Professional Documents
Culture Documents
AFFILIATION GUIDELINES
Uniform:
1. Students must wear their complete prescribed uniform.
2. OR/DR scrub suits must be worn in the theater only.
3. Smock gown must be worn whenever students go out of the OR theater.
4. Caps and mask must be removed. Students are required to wear their white uniform
whenever they need to go outside hospital premises.
5. Prescribed OR/DR footwear must be replaced with their clinical footwear whenever they go
outside the OR theater.
6. Students must bring their own OR/DR footwear and oblige with the following color-coding
scheme:
7. Students must wear their white uniform upon reporting to OR/DR whether for duty or for on-
call completion of OR/DR cases.
8. Failure to follow the above mentioned guidelines means NO DUTY.
OTHERS:
OR/DR/PACU/NICU
Objectives: After 4 weeks of duty the student shall have:
Skills:
1. Assesses with confidence in the client’s health care needs and problems through data
collection.
2. Followed steps correctly on how to admit the client in the operating room.
3. Demonstrated and mastered skills in doing ways of using monitoring device
4. Applied correctly the principles of sterilization techniques in the preparation and use of all
materials in the perioperative environment to prevent transmission of biological contaminants.
5. Prepared OR/DR suites before and after delivery and surgery respectively with less
supervision.
6. Prepared packs and sets for sterilization correctly.
7. Assisted with beginning confidence in surgical procedures and handles delivery.
8. Demonstrated immediate care of newborn
9. Applied the different roles and nursing duties of the circulating and scrub nurse with
confidence during preoperative, intraoperative and postoperative phases.
10. Performed preoperative preparations correctly like surgical scrubbing, gowning and gloving.
11. Assisted correctly in placing the client in the desired surgical position, taking into
consideration the nursing responsibilities.
12. Selected the appropriate instruments and/or equipment for the intended surgical
procedure correctly.
13. Applied perfectly the different nursing responsibilities of a PACU nurse.
Knowledge:
1. Created and implemented the nursing care plan for pre-operative, intra-operative, and post-
operative clients successfully.
2. Stated and memorized by heart the different principles of sterile techniques and discussed
the rationale.
3. Described and followed the roles and functions of each member of the surgical team with
less supervision during preoperative, intraoperative, and postoperative phases.
4. Identified correctly the different classes of instruments and equipment used in the OR/DR.
5. Identified correctly the appropriate needles to be used per tissue layer; and described the
different sutures used as to specific purposes.
6. Described and performed with confidence the pharmacologic and non-pharmacologic
methods used to promote relief of pain.
7. Executed the nursing responsibilities with beginning confidence when caring for surgical
client, and in so doing, utilized the nursing process, whose phases are assessment, planning,
intervention and evaluation.
8. Described correctly the operating room attire.
9. Described correctly the various positions used during surgeries.
10. Enumerated perfectly the different types of anesthesia and adjunctive drugs used in general
anesthesia.
11. Explained correctly the different methods of anesthesia, its actions and identified the drugs
for the adverse effects, different complications and related stages of anesthesia.
12. Discussed the responsibilities of clients receiving general, balanced, local and regional
anesthesia with confidence.
13. Created and implemented the nursing care plan successfully.
14. Identified the instruments and equipment used in the NICU correctly.
15. Identified correctly the duties and responsibilities of the nurse in the OR/DR/NICU/PACU.
16. Defined sterilization and explained correctly the different methods of sterilization and
described the indicators of sterility.
17. Discussed correctly the assessment of a client admitted in PACU as to patent airway and
vital signs.
18. Described perfectly the dressing and drains attached to the client.
19. Researched on the current issues related to surgical case assigned by the clinical instructor
and presented it successfully for learning.
20. Mastered the knowledge learned in formulating a teaching plan for postoperative clients.
Attitudes:
1. Appreciated and applied successfully the different functions and responsibilities in varied
settings.
2. Complied faithfully with the standard operating procedures.
3. Valued the importance of accurate data collection and documentation.
4. Valued the principles and processes I the operating room as evidenced by hi/her
performance of the core nursing competencies.
5. Listened attentively to the concerns of the client who will deliver or undergo surgery.
6. Integrated successfully the spiritual care as part of the healing ministry.
7. Recognized perfectly the importance of informed consent.
8. Showed genuine sensitivity to cultural differences.
9. Be aware and carefully handling responsibilities related to medico-legal cases.
10. Complied perfectly with the standard operating procedures.
11. Appreciated the importance of accurate data collection and documentation.
12. Internalized with confidence the new knowledge learned.
OR/PACU ACTIVITIES
Shifts Day 1 Day 2 Day 3 POST
AM PM NOC OR/DR OR/DR OR/DR CONFERENCE
6:30 – 2:30 – 10:30 Preconference Diagnostic Tests
6:45 2:45 – Devotional Week 1
10:45 Checking of 1. Urinalysis and
requirements, 24 hour urine
uniform, collection
paraphernalia 2. Stool Exam
Final include occult
announcement blood
and reminders 3. Typhi dot/
Widal test/
6:45 – 2:45 – 10:45 Orientation to Tubex test
8:00 4:00 – the OR setup, 4. CBC, platelet
12:00 policies, referral 5. Culture and
and hospital Sensitivity Test
routines (CI or with Antibiotic
NOD) Assists with Assists with Removing
Review the OR/PACU/ OR/PACU/ Device (ARD)
duties and NICU/ DR NICU/DR 6. Sputum
responsibilities activities activities Exam/AFB
or OR/PACU 7. Purified
nurse and NICU Protein
nurse Derivative
Reorientation to (PPD)/ Mantoux
OR/PACU forms Test
Review on 8. Fasting blood
surgical sugar
instruments 9. Random
8:00 – 4:00 – 12:00 Assists with Assists with Assists with blood sugar
11:30 6:30 – 2:30 OR/PACU/ OR/PACU/ OR/PACU/ 10. Glycosylated
NICU/ DR NICU/ DR NICU/ DR hemoglobin, 11.
activities activities activities 2 hours
11:30 – 6:30 – 2:30 – 1st batch meal 1st batch 1st batch postprandial
12:00 7:00 3:30 break meal break meal break glucose test
12:00 – 7:00 – 3:30 – 2nd batch meal 2nd batch 2nd batch 12. Oral glucose
12:30 7:30 4:30 break meal break meal break tolerance test
12:30 – 7:30 – 4:30 – Assists with Assists with Assists with (OGTT)
1:30 9:30 6:00 OR/PACU/ OR/PACU/ OR/PACU/ Week 2
NICU/ DR NICU/ DR NICU/ DR 1. Albumin/
activities activities activities Globulin Ratio
1:30 – 9:30 – 6:00 – Post- Post- Post- (A/G ratio)
3:00 11:00 7:00 conference, conference, conference, 2. Cardiac
Review or Review or Review or Enzymes
OR/PACU/DR/NI OR/PACU/D OR/PACU/DR 3. Lipid Profile
CU Routine 4. Liver enzymes
5. Thyroid Panel
Team R/NICU /NICU 6. Trop T and
Conference Routine Routine Trop I
Emphasis Team Team 7. Myoglobulin
1st week Conference Conference 8. Prothrombin
1. Review the Emphasis Emphasis time
principles of 2nd week 3rd week 9. Arterial Gas
sterile 1. Types of 1. Common Analysis (ABG)
technique surgical positioning 10. Serum
2. Review the specimens devices and Electrolytes
basic 2. Care and clinical Week 3
instrument set handling of implications 1. X-ray (all
3. Standardized surgical 2. Drug types)
instrument sets instruments review 2. CT Scan (all
4. Applications 3. (follow drug types)
of dressings and Manageme study format) 3. MRI (all
tape nt of tubes 3. types)
5. Transporting and drains Assessment 4. Upper GI
and moving and 4. of client Series/Barium
lifting the Preoperativ admitted in Enema
patient e health PACU 5. Lower GI
References: teaching 4. Contents Series/Barium
Preoperative plan of Enema
Nursing: implementa postoperativ 6. Ultrasound
Principles and tion e report from (all types)
Practice by the 7. Bone Scan
Susan S,. following: 8. Cystoclysis
Fairchild a. 9. Paracentesis
Operating Room Anesthesiolo 10.
Nursing gist Thoracentesis
Perioperative b. Surgeon Week 4
Practice by c. Circulating 1. Pap Smear
Pamela nurse 2. Colonoscopy/
Pagunsan – Proctosigmoidos
Villacrabs copy
3. Endoscopy
QUIZ (20 pts) QUIZ (20 4.
pts) Cholangiogram
5. Lumbar
Puncture
6.
Echocardiograp
hy
QUIZ (20 pts) 7. Liver Biopsy
8. Stress Test
9. Holter
Monitor
10. Cardiac
Catheterization
Note: Please identify what are the latest trends of these procedures worldwide, nationwide and
locally. Include some reliable references. (See Diagnostic Test Performance Evaluation Tool)
Diagnostic Test
a. Objectives
b. Definition of Terms
c. Introduction/ Definition
d. Indications/Contraindications
e. Normal Values/ Significant results/ Interpretation
f. Equipment used/Procedure
g. Nursing responsibilities: Pre-test, during, Post-test
h. Possible Complications (if any)
i. Drug Study
j. Validity of the Test
k. Latest update on the study
FIRST SEMESTER
OR/DR/NICU/PACU REQUIREMENTS
Day 1 Day 2 Day 3 Day 4
Week 1
To be pass during For students with For students with Diagnostic test
preconference in a surgical case surgical case: Presentation
long bond paper 1. Operating Room 1. Surgical Case Study
1. Define Anesthesia Information Sheet For students who
2. Enumerate the 2. Equipment has no surgical case:
different types of Functionality Test 1. Nursing care plan
anesthesia 3. Surgical Case Study (Intra-operative
3. explain the 4. Sponge, problem)
different methods of Instrument and 2. Discharge plan
anesthesia Needle Accounting 3. Annotated
4. Explain the action Sheet Readings (please use
of the following 5. Pre-operative Visit reading in our
a. General anesthesia Checklist College Library as the
b. Balanced For students who reference and must
anesthesia has surgical no have the signature of
c. Local and Regional surgical case: the Librarian)
anesthesia 1. Health Teaching The discharge plan
5. Describe the Plan should have the
methods of 2. One (1) Nursing following emphasis:
administration of: care Plan a. Work
a. General anesthesia (preoperative b. Rest
b. Balanced problem) c. Exercise
anesthesia 3. Identify the drug d. Wound
c. Regional and Local used for: e. Medication
anesthesia a. general anesthesia f. Follow-up
6. Enumerate the b. balanced
adjunctive drugs anesthesia
used in general c. local and regional
anesthesia anesthesia
7. Discuss the nursing 4. Identify the
responsibilities for adverse effects of
clients receiving: administration
a. General anesthesia techniques in:
b. Balanced a. general anesthesia
anesthesia b. balanced
c. Regional and Local anesthesia
Anesthesia c. Local and regional
anesthesia
5. Give the different
complications of:
a. general anesthesia
b. balanced
anesthesia
c. local and regional
anesthesia
Week 2
To be pass during For students with For students with
preconference in a surgical case: surgical case:
long bond paper 1. Operating Room 1. Surgical Case Study
1. Members of the Information Sheet For students who
surgical team and 2. Equipment has no surgical case:
their functions Functionality Test 1. Nursing care plan
2. Operating room 3. Surgical Case Study (Intra-operative
attire: 4. Sponge, problem)
a. Purpose Instrument and 2. Discharge plan
b. Policies regarding Needle Accounting 3. Annotated
OR attire Sheet Readings (please use
c. Basic OR attire 5. Pre-operative Visit reading in our
d. Attire for sterile Checklist College Library as the
team For students who reference and must
e. Protective gear has surgical no have the signature of
3. Types or degree of surgical case: the Librarian)
trauma 1. Health Teaching
Note: to be included Plan
in the 1st day quiz 2. One (1) Nursing
care Plan (intra
operative problem –
1st priority)
3. Surgical scrub
a. Purpose
b. Important
reminders
c. Preparations prior
to scrub
d. Length of scrub
e. Methods of
surgical scrub
4. Gowning and
gloving
a. Purpose
b. General
considerations
5. Surgical
Instruments
a. Cutting and
dissecting
b. Bone cutters and
debulking tools
c. Grasping and
holding
d. Clamping and
occluding
e. Exposing and
retracting
f. Suturing
instruments
Week 3
To be pass during For students with For students with
preconference in a surgical case: surgical case:
long bond paper 1. Operating Room 1. Surgical Case Study
Possible postop Information Sheet For students who
complications: 2. Equipment has no surgical case:
a. Definition Functionality Test
b. Risk factors 3. Surgical Case Study 1. Nursing care plan
c. Manifestations/ 4. Sponge, (Intra-operative
Vital signs Instrument and problem)
d. Nursing Needle Accounting 2. Discharge plan
management Sheet 3. Annotated
e. Medical 5. Pre-operative Visit Readings (please use
management Checklist reading in our
1. Hypotension For students who College Library as the
2. Bleeding has surgical no reference and must
3. Hypovolemic shock surgical case: have the signature of
4. Atelectasis 1. Health Teaching the Librarian)
5. Thrombophlebitis Plan
6. Paralytic ileus 2. 1 Nursing care Plan
7. Dehiscence (post-op patient – 1st
8. Evisceration priority)
Note: to be included 3. Eight (8) Surgical
in the 1st day quiz Positions
a. Indications
b. Example of surgical
procedure
c. Draw
4. Wound Closure
a. Interrupted
suturing
b. Continuous
● describe
● purpose
● example
● draw
Week 4
To be pass during For students with For students with
preconference in a surgical case surgical case:
long bond paper 1. Operating Room 1. Surgical Case Study
1. Abdominal Information Sheet For students who
Incisions (draw and 2. Equipment has no surgical case:
label) Functionality Test 1. Nursing care plan
2. Setting up the 3. Surgical Case Study (Intra-operative
instrument table 4. Sponge, problem)
3. Handling Instrument and 2. Discharge plan
instruments during Needle Accounting 3. Annotated
surgical procedure Sheet Readings (please use
4. Types of sutures 5. Pre-operative Visit reading in our
and its uses Checklist College Library as the
For students who reference and must
has surgical no have the signature of
surgical case: the Librarian)
1. Dismantling the
instrument table
2. Surgical
Preparation
3. Draw how to skin
prep the following:
a. Abdomen
b. Chest/breast
c. Lateral/
thoracotomy
d. Rectoperineal/
vaginal
e. Knee/ lower leg
f. Hip/lower leg
extremity
SECOND SEMESTER
OR/DR/NICU/PACU REQUIREMENTS
A. SCALPELS
B. KNIVES
C. SCISSORS
B. Stone Forceps
C. Tenaculums
Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts
Single-tooth
Uterine tenaculum
Jacob multi-toothed
Tenaculum
D. Bone Holders
A. Homeostatic Forceps
1. Malleable Retractor
2. Hooks
3. Self-Retaining Retractors
SUTURING INSTRUMENTS
NEEDLE HOLDERS
Name:__________________________________________________
Date:_____________________ Blocking/Area:___________________________
KINDS OF SUTURES/NEEDLES
Suture/Needle Type Color Frequent Usage
Reference: __________________________________
METHODS OF SUTURING
Reference: _________________________________
STAGES OF GENERAL ANESTHESIA
Stage Description Patient Reaction / Nursing Rationale
Biologic Response Implications /
Responsibilities
Reference: ________________________
Herniorrhapy
Open
Cholecystectomy
Hemorrhoidectomy
Crainiotomy
Reference: _________________________
NEWBORN PHYSICAL ASSESSMENT GUIDE
Pre-natal History
a. Pre-natal care: adequate, inadequate or none (specify)
b. Supervised by: doctor, nurse, midwife or “hilot”
c. Maternal Illness: include medical and surgical
d. Medication/Treatment taken
Vital Signs
a. Temperature (rectally)
b. Respiratory rate and character
c. Pulse rate
d. Blood pressure if taken
SKIN
a. Color (Describe and if there are abnormalities in some parts, note the periphery)
b. Birthmarks – check for location, size and characteristics
c. Condition – check if there are abnormalities such as edema, papules, ulcers or diaper
rashes, include also the smoothness, intactness, texture, opacity (visibility of blood
vessel) and desquamation.
d. Hydration and consistency (pinch skin between thumb and forefinger over abdomen or
inner thigh). Check for turgor subcutaneous fat deposits (cheek and buttocks). Check for
any weight loss.
e. Vernixcaseosa – amount, color, distribution, and odor if there is.
f. Lanugo – amount and distribution
g. Mila
ABDOMEN
Assess the size, contour and shape, circumference, inspect the umbilical cord for 2 arteries and
1 vein, color and condition if dry or still wet. Auscultate for bowel sounds, note amount,
number and characteristics of stool and behavior during elimination, movement of abdomen
during respiration.
GENITALS
Female: General appearance, presence of labia and clitoris and for any discharge
Male: Assess for metal opening, scrotum, or size, symmetry, and any abnormalities reflexes
(erection)
EXTREMITIES
General inspection and palpation on:
a. Arms: Degree of flexion, ROM, muscle tone, color, intactness and appropriate
placement of joints on shoulder, elbows, wrist and fingers, extra digits and grasp reflex
b. Legs: Intactness, length in relation to arms, number of toes, color
c. Hips: Examine for any discoloration
d. Back: Inspection and palpation of spine, check for any abnormality.
BEHAVIOR AND NEUROLOGICAL REFLEXES: Assess for the following if present (check if present;
put an “x” if absent) – indicate how it is elicited
a. Plantar Grasp
b. Hand Grasp
c. Babinski Reflex
d. Tonic Neck
e. Moro
f. Rooting
g. Sucking and Swallowing
h. Blink
PATIENTS OPERATING ROOM
INFORMATION SHEET
4x4
Bighots
Cherry
balls
Cotton
balls
Etc.
B. Medications/Anesthesia
a. Trade name
b. Generic name
c. Dosage given
d. Time given
e. Route
f. Nursing implications
C. Intra-OP IVF
a. Type
b. Amount consumed
I. Assessment (5 pts.)
A. Personal Data
Patient’s name:
Age:
Gender:
Civil status:
Date/Time of visit:
Room number:
Address:
Attending physician:
Surgeon:
First assistant:
Second assistant:
Anesthesiologist:
First scrub:
Second scrub:
Circulating nurse:
PACU nurse:
C. Pre-operative Diagnosis
PERSONAL DATA
Name: _______________________________________________
Age: _______________________________________________
Place of Birth: _______________________________________________
Religion: _______________________________________________
Race: _______________________________________________
Ethnic Background: _______________________________________________
Civil Status: _______________________________________________
Date of Admission: _______________________________________________
Time of Admission: _______________________________________________
OB Index: _______________________________________________
Age of Gestation: _______________________________________________
MENSTRUAL HISTORY
LMP _______________________________________________
EDD (Calculate) _______________________________________________
Menarche Age ____________ Interval _________ Duration ________
Symptoms: _____________________
OBSTETRICAL HISTORY
DATE DURATION/CHARACTER GENDER OF WEIGHT OF REMARKS
OF LABOR BABY BABY
MEDICAL/SURGICAL HISTORY
Disease/Illness: __________________________________________________
Previous Accident/s: ______________________________________________
Previous Surgery/ies: _____________________________________________
PHYSICAL EXAMINATION
STAGES OF LABOR
FIRST STAGE
SECOND STAGE
List all the instruments in the prime-set with their corresponding use. Include references.
Note and record the anesthetic agents/drugs administered.
Generic
Name:
Note the intravenous solution or blood given including amount and blood type.
________________________________________________
________________________________________________
NEONATE
THIRD STAGE
FOURTH STAGE
1.
2.
3.
Materials Needed:
1.
2.
3.
Evaluation: ____________________________________________________________
____________________________________________________________
YES NO
1. Reinforcement of physician explanation of surgical procedures
2. Explanation on how to deep breath and cough
a. Demonstrate and return demonstration
b. Incentive spirometer
3. Explanation of Oxygen drainage tubes, intravenous fluids and specific reasons for
having these
4. Patient informed regarding how often blood pressure, pulse and temperature
will be taken
5. Explanation of pain medicine given. Patient informed of need to request pain
medicine when needed
6. Patient informed about what will take place night before surgery. (enema, bath,
prep, sleeping pill, etc.)
7. Patient informed about what will take place early morning of surgery. (bath, vital
signs, and gown)
8. Patient shown how to turn from side to side. Turning encouraged every 2 hours
for 24 hours or longer after surgery. Patient encouraged to move himself (except
spinal surgery)
9. Patient shown how to move foot in circle and how to flex his leg slowly but often
10. Pre-op medication explained to the patient and reason for giving
11. Patient instructed in need to void prior to pre-op
12. Patient instructed to stay in bed after pre-op medication given and side rails be
kept up.
13. Explanation of “Nothing by Mouth” which usually is in effect after midnight
14. Patient instructed on how to record I&O and purpose
15. Patient instructed in self perineal care and catheter care if applicable
16. Patient instructed in removal of the following:
a. Dentures
b. Jewelry: watch, earrings, rings and necklace
c. Contact lens and eye glasses
d. Fingernail and toenail polish
e. Wigs, Hairpieces and hair pins
f. Hearing aid
g. Extra clothing
17. Specific information given to relatives on where to wait and when & where to
see the doctor
__________________________ __________________________
Patient’s Name & Signature Nurse’s Name & Signature
EQUIPMENT FUNCTIONALITY SHEET
Name: ___________________________ Age: ___ Sex: ___ Room: _____ Hospital No. ________
Surgeon: _______________ First Assistant: ____________ Anesthesiologist: _______________
Planned Surgical Procedure: ______________________________________________________
_____________________________________________________________________________
Type of Anesthesia: ______________________ Date of Surgery: ___________ Time: ________
_____ OR Light
_____ OR Table
_____ Cardiac/Patient Monitor
_____ Anesthesia Machine
_____ Suction Machine (Oral)
_____ Suction Machine (Abdominal)
_____ IV Pump
_____ Syringe Pump
_____ Laparoscope
Others:
________________________
________________________
________________________
________________________
________________________
___________________________
Name and Signature of OR Nurse
INSTRUMENT AND NEEDLE COUNT
INSTRUMENT AND NEEDLE COUNT
Needle Initial Adde Total Second Count Third Count Fourth Count Final Count Remarks
Count d
On On Total On On Total On On Total On On Total
table floor Table Floor Table Floor Table Floor
Adson w/
teeth
Adson
w/o
teeth
Allis
Army
Navy
Retractor
Bandage
Scissors
Babcock
Blade
Holder
De Bakey
Heaney
Kelly
(Curve)
Kelly
(Straight)
Kocher
(Curve)
Kocher
(Straight)
Mayo
scissors
Metz
Mosquit
oes
Needle
holder
Peans
(Curve)
Peans
(Straight)
Suture
Scissors
Thumb
Forceps
Tissue
Forceps
Towel
Clips
Others:
Needle
Blade
We hereby declare that the sponge, instrument, and needle counts are complete and accounted for.
SPONGE COUNT
Sponges Initial Adde Total Second Count Third Count Fourth Count Final Count Remarks
Count d
On On Total On On Total On On Total On On Total
table floor Table Floor Table Floor Table Floor
4x4
4x16
Big Hotz
Cottonoi
ds
Peanuts
Prep
Balls
Cherry
Balls
Others:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
CASE SHARING PERFORMANCE EVALUATION
Individual-40%
I. Delivery
a. Organization. Systematic and logical presentation of 15
the report
b. Clarity of voice, goof diction, grooming and poise 5
II. Content
a. Correctness of processing and interpretation of data 15
b. Clear and unambiguous presentation 5
c. Conciseness of presentation 5
d. Appropriate data presented 10
III. Audio-visual aids
a. Use of audio-visual aids to facilitate comprehension 5
IV. Mastery and Tact
a. Ability to answer relevant questions 20
b. Attitude toward criticism and suggestions 10
TOTAL 100
GROUP-40%
I. Delivery-30%
a. Utilization of appropriate, useful strategies to catch 20
audience interest, sustain attention and encourage
participation
b. Organized and well-outlined, comprehensive 50
presentation
c. Collaboration of members, provision of data and 20
participation in the Q and A, coaches each other
d. Time limit observance (1 and ½ hour) 10
e. Use of appropriate and relevant visual aids 10
f. Bibliography-annotated references used 10
Total 120
II. Content-60%
Introduction of the Case 10
Definition of Terms 5
Normal Anatomy and Physiology 20
Physical Assessment and Review of Systems 30
Diagnostic Tests 15
Risk Factors and Pathophysiology 30
Pharmacology/Medications 10
Nursing Care Plans (Appropriately prioritized) 50
Medical/Surgical Management 10
Discharge Plan and Health Education Plan 20
Prognosis 5
References 5
Recent Updates and Researches 10
TOTAL 230
III. Group Attitude Towards 10
Questions/Criticisms/Comments-10%
Total
FINAL COPY-20%
Individual 40%
Group 40%
CASE SHARING GUIDELINES
GROUPINGS
Case Sharing Groupings is outlines on the Level 3 Bulletin Board. The CS group is consists of 10-
12 members.
There will be 3 weeks of Case Sharing. One group will present in a day.
PRESENTATION
1. During the Presentation, each group will be given the tasks. One group will present the
case topic provided, and another group is assigned to be the TIME KEEPER and STAGE
COORDINATOR. This group will remind the presenting group of the remaining time and
budget of their presentation. They are also in charge in putting up the visual aids, maintain
the order of the stage, and attend the needs of the presenting group.
2. One group will be assigned as the CRITIQUE GROUP. The Critique Group will be in charged
in asking questions (together with Clinical Instructors), making constructive criticisms of the
work of the presenting group.
2. The Critique Group should study, scrutinize, criticize the output of the group and prepare
mind challenging questions a night prior to the presentation.
3. Submission of the final manuscript of the case presentation should be 1 week after the
presentation. Failure to do so, the group will receive a grade of zero for the final copy.
Late submission will not be accepted.
4. Manuscript submitted to the clinical instructors should be neat & tidy. Please check for any
typographical errors. Manuscript for the presentation will be written in a long bond-paper.
5. Practice for a dry run of the presentation will be done among the group. Expect for various
thought-provoking questions from the panel members
7. Use appropriate & relevant strategies in the presentation of the case. Extravagant
presentation that is out of context of the diagnosis being discussed, is highly discouraged.
2. The CP Final Grade depends upon the group and individual performance. Forty percent
(40%) of the Final Grade will come from the individual performance and 40% will come
from the group performance and 20% will come from the final copy.
3. Do approach/consult any of the attending CI’s for any suggestions, comments or initial
corrections of the output 1 week before the scheduled presentation. However, a night
before the presentation, there must be NO consultation and correction done. The CI’s will
use that time in preparing for the actual presentation. Thorough discussion about the case
must be done among the group before the presentation. Intermission numbers, ice
breakers, teaching strategies (play, drama, role playing, and games) must be rehearsed
ahead of time. Thought-provoking questions will be expected from the panel members.
4. On the day of the presentation, the group will submit a written program for the
presentation.
MINI MENTAL STATUS EXAMINATION FORM
Scoring: 21-30 – normal; 11-20 – mild cognitive impairment; 0-10 – severe cognitive
impairment
I. Presentation
A. General Appearance
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
B. General Mobility
a. Posture and Gait:
b. Activity
i. Normoactive
ii. Psychomotor Retardation
iii. Hyperactive
iv. Agitated
c. Behavior
Friendly Impulsive Angry Embarrassed Negativistic
e. Quality
Talkative Dependent
Others: ____________________________________________
C. Speech Patterns
a. Character
Spontaneous Deliberate Pressured Blocking
b. Organization of Talk
Mute Inaccessible
1. Mood
Euthymic Depressed Euphoric Labile Irritable
Guilty Anxious Fearful Sad Despairing
2. Affect
Appropriate Inappropriate
3. Quality
Flat Blunt Restricted Labile
E. Thought Content
Delusion?
Type: ________________________________________________________________
_____________________________________________________________________
Obsessions/Paranoia/Phobias/Ritual
_____________________________________________________________________
_____________________________________________________________________
Perceptual Disturbances
i. Hallucinations: _______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
ii. Depersonalizations or Derealizations: ____________________________________
_____________________________________________________________________
iii. Illusions: ___________________________________________________________
iv. Others: ____________________________________________________________
F. Neurovegetative Functions
a. Sleep
b. Appetite: ___________________________________________________________
d. Weight: ___________________________________________________________
e. Libido: ____________________________________________________________
A. Orientation
i. Time: __________________________________________________________
ii. Person: ________________________________________________________
iii. Place: _________________________________________________________
iv. Level of Consciousness: ___________________________________________
_________________________________________________________________
v. Calculation: _____________________________________________________
_________________________________________________________________
vi. Concentration: __________________________________________________
_________________________________________________________________
vii. General Information: _____________________________________________
_________________________________________________________________
viii. Abstract Thinking: _______________________________________________
__________________________________________________________________
__________________________________________________________________
ix. Judgment: _______________________________________________________
__________________________________________________________________
__________________________________________________________________
x. Memory:
1. Immediate: ___________________________________________________
_______________________________________________________________
2. Recent: ______________________________________________________
_______________________________________________________________
3. Remote: ______________________________________________________
_______________________________________________________________
xi. Insight: _________________________________________________________
__________________________________________________________________
xii. Adaptive Use of Coping/Ego Mechanisms: ____________________________
__________________________________________________________________
__________________________________________________________________
Daily Objectives:
A.
B.
C.
D.
E.
Note: CI must check this form a night before therapy. Students must make the activity
interesting. Allow creativity artistic prowess, and resourcefulness to come in to play. Reserve
more icebreakers and games just in case needs one
PSYCHIATRIC NURSING PROCESS RECORDING
FORMAT
Name: ________________________________________ Age: ______ Date: _____________
Diagnosis: _______________________________ Attending Physician: __________________
II. OBJECTIVES
LTO (formulate 5 objectives for the whole exposure. E.g. Within 3 weeks…)
PATIENT:
NURSE:
PATIENT:
V. EVALUATION OF STO
Note:
Should be recorded daily
Monday and Tuesday NPI will be submitted Wednesday during Preconference
Wednesday and Thursday NPI will be submitted Friday during Preconference
PSYCHIATRIC-MENTAL HEALTH NURSING
CARE PLAN FORMAT
Psychopharmacology
Theory: (Collaborative)
PSYCHIATRIC NURSING STUDY FORMAT
I. INTRODUCTION
II. OBJECTIVES
III. INFORMANT
A. ANAMNESIS: (past personal history) History of the patient’s life from infancy to the present
to the extent that can be recalled, gaps in history as spontaneously related by the patient,
emotions associated with these life periods- pain, stressful, and conflictual. Each health history
and developmental milestone. Anchor these theories.
a. Prenatal/Perinatal History
b. Infancy
c. Toddler
d. Preschooler
e. School Age
f. Adolescent: social, relationships, school history, cognitive and motor development, emotional
and physical problems and sexuality
g. Early Adulthood
h. Middle Adulthood
i. Late Adulthood: occupational history, marital relationship history, education history, religion,
social activity, current living situation, legal history
D. GENOGRAM AND FAMILY HISTORY: Elicited from patient and from someone else
because quite different descriptions may be given of the same people and events; ethnic,
national and religious traditions; other people in the home, description of them – personality
and intelligence and what become of them since the patient’s childhood; descriptions of
different households live in; present relationship between patient and other people who were
in the family; role of illness in the family; history of mental illness and treatment.
V. PROGRESS NOTES
B. LABORATORY DATA:
In addition to medical test, one should record the result of any psychometric test.
VIII. PROGNOSIS
Opinion as to the probable future course, event and extent and outcome of the illness; goals of
therapy.
Prognosis Documentation
Onset of Illness (if chronic/acute)
Precipitating Factors (if present/absent)
Family Support (if strong/weak/poor/absent)
Depressive feature (if present/absent)
Mood and Affect (if appropriate/
Inappropriate)
Willingness to take medications
Note: Prognosis can be either be Good, Fair, or Poor. Summarize by making a conclusion in the
overall prognosis of the client based on the criteria above. Cite documentation about the
prognosis of the disease according to the book. Write the reference.
IX. RECOMMENDATIONS
A. PATIENT
B. FAMILY
C. NURSE
D. PHYSICIAN
E. COMMUNITY
X. REFERENCES
XI. APPENDIX
CASE STUDY FORMAT
Contents:
Title Cover
Table of Contents
The Authors
Acknowledgment
Dedication
Objectives of the Study
Patient Centered
Student Centered
Introduction
Definition of the Case, Types, History, Etiology, Epidemiology, Prevalence (Global and
National), Recent Studies and Findings
Chapter I: Assessment
A. Psychiatric Nursing History
a. Vital Information
b. Informants
c. Chief Complaints
d. Personal Identification
e. History of Present Illness
f. History of Past Illness
g. Allergies
h. Medication and Drug Study
i. Family History
j. Personality
k. Psychosexual History
l. Current Social Situation
m. Assets
n. Dreams, Fantasies and Value System
B. Anamnesis
C. Genogram
D. Mini Mental Status Examination (Include daily MMSE and compare for each day)
E. Mental Status Examination (Include weekly MSE and compare for each week)
F. Physical Assessment (Perform it weekly)
G. Spiritual Assessment
H. Diagnostic Studies (From admission until the week of care)
I. Nurses Progress Notes (From orientation phase until termination phase)
Chapter II: Diagnosis and Analysis
A. Psychodynamics
B. Psychodynamics Concept Map
C. Life Chart (refer to sample given)
D. Diagnostic and Statistical Manual of Mental Disorder
Chapter III: Planning and Implementation
A. Nursing Care Plan
B. Psychotherapies
C. Nurse Process Recording (NPI only the significant interaction)
Chapter IV: Psychopharmacology
Chapter V: Discharge Plan (M.E.T.H.O.D.S.)
Chapter VI: Evaluation (Prognosis and Recommendations)
Appendices (Pictures, Letters, etc)
Glossary
Bibliography
Make a scrapbook
Note:
Chief Complaint: Exactly why the patient came to the psychiatrist, preferably in the
patient’s own words; If this information does not come from the patient, note who
supplied it. The patient’s explanation, regardless of how bizarre or irrelevant it should
be recorded verbatim in the section of the chief complaint.
Personality: the patient’s illness and attitudes and beliefs, moral values, standards and
reaction to stress
Psychosexual History: e.g. how the patient acquired sexual information, varieties and
frequency of sexual practice and fantasy, marital history with details of engagement,
marriage and pregnancies and their outcome. In females there should be careful inquiry
about psychiatric disturbance during and after pregnancy.
Current Social Situation: where does the patient live – neighborhood and particular
residence of the patient; is home crowded; privacy of family members from each other
and from other families; sources of family income and difficulties obtaining it; who is
caring for the children.
Biological father/mother/brothers/sisters; state their age, health, education,
occupations, psychological functioning and job history. Please include the adaptive or
step parents and others. Upbringing (family constellation, socioeconomic status,
religion). School and occupational history (grade completed and age stopped, for what
reason, ability, performance and behavior in school). Type of work and job, and its
history. Sexual and marital history (details of not only sexual experience, but also of the
family dynamics and patient’s may be of importance. Premorbid personality of patient
before the onset of an acute psychiatric illness. Describe briefly his premorbid activities,
interest, general mood and social patterns.
Assets: Medicare requires statements regarding the patient’s assets. Briefly mention
patient’s attributes such as talents, compliance, supportive people in the patient’s life,
insurance status, education and job status, housing wealth that may contribute to the
patient’s treatment.
Dreams, Fantasies and Value Systems: If patient has nightmares, what are their
repetitive themes? Can a patient describe a recent dream and discuss its possible
meanings? Fantasies and daydreams are another value source of unconscious material.
What are the patient’s fantasies about the future? If the patient could make any change
in his or her life, what would it be? What are the patient’s most common favorite
current fantasies? Does the patient experience daydreams? Are the patient’s fantasies
grounded in reality or is the patient unable to tell the difference between fantasy and
reality? Ask the patient’s system of values both social and moral, including values that
concerns work, money, play, children, parents, friends, sex, community concerns and
cultural issues. For instance, are children seen as a burden or a joy? Is work experienced
as a necessary evil, an avoidable chore or an opportunity? What is the patient’s concept
between right and wrong?
Spiritual Assessment: Ask the patient; What importance does religion or spirituality
have in your life? Do your religious or spiritual beliefs influence the way you take care of
yourself or illness? How? Who or what supplies you with hope?
Cultural Assessment: Ask the patient; With what cultural group do you identify? Have
you tried any cultural remedies or practices for your condition? If so, what do you use
any alternative or complimentary medicine/herbs or any practices?
BEHAVIOR PATTERN ANALYSIS
Points
A. Vital Information
1. Demographic Data/Other Petinent Data
Name of Patient Age
Address Religion 10
Civil Status Date of Admission
Diagnosis Attending Physician
2. Brief Discussion of the disorder or the diagnosis of your client 10
3. Chief Complaints 5
4. History of Illness 10
5. Family History 10
6. Personal History 10
B. Behavior Patterns Interpretation with Reference
Enumerate all the signs and symptoms or the manifestation of client, classifying
them according to the items below, state the signs and symptoms then describe how 20
the client manifested it. Lastly, document the signs and symptoms by explaining its
psychodynamics; indicate the reference (e.g. delusion of grandeur {describe the clients
behavior then explain the cause of the grandiose delusion} )
1. Appearance and Behavior
a. 5
b.
2. Emotional State
a. 5
b
3. Thought and Perceptual Disturbances
a. 5
b.
4. Speech and Stream of Talk
a. 5
b.
5. Cognition, Memory and Orientation
a. 5
b.
C. Evaluation/Evaluate client based on:
a. Behavior Patterns (signs and symptoms of the client) 10
b. LTO (based on the LTO formulated in the NPI
Total points 110