UNIVERSIDAD DE MANILA Mehan Garden, Manila College of Nursing VITAL SIGNS SHEET Name of the Patient:_______________________ Age/ Sex:

__________

Diagnosis:__________________________________ Case #:___________

Date/ Time

Blood Pressure

Temperature

Pulse Rate

Respiratory Rate

Remarks

Prepared by: ________________________Noted by: _____________

UNIVERSIDAD DE MANILA Mehan Garden, Manila College of Nursing INTAKE AND OUTPUT SHEET Name of the Patient:________________________ Age/ Sex: _________

Diagnosis:_________________________________ Case #:____________ Date/ Time Intake Oral IVF NGT Total UO Output Stool Drains Total Remarks

6 am 7 am 8 am 9 am 10 am 11 am 12 nn 1 pm 2 pm Total 3 pm 4 pm 5 pm 6 pm 7 pm 8 pm 9 pm 10 pm Total 11 pm 12 mn 1 am 2 am 3 am 4 am 5 am 6 am Total Prepared by: ______________________

Noted by: ______________

UNIVERSIDAD DE MANILA Mehan Garden, Manila College of Nursing

INTRAVENOUS FLUID MONITORING SHEET Name of the Patient:_____________________ Diagnosis:_____________________________ Age/ Sex: __________ Case #:____________ Signature of the Staff Nurse

Date/Time

Name of IVF

Additives

Time Started

Time Ended

Remarks

Prepared by: ________________________

Noted by: _______________

UNIVERSIDAD DE MANILA Mehan Garden, Manila College of Nursing CHECKLIST OF NURSING TASK Name: ____________________________ Date/ Day:_____________

Year/ Section_______ Group Number_______ Rating:________________ Direction: Put a check on the skills observed / performed, of not please include remarks on the space provided. Legend: 5- Outstanding. Accomplishes expected tasks in a very logical manner with minimal guidance and supervision 4- Very Satisfactory. Accomplishes expected tasks in a logical manner with minimal guidance and supervision 3- Satisfactory. Accomplishes expected tasks in a moderately logical manner with frequent guidance and supervision 2-Needs Improvement. Accomplishes expected tasks in a rarely logical manner with close guidance and supervision 1-Unsatisfactory. Does not accomplish expected tasks even with close guidance and supervision

A. KNOWLEDGE 1. With enough knowledge in gathering data 2. With enough knowledge of the different methods used in physical assessment. 3. Adequate knowledge regarding normal values and other laboratory results. 4. Identifies nursing problems of patient and its cause 5. Explains scientific principles behind patients condition and management. 6. Knowledge in setting goals and prioritization of patients needs 7. Knows intervention to be given and the rationale. 8. Knows the theories and rationale behind nursing procedures being implemented. 9. Knows the principle of drug administration and its

action. 10. Knowledge on how to relate nursing interventions to outcomes. Subtotal: B. SKILLS 1. Checks, records and interprets accurately the vital signs of assigned patients. 2. Ability to manipulate and care for the equipment. 3. Ability to collect specimens for the laboratory examination. 4. Demonstrate skill in providing comprehensive nursing care. 5. Performs nursing procedures with maximum result with minimum time, effort and materials at her/his level. 6. Implements nursing care according to priorities. 7. Provides health teaching for patient and his family as manifested by good communication skill. 8. Coordinates with other members of the health team with regards to patients condition. 9. Ability to transcribe doctors order. 10. Records accurately patients conditions and nursing intervention. Subtotal: C. ATTITUDE & VALUES 1. Punctual and regular in attendance. 2. Observes professionalism in uniform. 3. Honest and sincere. 4. Resourceful and creative. 5. With sense of responsibility. 6. Initiative, Diligence and Industry. 7. Tolerance and Patience. 8. Polite and Respectful to self and others. 9. Works harmoniously with others. 10. Aware and understands the needs and emotions of others. Subtotal:

___________________ Students Signature

_____________________________ Clinical Instructors Signature

UNIVERSIDAD DE MANILA Mehan Garden, Manila College of Nursing

Name:____________________________________ Date:______________ Yr/Sec:______________ Group:___________ Rating:__________________ Area:_______________ Clinical Instructor:__________________________ PERFORMANCE EVALUTION TOOL (STUDENT HEAD NURSE TO STUDENT STAFF NURSE) Numerical Rating 5 4 3 Quantitative Rating Outstanding Very Satisfactory Satisfactory Descriptions Accomplishes expected tasks in a very logical manner with minimal guidance and supervision Accomplishes expected tasks in a logical manner with minimal guidance and supervision Accomplishesexpected tasks in a moderately logical manner with frequent guidance and supervision Accomplishesexpected tasks in a rarely logical manner with close guidance and supervision Does not accomplish expected tasks even with close guidance and supervision

2 1

Needs Improvement Unsatisfactory

5 PERFORMANCE I. Assessment/ Planning 1.1 Establishes rapport with subordinates 1.2 Able to involve patients in plan of care Review and reports 1.3 Punctual and prompt in all activities 1.4 Able to maintain stability under pressure 1.5 Gathers data using interview, observation, records 1.6 Formulates appropriate nursing care plan 1.7 Wears complete prescribed RLE uniform

II. IMPLEMENTATION a. Carries out assigned tasks based on the criteria of distribution of assignments b. Follows principles of time management c. Equipped with required paraphernalia for RLE d. Observes proper channels of communication e. Carries out plan of care, including: A. Bedside Care B. Administration of medications C. Administration of treatments (nebulization, IVF) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III. EVALUATION Notifies immediate superior about untoward situations conditions related to patient care in the area Make revisions in the plan of care as necessary Evaluates Nursing Care rendered

1. or 2. 3.

IV. ETHICOLEGAL CONSIDERATIONS 1. Demonstrates honesty at all times 2. Conducts self in a tactful manner 3. Keeps confidential patient information 4. Observes the PNA Code of Ethics 5. Guided by RA 91736. Observes the 11 Core Competency Guidelines Remarks:

Evaluated by:__________________________ Conformed by: ________________________ Noted by: ____________________________

UNIVERSIDAD DE MANILA Mehan Garden, Manila College of Nursing Name:_______________________________ Date:___________________ Yr/Sec:______________ Group:___________ Rating:__________________ Area:____________________ Clinical Instructor:____________________ PERFORMANCE EVALUTION TOOL (STUDENT STAFF NURSE TO STUDENT HEAD NURSE) Numerical Rating 5 Quantitative Excellent Descriptions Accomplishesexpected behavior in a very logical and independent manner with less supervision and guidance. Accomplishesexpected behavior in a logical and independent manner that requires minimal supervision and guidance. Accomplishesexpected behavior in rarely independent manner requiring more supervision and guidance. Accomplishesexpected behavior in rarely independent manner requiring close supervision and guidance. Accomplishesexpected behavior under close supervision and guidance.

Very Satisfactory Satisfactory

Fair

Needs improvement

5 PERFORMANCE A. Knowledge 1. Applies as appropriate theory as a basis for decision making in nursing practice. 2. Assesses staffs presenting symptoms to determine a nursing diagnosis and plan of action based on a medical expertise and knowledge. 3. Knowledge in communication, clarification and interpretation of existing problems with staff and nursing responsibilities.

4. Inform the staff of the likely causes of errors defects and waste. 5. Suggest in which risk, errors, quality of problems maybe reduce. B. Attitude 1. Neat and well groomed. Adheres to dress code. 2.Punctual in reporting for duty 3. Complies with the code of ethics of the nursing profession and upholds and implements schoo lrules. 4. Assist in training staff in particular by setting a good example. 5. Promotion of professional responsibility, accountability and behavior. C. Skills 1. Provide leadership in the assessment, planning, implementation, and evaluation of comprehensive school health program. 2. Respond to the student/ staff medical emergencies. 3. Instruct subordinates in appropriate method and procedure in providing care. 4. Initiate and facilitate any steps necessary to improve methods, equipments, materials and condition in the work area for which they are responsible. Remarks:

Evaluated by:__________________________ Conformed by: ________________________ Noted by: ____________________________

UNIVERSIDAD DE MANILA Mehan Garden, Manila College of Nursing Name:____________________________________ Date:______________ Yr/Sec:______________ Group:___________ Rating:__________________ Area:_______________ Clinical Instructor:__________________________

PERFORMANCE EVALUTION TOOL (CLINICAL INSTRUCTOR TO STUDENT STAFF NURSE) Numerical Rating 5 4 3 Quantitative Rating Outstanding Very Satisfactory Satisfactory Descriptions Accomplishes expected tasks in a very logical manner with minimal guidance and supervision Accomplishes expected tasks in a logical manner with minimal guidance and supervision Accomplishes expected tasks in a moderately logical manner with frequent guidance and supervision Accomplishes expected tasks in a rarely logical manner with close guidance and supervision Does not accomplish expected tasks even with close guidance and supervision

2 1

Needs Improvement Unsatisfactory

5 PERFORMANCE V. Assessment/ Planning 1.1 Establishes rapport with subordinates 1.2 Able to involve patients in plan of care Review and reports 1.3 Punctual and prompt in all activities 1.4 Able to maintain stability under pressure 1.5 Gathers data using interview, observation, records 1.6 Formulates appropriate nursing care plan 5.7 Wears complete prescribed RLE uniform

VI. IMPLEMENTATION a. Carries out assigned tasks based on the criteria of distribution of assignments b. Follows principles of time management c. Equipped with required paraphernalia for RLE d. Observes proper channels of communication e. Carries out plan of care, including: D. Bedside Care E. Administration of medications F. Administration of treatments (nebulization, IVF) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings VII. EVALUATION Notifies immediate superior about untoward situations conditions related to patient care in the area Make revisions in the plan of care as necessary Evaluates Nursing Care rendered

1. or 2. 3.

VIII. ETHICOLEGAL CONSIDERATIONS 1. Demonstrates honesty at all times 2. Conducts self in a tactful manner 3. Keeps confidential patient information 4. Observes the PNA Code of Ethics 5. Guided by RA 91736. Observes the 11 Core Competency Guidelines

Evaluated by:__________________________ Conformed by: ________________________ Noted by: ____________________________