CENTRAL LUZON DOCTORS HOSPITAL EDUCATIONAL INSTITUTION

SAN PABLO TARLAC CITY

INSTRUCTIONAL TEACHING PLAN
NCM 104 (Curative and Rehabilitative Nursing Care Management)
First Semester S.Y. 2009-2010
Concept: 11 Core Competencies
Placement: NCM 104 (Medical-Surgical)
General Objectives: Given a client, the students will be able to acquire skills, knowledge and attitude towards the care of the client by utilizing the RN
process.
KEY AREA OF RESPONSIBILITY
A. Safe and Quality nursing care

CORE COMPETENCIES
Demonstrate knowledge based on the health/illness
status of the individual in medical and surgical area.

PERFORMANCE INDICATOR
Identifies the health needs of the client with:
1. Medical problems such as:
a. Immunologic problem
b. Cellular aberration on oncological
problem
c. GI problem
d. Neurologic problem
e. Endocrinologic problem
2. Client that undergo surgery
Explain the health status of the client with medical
and surgical problem based on
a. Health history

Provide sound decision making in the care of the

client with medical and surgical problem considering
their beliefs and values.

Promote safety and comfort and privacy of clients

Sets priorities in nursing care based on clients needs

b. Results of diagnostic exam

c. Socio and cultural problem
d. Genetics
Identifies clients wellness potential and/or health
problem.
Gathers data related to the clients condition.
Determine confirmative and supportive
diagnosis
Performs physical assessment, cephalo caudal
assessment and ROS.
Monitor the following:
o Vital sign
o NVS
o GCS
o Pain
Note the PQRS of the pain
Assesses the client
Analyses the data gathered and diagnostic
exam
Monitor the progress of the action taken
Performs age-specific safety comfort
measures in all aspects of client care.
o Assists the client in proper positioning
for comfort.
o Instruct the client to perform
appropriate breathing and relaxing
and coughing techniques/exercises
during in pain.
o Keep siderails up

Ensure continuity of care

Administers medications and other health

therapeutics
Utilizes the nursing process as framework for
nursing
Performs comprehensive and systematic nursing
assessment

Formulates a plan of care in collaboration with client

and other members of the health team

o Ensure safety and privacy during

gathering of diagnostic data
assessment.
Identifies the priority needs of the client.
o Provision of safety, comfort and
privacy and emotional support in the
entire hospitalization.
Analyses the needs of clients.
Determines appropriate nursing care to be
provided according to the case of the client
through the help of NCP.
Refers identified problem to appropriate
clients of medical and surgical cases
Establishes means of providing continuous
patient care.
Conforms to the 10 golden rules in
medication administration, health
therapeutics of each client.
Utilizes the nursing process in the care of the
client with medical and surgical problem.
Obtain consent.
Performs effective assessment techniques
Obtain comprehensive client information.
Maintain privacy and confidentiality
Identifies health needs.
Includes patient and his family in the plan of
care.
Collaborate with other member of the health
team.

Implements planned nursing care to achieve

identified outcome

Evaluates progress toward expected outcomes

B. Management of Resources and Environment

Organizes workload to facilitate client care

o Medical Department
o Respiratory Dept.
o Radiology Dept.
State expected outcomes of nursing
intervention
Develops comprehensive nursing care plan
Accomplishes patient centered discharge plan
Explain every intervention that is safe and
comfortable.
o Performing safety comfort measures
o Using pain management
Acts to improve clients health condition or
human response.
Performs nursing activities effectively and in
timely manner.
Monitor effectiveness of nursing
interventions to medical and surgical clients.
Revises care plan when necessary.

Identifies tasks/activities that need to be

accomplished.
o Monitoring vital signs
NVS
GCS
Pain
o Provision of safety, privacy and
comfort measures
Proper positioning
Instructing proper breathing

Utilizes financial to support client care

Ensure proper functioning of equipments

Maintain a safe environment

C. Health Education

Assess the learning needs of the client partners

Develops health education plan based on assessed

and anticipated needs
Develops learning material for health

and coughing exercises

Promote airway patency
Plans the performance of task or activities
based on priorities
Determine tasks and procedure that can safely
assigned to members
Finishes work assignment on time
Identifies the cost-effectiveness in the
utilization of resources
Determine the resources of the client for the
whole hospitalization
Use supplies and equipment wisely
Check equipment regularly and report for any
malfunctioning
Complies with standards and safety codes
prescribe by laws
Adheres to policies, procedures and protocols
in prevention and control of infection
Proper disposal of waste
Coordinate to different agencies during
natural disaster

Obtains learning information through

interview, observation and validation
Analyzes gathered data
Identifies priority needs
Consider nature learner in relation to socio
cultural, political, economic, educational and
religious factors

Implements the health education plan

Evaluate outcomes on health education

D. Legal Responsibility

Adheres to practices in accordance with the nursing

law and other relevant legislation including contracts
and informed consent

Adheres to organizational policies and procedures

local and National
Documents care rendered to clients

E. Ethico Moral Responsibility

Respects the right of individual/groups

Accepts responsibility and accountability for own
decision and actions

Develops information education nationals

appropriate to level of the client
Health education materials
Provide conductive learning
Considers client and family readiness
Utilizes appropriate strategies
Monitor client and family responses to health
education
Evaluate and document outcome of care
Revise health education plan when necessary
Fulfill legal requirement in nursing practices
Holds current professional license
Acts accordance in the contract of
employment and other rules and regulations
Complies with required continuing
professional education
Confirms information given by the doctor on
informed consent
Articulates the vision, mission of the
institution where we belongs
Utilizes appropriate client care records and
reports
Properly documents on procedure and
intervention done.
Renders nursing care consistent with the
clients bill of rights
Meet nursing accountability requirements as
embodied in the job description

F. Personal and Professional Development

Identifies own learning needs

Pursue continuing education

Get involved in professional organizations and civic
activities
Projects a professional image of the nurse
Possesses positive attitude towards change and
criticism
G. Quality Improvement

Gathers data for quality improvement

Participate in nursing audits and rounds

Justifies basic for nursing actions and

judgment
Identifies ones strengths, weaknesses and
limitations
Determines personal and professional goals
and aspirations.
Facilitate health education
Applies learned information for the
improvement of care
Participate actively in professional, social,
civil and religious activities
Support activities related to nursing issues
Demonstrates good manners and right
conducts at all times
Always in proper attire
Behave appropriately at all times, listens to
suggestions and recommendations
Adapts to changes willingly
Identifies appropriate quality improvement
for clinical problems
o Monitor vital signs of the client and
detect variation
o Reports necessary elements at the
bedside to improved patient stay
o Gather feedbacks
Contribute relevant information about the
client condition
Shares with the team current information
Encourage the client to verbalize what is

Identifies reports variances

Recommends solutions to identified problems

H. Research

Gather data using different methodologies

Recommends actions or implementation

Disseminate results of research findings
Applies research findings in nursing practice

relevant to his/her condition

Documents and records all actions taken
Performs daily activities of clients
records/conditions
Actively contributing relevant information of
patients during rounds through endorsement
Reports to a appropriate person and for any
variances/changes occurs immediately
Documents and reports accordingly
Gives appropriate suggestion on corrective
and preventive measures
Communicates and discusses with
appropriate groups
Report accurately what you observed
Identifies researchable problem regarding
patient care and community health
Combine qualititative and quantitative
nursing design through simple explanation in
the phenomena observed
Analyses data gathered
Formulates practical solutions appropriate to
the problem based in interpretation of
significant findings
Presents the results findings in
colleagues/clients/family
Utilizes finding in research for nursing care
of the client
Make used the evidence-based nursing to

I. Records Management

Maintain accurate and updated documentation of

client care

Records outcome of client care

Observes legal imperatives in record keeping

J. Communication

Establishes rapport with clients, significant others

and members of the health team
Listen actively to clients queries and requests
Identifies verbal and non-verbal cues

enhance nursing practice

Completes updated documentation of client
care
Accomplishes properly all the monitoring
sheets and records of the client accurately
Documents all records and data accurately
Utilizes a records system e.g. Kardex on
hospital information system (HIS)
Observes confidentiality and privacy of
clients records
Maintain an organized system of filling and
keeping clients records in designated area
Follows protocol/SOP of each agencies you
are affiliated

Create trust and confidence

Spend time with the client to proper NPI.
Be sensitive on what you see, what you hear
Observe, interpret and validates client body
language and facial expressions

Utilizes formal and informal channels

Makes use of available visual aids

Responds to need of individuals, family, group and

community

Provides reassurance through therapeutic

touch, warmth and confronting words of
encouragement

Uses appropriate information techniques to facilitate

communication

K. Collaboration and team work

Establishes collaborative relationship with

colleagues and other members of the health team

Collaborates plan care with other members of the

health team

o Keeps the client information any

procedures/diagnosis
o Provides emotional support to the
significant others during the entire
hospitalization
Utilizes telephone and electronic media for
disease information
Support, delivery of health care by utilizing
information through different medias
Contributes to decision making regarding
clients needs and concerns
Participates actively in patient care
management
Recommends appropriate intervention to
improve client care
Respect the role of other members of the
health team
Maintain good interpersonal relationship to
other health team
Refers client to allied health team priorities
Be patient-advocate
Documents properly for effective
communication services

Prepared by:
Clinical Instructor

Signature over printed name