Professional Documents
Culture Documents
No Competencies Approval
. Common symbols: Date CI Signature
45 Hx
46 Kg
47 L
48 LLQ
49 LUQ
50 LMP
51 LOC
52 Lpm
53 M
54 Min
55 MI
56 Mm
57 Na
58 NC
59 Neg
60 N&V
61 O₂
62 □
63 PE
64 Pt
65 Px
66 R
67 RBC
68 RLQ
69 RUQ
70 R/O
71 Rx
72 □
73 SOB
74 Temp
75 Tx
76 VS
77 WBC
78 w/
79 w/o
80 w/c
81 wt
82 yr
3
Competencies Approval
No.
Terminology: Date CI Signature
1 Acro-
2 ad-
3 -algia
4 Amni
5 -amnios
6 An
7 -an
8 Ana-
9 Ankyl
10 Ante-
11 Anti-
12 Auto-
13 Az
14 Bi-
15 Brady-
16 Calcul
17 -carcinoma
18 -cardia
19 -cele
20 -centesis
21 -chalasia
22 Cholangi/o
23 Cholecyst/o
24 Chromate/o
25 Circum-
26 Cirrh/o
27 -clasis
28 Contra-
29 -crine
30 -cyesis
31 -cytosis
32 -ectasis
33 -ectomy
34 -edema
35 -emesis
36 -emia
37 -esis
38 -gram
39 -graph
40 -graphy
41 -gravida
42 Hemi-
43 Hyper-
44 Hypo-
45 -ia
46 -iasis
4
Competencies Approval
No.
Common symbols: Date CI Signature
47 In-
48 Infra-
49 Inter-
50 Intra-
51 -ion
52 -ior
53 -ism
54 -ist
55 -it is
56 -lepsy
57 -listhesis
58 -logy
59 -lysis
60 -malacia
61 -mania
62 -megaly
63 Meta-
64 -meter
65 -metry
66 Micro-
67 Mono-
68 Neo-
69 -oid
70 -oma
71 -opsy
72 -opsia
73 -orexia
74 -ose
75 -osis
76 -ous
77 Pan-
78 Para-
79 -para
80 -paresis
81 -pathy
82 -penia
83 -pepsia
84 Per-
85 Peri-
86 -pexy
87 -phagia
88 -phobia
89 -phylaxis
90 -plasm, -plasia
91 -plasty
92 -plegia
93 -pnea
5
Approval
No. Competencies
Date CI Signature
94 -poiesis
95 Pre-
96 Pro-
97 -ptosis
98 -ptysis
99 Quadri-
100 Re-
101 -rrhage, -rrhagia
102 -rrhaphy
103 -rrhea
104 -rrhexis
105 -salpinx
106 -sarcoma
107 -sclerosis
108 -scope
109 -scopy
110 -spadias
111 -spasm
112 -stalsis
113 -stasis
114 -stenosis
115 -sthenia
116 -stomy
117 Sub-
118 Supra-
119 Syn-
120 Tachy-
121 -tension
122 -therapy
123 -thorax
124 -thymia
125 -tion, -ization
126 -tocia
127 -tome
128 -tomy
129 -tresia
130 -tripsy
131 -trite
132 -trophy
133 Uni-
134 -uria
135
136
137
138
139
140
6
Approval
No. Competencies
Date CI Signature
Acute Pain
1 Onset
2 Duration
3 ANS response
4 Relevance to healing
5 Response to analgesic
Chronic Pain:
1 Onset
2 Duration
3 Ar response
4 Relevance to healing
Reffered Pain:
1 Heart
7
Approval
No. Competencies
Date CI Signature
2 Lungs
3 Diaphragm
4 Liver
5 Spleen
6 Stomach
7 Kidney
8 Pancreas
9 Gallbladder
10 Ovaries
11 Appendix
12 Ureters
13 Bladder
1 Anoxia
2 Apnea
3 Asphyxia
4 Aspiration
5 Atelectasis
6 Bronchoscope
7 Cheyne –stokes respiration
8 Cyanosis
9 Epistaxis
10 Fremitus
11 Hemoptysis
12 Hemothorax
13 Hypercapnemia
14 Hyperpnea
15 Hyperventilation
16 Hypoventilation
a17 Hypoxia
18 Intubation
19 Kussmaul breathing
20 Lobectomy
21 Mantoux test
22 Rale
23 Ronchi
24 Spirometer
25 Stridor
26 Tachypnea
27 Thoracentesis
28 Tracheostomy
29 Tracheotomy
30 Wheeze
31 ABGs
32 AFB
33 ARDS
34 ARF
8
35 BVM
36 CPR
37 ENT
38 IPPB
39 JVD
40 PPD
41 RDS
42 SOB
1 Aneurysm
2 Arrhythmia
3 Bradycardia
4 Cyanosis
5 Diastole
6 Dyspnea
7 Edema
8 Embolism
9 Embolus
10 Hypertension
11 Hypotension
12 Infarction
13 Ischemia
14 Palpitation
15 Phlebitis
16 SA node
17 Stenosis
18 Systole
19 Tachycardia
20 Thrombosis
21 Thrombus
22 AF
23 AR
24 ASD
25 AT
26 BP
27 CABG
28 CAD
29 CHF
30 CPR
31 CPR
32 EKG
33 HDL
34 JVP
35 LDL
36 PMI
37 VT
38
9
Approval
No Abbreviation
Date CI Signature
Medicine
1 ac
2 No AD Approval
3 . Competencies
AS Date CI Signature
4 1 AU
Anorexia
5 2 Aphagiabid
6 3 c
Appendicitis
7 4 cap
Ascites
8 5 dc
Constipation
9 6 gtt
Defecation
10 7 Dyspepsiahs
11 8 IM
Flatus
12 9 INF
Icterus
1310 MelenaIO
1411 IV
Obstipation
1512 IVFD
Ostomy
1613 KVO/KO
Regurgitation
1714 NGT
Stoma
1815 NPO
-chalasia
1916 NS
-chezia
2017 OD
-emesis
2118 oint
-litothomy
2219 OS
-pepsia
2320 OU
-pexy
2421 PC
Calcu/o
2522 PO
Chol/e
2623 prn
Cholangi/o
2724 q
Cholecyst/o
2825 q1h
Choledoch/o
2926 Bm q2h
3027 ERCP q3h
3128 GERD q4h
3229 GIq6h
3330 IBSq8h
3431 qAM
n&v
3532 TPNqd
3633 qh
37 qid
38 qod
39 qPM
40 S/S
41 SC
42 Sdm//tbsp/C
43 Sdt/tsp/cth
44 Sol
45 stat
46 supp
47 Syr
48 Tab
49 Tid
10
Eye:
ointment/drop
Ear drops
Nasal drops/spray
i. Inhalation medication
j. Right Documentation
3. Administering transfusion
with blood products:
a. Whole blood
b. Platelets
c. Packed red blood cells
(PRC)
Respiratory System
1. Perform nursing
assessment for respiratory
system disorders
2. Promoting Oxygenation
a. Administering oxygen
with cannule
b. Administering oxygen
with masker
c. Perform suctioning
3. Preparing and
administration of
nebulization
4. Perform chest
physiotherapy
5. Perform postural drainage
technique
6. Water Seal Drainage Care
7. Tracheostomy Care
8. Collecting sputum
specimen
9. Arterial blood gases
analysis
10. Others
5. Management with
Nasogastric tube:
a. Inserti NGT
b. Gastric irrigation
c. Feeding via NGT
d. Removing NGT
6. Promoting Nutrition
a. Serving food for
independent client
1st 2nd 3rd
Competencies CI Approval
Performance Performance Performance
Skills: Date Sign Date Sign Date Sign Date Sign
a. Feeding for dependent
client
b. Feeding via NGT
16
Endocrine System
1. Perform complete physical
assessment of Endocrine system
2. Care the client with:
a. Thyroid disorder
b. Diabetes mellitus
c. Others
3. Prepare of client for change
dressing
4. Health teaching
5. Insulin Administration
6 Random blood glucose test
7. Others
Immune System
1. Perform Physical assessment
2. Perform pain management
3. Wound care
4. Provide health teaching
a.
b.
c.
d.
5. Others
1st 2nd 3rd
Competencies CI Approval
Performance Performance Performance
Skills: Date Sign Date Sign Date Sign Date Sign
Urinary System
1. Perform Physical assessment
for genitourinaty system
2. Inserting urine Catheter
17
a. Regular catheter
b. retention catheter
c. applying condom catheter
3. Bladder irigation
4. Health teaching
a. Increasing fluid intake
b. Fluid intake limitation
c. Others
6. Collecting urine specimen
a. Urine rutine
b. 24 hours
7. Monitoring intake & output
8. Wound Care
9. Maintaining the patency of
the three way closed irrigation
and drainage
10. Monitoring urine output for
color, and volume
12. Bladder traning
13. Catheter out
14. Other
related to neurology
system:
a. Head CT Scan
b. MRI
c. Cerebral angiography
d. Lumbar puncture
e. Encephalography
Musculoskeletal system
3. Perform musculoskeletal
system assessment
4. Manage client with:
a. Cast
b. Splint/brace
c. Traction
d. Assisting client for
ambulation using:
- Crutches
- Walker
- others
5. Preparing client for
diagnostic procedure:
a. X-ray
6. care for post operative
clients:
a. amputation
b. spinal surgery
c. post ORIF
d. Tendon repair
e. Others
Integumentary System
1. Perform complete physical
assessment of integument
system
2. Care the client with:
a. Burn
b. Dermatitis
1st 2nd 3rd
Competencies CI Approval
Performance Performance Performance
Skills: Date Sign Date Sign Date Sign Date Sign
c. Herpes simpleks
d. Herpes Zoster
e. Pediculosis
f. Pruritus
19
g. Tinea capitis
h. Ulcu decubitus
i. Varicela
3. Prepare of client for change
dressing
4. Health teaching
Renal Unit
1. Pre HD
a. Machine preparation
Identifying and Preparing
reverse Osmosis
Identifying and preparing
hemodyalisis machine
b. Instruments preparation
pre-primming Instruments
primming
Instruments for blood
access
c. Client preparation
measuring weight
Measuring vital signs
Identify, note, and report
objective and subjective
data
2. Hemodialysis performance
a. Assissting in blood access
and connecting circulating
b. Counting TMP, bicnat dose
c. Perform HD monitoring
d. Indentifying and managing
complication during HD
3. Post HD
a. Assisting in HD
accomplishment
b. Obtaining and
documenting weight post
HD
1st 2nd 3rd
Competencies CI Approval
Performance Performance Performance
Skills: Date Sign Date Sign Date Sign Date Sign
c. Obtaining and documenting
vital signs post HD
d. Sterilizing Instruments
4. Others
Operating Room
20
1. Circulate Nurse:
a. assisting in preparing
instruments
b. Assisting in preparing sterile
linen, gown, gloves, towel
and minor sheet
c. Put cap and gown to the
patient
d. Remove client’s nail polish
e. Remove client’s dentures
and jewelries
f. Checking the informed
consent/ legal implications
g. checking pre-op medication
h. with circulating nurse,
anticipate needs of the
sterile team
i. with circulating nurse
prepare for the next case &
lose no time between them
2. Scrub Nurse
a. Perform surgical preps
b. Scrubbing
c. Opening the bundle
d. Preparing minor tray
e. Wearing gloves
f. assisting the surgeon to wear
the sterile gown and gloves
g. assisting the scrub nurse in
supplying the instrument to
the surgeon
h. counting the gauzez before
and after surgery
i. dressing the incision
j. Transferring the client to the
recovery room
k. note time of surgery
termination