARATION 250mg/5ml 3ml q4 PRN for pain Syrup GENERIC NAME: Paracetamol CLASSIFIC ATION Analgesic Muscle Relaxant MECHANISM OF ACTION
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

Date: March 5, 2013 ADVERSE REACTIONS


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

Score: 90 NURSING CONSIDERATIO NS


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.

ACTUAL ADVERSE REACTIONS -none-

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Pharex Coamoxiclav DOSAGE FREQUENCY PREPARATION 4mg/5ml TID x 7 days Syrup CLASSIFIC ATION Antibiotic MECHANISM OF ACTION
Inhibits enzymes involved in formation of peptidoglycan layer of bacterial cell wall No effect on human cell walls Bactericidal; only works on dividing bacteria Well absorbed enterally Clavulanic acid inhibits bacterial lactamase

Date: March 5, 2013 ADVERSE REACTIONS


Hepatitis, cholestatic jaundice Erythema multiforme (including StevensJohnson) Toxic epidermal necrolysis; exfoliative dermatitis Diarrhea, vomiting Rashes Neutropenia

Score: 90 NURSING CONSIDERATIO NS


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

ACTUAL ADVERSE REACTIONS -none-

GENERIC NAME: Coamoxiclav

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Oxacillin DOSAGE FREQUENCY PREPARATION 100 mg IV q6 CLASSIFIC ATION Antibiotic antibacterial MECHANISM OF ACTION Date: Mar. 14, 2013 ADVERSE REACTIONS
CNS: Lethargy, Hallucination, seizures GI: Glossitis, stomatitis, gastritis, sore mouth, vomiting, diarrhea, abdominal pain, bloody diarrhea, enterocolitis, pseudomembranous colitis, non specific hepatitis GU: nephritis, oliguria, proteinuria, hematuria, cast, azotemia, pyuria Hypersensitivity: rash, fever, wheezing

Score: 89 NURSING CONSIDERATIO NS 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.

ACTUAL ADVERSE REACTIONS -none-

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

GENERIC NAME: Oxacillin Sodium

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing DRUG STUDY Name: Castro, Gian Arlo H. Area: POC-Children's Ward Clinical Instructor: Jerry Manlapaz RN, MAN NAME OF THE DRUG BRAND NAME: Tiki-Tiki DOSAGE FREQUENCY PREPARATION CLASSIFIC ATION Supplement 1 tsp. OD Syrup MECHANISM OF ACTION
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

Date: March 14, 2013 ADVERSE REACTIONS


Urine discoloration, allergic reaction to preservatives, additives or colorants

Score: 90 NURSING CONSIDERATIO NS


-none-

ACTUAL ADVERSE REACTIONS -none-

GENERIC NAME: Multivitami ns

PHILIPPINE REHABILITATION INSTITUTE FOUNDATION, INC. College of Nursing NURSING CARE PLANS (NCP) Name: Clinical instructor: CUES NURSING DIAGNOSIS Area: SCIENTIFIC EXPLANATIO N OF THE PROBLEM PLANNING Date: INTERVENTI ONS Score: RATIONALE EVALUATION