BROKENSHIRE COLLEGE SOCSKSARGEN INCORPORATED Ced Avenue, National Highway, General Santos City COLLEGE OF NURSING RLE 106

6 REQUIREMENTS AY 2012-2013 DUTY PERIOD: Wednesdays- Fridays ; 8 hours shift AFFILIATING AGENCIES: Mindanao Medical Center, St. Elizabeth Hospital and Gen. Santos City Hosp., labella Hosp WARD CLASS: Every Fridays of duty week at 8am INDIVIDUAL:

1.
GROUP:

AT LEAST TWO(2) CASE STUDIES FOR THREE ROTATIONs

1. 2. 3.

Group Case presentation(2 cases- choose from among individual case studies for defense),at least two CPs for three rotations Computerized written output of the selected case. Special RLE Procedures Group reporting(the two main groupings will be sub divided into 3 sub groups)

Group outputs must be submitted in a long sized bond paper( computerized)

1. INFLAMMATORY GROUP RED(VALIN) 2. HYPERSENSITIVITY GROUP GREEN(PUNAY)

NOTE: tasks both individual and group may change anytime depending on circumstances. Batch output must be in hard bound manuscript.

FORMAT & CONTENT OF CASE STUDY: The following format and expected contents shall be the standard to be followed by individual as well as group requirements.

I.

HEALTH HISTORY: Subjective data of the client. A. Biographical Data Name: Patient Dom Adress: Dole Cannery Polomolok, South Cot. Home phone:(OPTIONAL) Work phone: (OPTIONAL) Sex: Age:

Birth date: Place of Birth: Nationality: Marital status: Dependents: Religion: Education: Occupation: Health insurance: Diagnosis: B. Reason for seeking healthcare: SAMPLE: Ive been feeling tired lately, for about a month now, so I wanted a health exam to make sure nothing is wrong. C. Current health status SAMPLE: Says shes been feeling tired for about a month. Denies any other symptoms. Denies loss of appetite or blood loss or anemia. States that she has been busier at work than usual and hasnt had enough time to spend with her children because shes going to night school for her masters degree. Thinks fatigue maybe related to a busy schedule rather than a physical problem last had a complete physical including papsmear 4 years ago. D. Past Health History: Childhood illnesses: Hospitalizations and surgeries: Serious injuries: Chronic illnesses if any: Immunizations: Allergies: Medications: Travel: Recent

E. Family History: documented by listing family members

and health status: Patient: alive and well Spouse: age 50,separated,alcoholism Daughter/s: age 14, alive and well Son/s: age 12, alive and well Brother/s: Sister/s: Father: Mother: Paternal grandmother: Paternal grandfather: Maternal grandfather: Maternal grandmother:

F.

Review of Systems:(PAST HISTORY) General health survey: Complains of fatigue. Had two headcolds in the past year. No other illnesses. Good exercise tolerance. Skin,hair and nails: Head and neck: Nose and sinuses: Mouth and Throat: Eyes: Ears: Respiratory: Cardiovascular:

Breast: Gastrointestinal: Genitourinary: Reproductive: Neurological: Musculoskeletal: Immune/ Hematologic: Endocrine: G. Psychosocial Profile: Health Practices and Beliefs: Typical Day: Nutritional Patterns: Activity and Exercise Pattern: Recreation, Pets and Hobbies: Sleep/ rest Patterns: Personal Habits: Occupational Health Patterns: Socioeconomic Status: Environmental Health Patterns: Roles/Relationship/Self Concept: Cultural Influences: Religious/ Spiritual influences: Family Role and relationship: Sexuality Patterns: Social Support: Stress and Coping Patterns:

II.

HEAD TO TOE PHYSICAL ASSESSMENT(PRESENT) A. General Health Survey: B. Integumentary: - Skin - Hair - Nails C. HEENT - Head and Neck - Eyes - Ears - Nose - Throat D. Respiratory System E. Cardiovascular System F. Peripheral- vascular and Lymphatics G. Breast H. Abdomen I. Female/Male Genitourinary J. Motor- Musculoskeletal K. Sensory Neurologic

III.

PLANS OF NURSING CARE: These plans provided for selected disorder, illustrate how the nursing process is applied to meet the persons health care and nursing needs by reviewing key nursing interventions and the rationales for those interventions.( PLEASE USE TABULAR FORMAT) A. B. C. D. Nursing Diagnosis Planning/Goal Setting Implementation Evaluation/Expected outcome

IV.

PHARMACOLOGY CHARTS AND TABLES: reminds the students of important considerations relative to administering medications and monitoring drug therapy. A. Drug class and Examples B. Actual dosage C. Mechanism of action D. Common side effects E. Actual health teachings PHYSIOLOGY/PATHOPHYSIOLOGY: these illustrations and algorithms help students to understand normal Physiologic and pathophysiologic processes. PATIENT EDUCATION CHARTS: these charts help the nurse student to prepare the patient and the family for procedures and as part of patient education prior to discharge. Assist them with understanding the patients condition. It will also help the nurse to educate the patient regarding the disease and its process. A. Definition of the disease B. Clinical manifestations C. Assessment and diagnostic findings D. Preventions E. Medical management F. Nursing management G. FOR PROCEDURES;INNUMERATE THE DIFFERENT STEPS AND THE NURSING CONSIDERATIONS

V.

VI.

TENTATIVE SCHEDULE OF DATES FOR RLE 106 WARD CLASSES A.Y 20122013- 1ST SEMESTER DATES JUNE 13/14/15 JUNE 27 JUNE 29(FRI) TASKS ORIENTATION WEEK(CONSIDERED RLE) FIRST DAY OF DUTY 1 SUBMISSION OF INDIVIDUAL CP
st

GROUP

JULY 6(FRI) JULY 13(FRI)

FIRST WARD CLASS1st SPECIAL RLE PROCEDURE REPORTING ( TOPIC: .Performing Hemodialysis and Peritoneal Dialysi,.Central Line Set up and Insertion,.Arterial Blood Gas Interpretation) First Group Case presentation 2nd SPECIAL RLE PROCEDURE REPORTING( TOPIC: Insertion and management of Chest Drains, Suctioning and Mechanical, Ventilation,.Assisting in Endotracheal Intubation, 2ND SUBMISSION OF INDIVIDUAL CP 3RD SPECIAL RLE PROCEDURE REPORTING (TOPIC: .E Cart&Performing Basic Code Management,.ECG Placement and Cardiac Monitoring,.Defibrillation and ,Cardioversion,Automated Electric Defibrillation, Monitoring Cardiac OutpuT 2ND Group Case presentation(topic from July 13 duty) 4th SPECIAL RLE PROCEDURE

Tbd

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AUG 3(FRI)

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AUG 10(FRI) AUG 31(FRI)

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NOTE: A copy of the group report must be submitted to the adviser one(1) week before the scheduled day of reporting.( Computerized/ long bond paper)

BROKENSHIRE COLLEGE SOCSKSARGEN,INC. Ced Avenue, General Santos City NCM 106 SUMMARY OF CLINICAL ROTATION Name:________________________________________________ Section:__________ Academic Year:_______________ NCM 106: REHABILITATIVE NURSING CARE MANAGEMENT;144 hours lecture, 408 hours RLE /FIRST SEM.,BSN IV: Concepts and principles of nursing care management of clients with alterations in human functioning across the life span in varied settings. This is a continuation of NCM 102,103. TERMINAL COMPETENCIES: Given a client with simple to complex health problems/ work related health problems and life threatening conditions in any health care situation, the student provides nursing care utilizing the nursing process. CONCEPTS INCLUSIV E DATES AREA OF EXPOSURE RATING CIS SIGNAT URE REMARKS

INFLAMMATORY & IMMUNOLOGIC DISTURBANCES ONCOLOGIC NURSING ACUTE BIOLOGIC CRISIS EMERGENCY NURSING

Narba jose R. Punay, RN Level 4 Coordinator

Lourdes Decrepito, RN RLE Coordinator

Sherlita P. Lapore, RN MAN Dean- Nursing Dept.

BROKENSHIRE COLLEGE SOCSKSARGEN INCORPORATED Ced Avenue, National Highway, General Santos City COLLEGE OF NURSING PERFORMANCE RATING SCALE FOR CASE PRESENTATION (APPLICABLE FOR INDIVIDUAL AND GROUP) STUDENT/GROUP NAME: ____________________ DATE OF EVALUATION: _______________ I T E R I A SUBJECTIVE DATA I : ORGANIZATION OF THE REPORT a. systematically presented II: CONTENT: HEALTH HISTORY a. Biographical data taken completely & accurately b. Current health status, Past health history, & family history taken completely & accurately c. Review of Systems obtain completely & accurately d. Psychosocial profile/ Gordons pattern acquired and discussed completely & correctly. e. Identify modifications needed in obtaining health history. OBJECTIVE DATA(head to toe PE) I : ORGANIZATION OF THE REPORT a. systematically presented II : CONTENT a. Able to apply & made proper use of the IPPA technique in performing physical assessment of the major body systems of a patient b. Discussed & relate assessment of all major body systems in relation to other body parts/systems. c. Paid particular attention to organ/system involved. d. Able to identify, discuss & incorporate in the assessment data all necessary laboratory/diagnostic procedures of the patient. e. Identify modifications needed in obtaining physical assessment such as pediatric and gerontologic considerations. f. Identify ethical considerations necessary for persons right related to data collected. ANALYSIS a. Able to present & discuss the anatomy & physiology of the system/s or organ/s involved in the disease. b. Comprehensively/ accurately presented the IDEAL and the ACTUAL pathophysiology of the disease involved. MANAGEMENT I : MEDICAL a. Medical management well understood through C R 3 2 1 0

discussion of its relevance. b. Ideal management presented comprehensively. c. Laboratory/diagnostic examinations interpreted correctly. II : NURSING a. Identified appropriate nursing diagnosis based on available cues. b. Identified and prioritized 3 important problems. APPROPRIATE FORMULATION OF: 1. Nursing diagnosis 2. Needs identification 3. Objectives ( SMART) 4. Intervention 5. Rationale 6. Evaluation PHARMACOLOGIC CHART a. Completely and correctly presented as to important ACTUAL considerations in administering medications including monitoring drug therapy & important NURSING RESPONSIBILITIES APPLICABLE TO THE PATIENTS CASE. PATIENT EDUCATION CHART a. Completely, accurately & comprehensively discussed the health teachings according to clients needs and case. AUDIO-VISUALS a. Use of audio visual aids facilitated comprehension b. Neat & proportional c. Complete and well prepared. TOTAL POINTS LEGEND: 0 Not done or inappropriately done 2 1 Needs improvement 3 outcome PERFECT SCORE IS 93 POINTS COMPUTATION: RS x 50 + 50 = _____ x ___ % TS

Satisfactory Meets expected

__________________________________ ______________________ NAME/ SIGNATURE OF EVALUATOR NAME/ SIGNATURE OF STUDENT

BROKENSHIRE COLLEGE SOSKSARGEN, INC. Ced Avenue, National Highway, Lagao, General Santos City Tel. No. (083) 552-1218 / 552 -1288 WARD and SPECIAL AREAS STUDENT PERFORMANCE EVALUATION SHEET Students Name: ________________________________ ____________ Area and Shift: ________________________________ Concept (s): ________________________________ Inclusive Dates:

I.

KNOWLEDGE a. Quizzes

(40%) (10%)

Actual Rating _____ _____ _____ ______

Justification

b. Interviews/ Reports (10%) c. Requirements (20%) (40%) (20%) (5%)

II.
III.

SKILLS ATTITUDE a. Attendance

______

b. Personality

(5%) ______ maintains good grooming at all times (2) endeavors to improve quality of performance (3)

c. Behavior

(10%) ______ courtesy, tactfulness and respect(4) ___ accepts constructive criticisms positively(3) ___ does best to perform tasks efficiently(3) ___ TOTAL (100%) _________

IV.

Evaluators Name and Signature:

I hereby accept the actual ratings that appear on this evaluation sheet and that it has been justified and explained to me by the evaluator whose signature is affixed. Signed: ________________________ (Students name and signature)