Professional Documents
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COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Room: ___________ Case Number.: ______________ Date & Time of Admission: ________________
Patient’s Name: _______________________________ Attending Physician: ______________________
Age & Sex: _________ Birthday: ____________ Final Diagnosis: _________________________
Chief Complaint: _____________________________ _______________________________________
Admitting Diagnosis: __________________________ Date & Time of Discharge: _________________
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
K A R D E X
LOC AFFECT ACTIVITIES MONITORING
___ Conscious ___ Calm ___ may ambulate ___ V/S _____________________
___ Confused ___ Depressed ___ may sit at bedside ___ NVS ____________________
___ Lethargic ___ Anxious ___ CBR with BRPs ___ BP ______________________
___ Stuporous ___ Restless ___ CBR without BPRs ___ PR/CR __________________
___ Comatose Others: Others: ___ RR _____________________
______________ _________________ ___ Temp. ___________________
___ I & O ___________________
___ Wt. _____________________
Others: _____________________
SURGICAL SLIP
Name of Hospital/Agency: ______________________________________________________
Date: ________________ Shift: _________________
Name of Patient:
______________________________________________________________________________ First
Name Middle Name Last Name
Case Number: _____________________ Time Started: __________________
Age: ______ Sex: _________
Student Nurse
Instrument Nurse: ______________________________________________________________
Circulating Nurse: ______________________________________________________________
OR Nurse On Duty
______________________________________________________________________________
First Name Middle Name Last Name
License Number: ____________________ OR Nurse Signature: ___________________
Clinical Instructor
Name: ________________________________________________________________________
License Number: ____________________ Signature: _________________________
Form No.: TSU-COS-SF-05 Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 6
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
ATTENDANCE LOGSHEET
Year and Section: _______ Group No. _____
Area / Ward: ________________ Rotation Period: ________________________
Date
No. Name of Students
Time-in Signature Time-in Signature Time-in Signature Time-in Signature Time-in Signature Time-in Signature Time-in Signature Time-in Signature
1
2
3
4
5
6
7
8
9
10
Clinical Instructor:
____________________________
(Signature Over Printed Name)
Chairperson:
___________________________
(Signature Over Printed Name)
Form No.: TSU-COS-SF-12 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Assessment
Area N AbN Description of Findings & Interpretation
General Appearance
Posture
Hygiene/Grooming
Nutrition/Diet
Body Size/Habitus
Height: ________
Weight: _______
Supply appropriate data:
➢ IBW: ___________
➢ BMI: ___________
➢ IRS: ____________
Behavior
LOC
Vital Signs
Temperature: _______
Pulse Rate: _________
Rhythm: __________
Respiration Rate: ________
Rhythm: ___________
Blood Pressure: __________
Skin
Color
Temperature
Turgor
Texture
Integrity
Unusual Marks
Rashes, Lesions
Pressure sore: Yes ___ No
Site: ___________________
Edema: Yes ____ No ____
Site: _______
Type: _____
Size/Degree: _____
Hair
Texture
Thickness
Color & Distribution
Hygiene Status
Nails
Color & Shape
Hygiene Status
Presence of Clubbing
Head
Shape & Symmetry
Unusual swelling
Cranial bruit
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 6
Assessment
Area N AbN Description of Findings & Interpretation
Chest and Lungs
Breathing
➢ Spontaneity
➢ With Ventilator
➢ With Tracheostomy
➢ Rhythm
➢ Depth
➢ Effort
Use of Accessory Muscles
a. Intercostals
b. Abdominal
c. Sternocleidomastoid
d. Trapezius
Cough
Sputum Production: Yes __ No: __
➢ Amount: _____________
➢ Consistency: __________
➢ Color: _______________
➢ Odor: _______________
Chest X-ray Result
Breath Sound (Specify)
a. Bronchial
b. Crackles
c. Rhonci
d. Wheezes
e. Stridor
f. Crepitus
CTT
Location: __________
Suction: ___________
Water Level: _______
Quality of Drainage: ___________
ABG
Other Findings: ________________
Heart
History
With Palpitation
Dyspnea
Rhythm
Point of Maximal Impulsec(PMI)
(PMI is felt at 5th ICS at apex
of heart) Specify:
a. Heaves
b. Clicks
c. Splitting
d. Thrills
e. Callops
f. Muffles
Presence of Heart Sounds
a. S1
b. S2
c. S3
d. S4
Murmurs
a. Systolic
b. Diastolic
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 3 of 6
Assessment
N AbN
Area Description of Findings & Interpretation
Abdomen
Diet: ____________________
Mode of Feeding: __________
Shape and Symmetry
Umbilicus Protrusion
Bowel Sound (Indicate Sound)
➢ LUQ: __________
➢ RUQ: __________
➢ LLQ: __________
➢ RLQ: __________
Abdominal Bruit
Distention
Ascites: Yes: ____ No: ____
Nausea
Vomitus/Hematemesis
Amount: _______________
Consistency: ____________
Color: _________________
Odor: _________________
Frequency: _____________
Drainage Tube
Abdominal Mass
Abdominal Girth: __________
Other Findings: ________________
Back
➢ Spine
➢ Paralumbar
Other Findings: ________________
Genitalia
Symmetry
Presence of Tenderness
Urethral Discharge
Bleeding
Pelvic Pain
LMP: ________________
With Dysuria
With Flank Pain
Nocturia
History of Urinary Stone
History of Impotence
With Urinary Catheter
Urinalysis Finding: _____________
Peritoneal Dialysis (PD)
a. Date Started
b. Incorporation
c. Cycle Exchange
Amount: _______________
Dwell Time: ____________
Drainage Time: __________
d. PD Return
Color: __________
Flow: __________
Hemodialysis
Frequency: ________________
Last HD: __________________
Amount of Fluid Removed: _____
Next HD: __________________
Place: ____________________
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 4 of 6
Assessment
Area N AbN Description of Findings & Interpretation
Rectal Examination
Anal Inspection
With Hemorrhoids: Yes:__ No:__
Location: ______________
Characteristics: _________
Mass
Last Bowel Movement: _________
Characteristic of Stool: __________
Other Findings: ________________
Nodes
Lymphadenopathy
Location
a. Cervical R ___ L ___
b. Axillary
c. Inguinal R ___ L ___
Others ______________
Extremity
Texture
Capillary Refill
Peripheral Pulse (both sides)
➢ Carotid
➢ Radial
➢ Ulna
➢ Brachial
➢ Femoral
➢ Posterior Tibial
➢ Dorsalis Pedis
➢ Popliteal
Clubbing of Fingers
Varicosities
Thrombophlebitis
Cyanosis
Joints
➢ Erythema
➢ Tenderness
➢ Deformity
➢ Swelling
Muscles
➢ Bulk
➢ Tone
➢ Tenderness
Ulcerations
Edema
Other Findings: ________________
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 5 of 6
Assessment
N AbN
Area Description of Findings & Interpretation
Hematopoietic
Easy Bruisability
Excessive Bleeding
Anticoagulants
Bleeding Profile
Anemia
Hematology Report
Other Findings: ________________
Neurology
Assessment of Cranial Nerves
➢ CN I (Olfactory)
➢ CN II (Optic)
➢ CN III (Oculomotor)
➢ CN IV (Trochlear)
➢ CN V (Trigeminal)
➢ CN VI (Abducens)
➢ CN VII (Facial)
➢ CN VIII (Vestibulocochlear)
➢ CN IX (Glossopharyngeal)
➢ CN X (Vagus)
➢ CN XI (Spinal Accessory)
➢ CN XII (Hypoglossal)
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 6 of 6
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
NURSING HISTORY:
PATHOPHYSIOLOGY:
DIAGNOSTIC PROCEDURES:
MEDICAL MANAGEMENT:
Name of Student:
Date Submitted: C.I.’s Signature
Form No.: TSU-COS-SF-04 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
‘
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Date: _______________
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Form No.: TSU-COS -SF-01 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 3
Date Performed with C.I.’s Signature
Skills / Procedures 1st 2nd 3rd 4th 5th 6th
Rotation Rotation Rotation Rotation Rotation Rotation
Date C.I. Date C.I. Date C.I. Date C.I. Date C.I. Date C.I.
Assisting Client to Sit on Side of
Bed (Dangling)
Transferring Client Between
Bed and Chair
Transferring Between Bed and
Stretcher
Assisting Client to Ambulate
Providing a Back Massage
Administering an Enema
Performing Urinary
Catheterization
Performing Bladder Irrigation
Administering Oxygen by
Cannula, Face Mask
Starting an Intravenous Infusion
Monitoring an Intravenous
Infusion
Changing an Intravenous
Container, Tubing
Discontinuing an Intravenous
Infusion
Changing an Intravenous
Catheter to an Intermittent
Infusion Lock / Heplock
Nebulization
Obtaining Capillary Blood
Specimen and Measuring Blood
Glucose
Obtaining Wound Drainage
Specimen
Irrigating a Wound
Pre-Op Care: Teaching Moving,
Leg Exercises, Deep Breathing
& Coughing Purposes
Managing Gastrointestinal
Suction
Cleansing Sutured Wound and
Applying Sterile Dressing
Inserting Nasogastric Tube
Removing Nasogastric Tube
Administering Tube Feeding
Performing Gastrostomy or
Jejunostomy Feeding
Changing Bowel Diversion
Ostomy Appliance
Providing Tracheostomy Care
Suctioning Oropharyngeal and
Nasopharyngeal Cavities
Suctioning a Tracheostomy or
Endotracheal Tube
Initiating, Maintaining and
Terminating a Blood
Transfusion
OR Gloving and Gowning
Instrumentation Preparation
(Minor & Major)
Assisting During Anesthesia
Induction
Assisting in Lumbar Puncture
Administration of TPN and PPN
Care of Chest Tube Drainage
ECG Monitoring
Others: (Specify)
O: Observed
P: Performed
Form No.: TSU-COS-SF-01 Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 3
TO BE ACCOMPLISHED BY THE STUDENT:
Clinical Instructor
Noted by:
Form No.: TSU-COS-SF-01 Revision No.: 00 Effectivity Date: June 22, 2016 Page 3 of 3
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Clinical Instructor
Noted by:
Name of Patient:
__________________________________________________________________________________
Middle Last
First Name Name Name
Time Started:
Case Number: ____________________________ __________________________
Age: ____________ Sex: (For the Newborn) ____________
Procedure Performed:
__________________________________________________________________________________
Clinical Instructor
Name: ___________________________________________________________________________
License Number: __________________________ Signature: ___________________
________________________
Date
Sir / Madam:
Please be informed that the College’s Retention Policy is strictly enforced to sustain and uplift the
quality of Nursing Education. It would be greatly appreciated if you can find time to see the herein
signed Instructor of the subject/concept to discuss with the details of the above-mentioned Midterm
Grade and the academic performance of your son/daughter during the Midterms period.
Thank you.
Respectfully yours,
_______________________________
Signature Above Printed Name of Instructor
NOTED:
=====================================================================
===========
ACKNOWLEDGEMENT
This is to certify that I have read the notice and was made aware of my son’s / daughter’s
computed Midterm Grade on the above-mentioned Subject / Concept.
NOTE:
This part should be returned to the concerned Instructor.
Form No.: TSU-COS-SF-07 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Name Area
Inclusive dates
Year Level RLE Group
of Rotation
PARAPHERNALIA CHECKLIST
Items / Date
Sphygmomanometer
Stethoscope
Small ruler
Penlight
Thermometer (Digital) – 2
Medicine cup
Medicine tray
Surgical gloves – clean
Surgical gloves – sterile
Tongue depressor
Tape measure
Kidney basin
Mask
Syringes (1cc, 3cc, 5cc, 10cc)
Logbook
Pencil
Eraser
Sharpener
Ballpens (blue/black, red, green)
Dry cotton balls
Wet cotton balls(with alcohol)
Alcohol
Betadine
Bandage scissor
Torniquet
Hypoallergenic/Micropore tape
Gauze
Hand towel
Soap
NANDA Handbook
Forms: RLE Notice
Skills Inventory
Physical Assessment
Performance Evaluation
Rubrics for Charting
Others: LR/DR/NB slip
OR slip
PRC form
REMARKS
___________________
Clinical Instructor
Form No.: TSU-COS-SF-08 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Name Area
Inclusive
Year Level RLE Group dates of
Rotation
Name of
Age Gender
Patient
Date
Diagnosis
Admitted
Form No.: TSU-COS-SF-09 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
COLLEGE COPY
Based on the existing RLE Policy and Guidelines, he / she is hereby given a disciplinary
action of: _______________________________________________________________
NOTED: ______________________
Chairperson
=================================================
Based on the existing RLE Policy and Guidelines, he / she is hereby given a disciplinary
action of: _______________________________________________________________
NOTED: ___________________________________
Chairperson
Form No.: TSU-COS-SF-10 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Name: ____________________________________ Section/Group: ______________
Learning Outcome: The student will develop their clear and concise written requirement
TOTAL SCORE:
Transmuted Grade:
__________________________
Student’s Signature and Date
__________________________
Clinical Instructor’s Name and Signature
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
______________________
Clinical Instructor
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Name: ________________________________________
Section: __________________
Clinical Group: ______
Area: _________________________
SOAPIE CHARTING
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Phase I Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
DATE PERFORMED AND PATIENT’S INITIAL ONLY SURGICAL PROCEDURE O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Name and Signature)
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
DATE PERFORMED AND PATIENT’S INITIAL ONLY SURGICAL PROCEDURE O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Name and Signature)
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Phase I Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
DATE PERFORMED AND PATIENT’S INITIAL ONLY SURGICAL PROCEDURE O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Name and Signature)
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
DATE PERFORMED AND PATIENT’S INITIAL ONLY IMMEDIATE NEWBORN O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER CARE PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Not applicable for Birthing/Lying-in, Indicate where performed (e.g. D.R., (if Midwife on Duty, signature not (Name and Signature)
Clinics/Homes) Nursery, NICU or Homes) required)
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
DATE PERFORMED AND PATIENT’S INITIAL ONLY PROCEDURE O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Not applicable for Birthing/Lying-in, (if Midwife on Duty, signature not (Name and Signature)
Clinics/Homes) required)
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Name: ____________________________________
Section/Group: ________________
NURSING CARE PLAN
Name: ____________________________________
Section/Group: ________________
DRUG STUDY
NAME OF THE ROUTE, DOSAGE, MECHANISM OF INDICATIONS CONTRAINDICATIONS/ SIDE EFFECTS NURSING
DRUG & FREQUENCY ACTION PRECAUTIONS RESPONSIBILITIES