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 INTRAVENOUS FLUID FLOW DATE SIDE DRIP/BLOOD TRANSFUSION FLOW Room: Case Number.: Patient’s Name: Age & Sex: Birthday: Chief Complaint: Admitting Diagnosis: SPECIAL ENDORSEMENT Date & Time of Admission: Attending Physician: Final 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 Conscious Confused Lethargic Stuporous Comatose DIET Full Soft Liquid NPO Others: AFFECT Calm Depressed Anxious Restless Others: ACTIVITIES may ambulate may sit at bedside CBR with BRPs CBR without BPRs Others: CONTRAPTIONS NGT IFC CTT Colostomy O2 Others: Traction Drain Cast MONITORING V/S NVS BP PR/CR RR Temp. I&O Wt. Others: ALLERGIES (FOOD/MEDICATION) 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 SURGICAL SLIP Name of Hospital/Agency: Date: Shift: Name of Student: Name of Patient: First Name Case Number: Age: Middle Name Last Name Time Started: Sex: 1st Surgeon: 2nd Surgeon: Anesthesiologist: Type of Anesthesia: Pre-Op Diagnosis: Post-Op Diagnosis: Surgical Procedure Performed: Student Nurse Instrument Nurse: Circulating Nurse: OR Nurse On Duty First Name License Number: Middle Name Clinical Instructor Name: License Number: Form No.: TSU-COS-SF-05 Last Name OR Nurse Signature: Signature: 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: Area / Ward: Group No. 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 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 Signature Time-in 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 DAILY PHYSICAL EXAMINATION REPORT Name of Patient: Medical Diagnosis: Assessed by: Area Age: Date of Birth: Nursing Diagnosis: Date of Assessment: Assessment N AbN Time: 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.: TSUCOS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6 Area Assessment N AbN Description of Findings & Interpretation Revision No.: 00 Effectivity Date: June 22, 2016 Eyes Size, placement & alignment Cornea Pupils Size (mm) PERRLA Visual Acuity Orbital Bruit Other Findings: Ear Location/Alignment Pinna, Cannals, Drums Hygiene Discharge and Odor Hearing Acuity Tinnitus Vertigo/Dizziness Other Findings: Nose Shape Symmetry Patency Mucosal Integrity Epistaxis Sinuses Other Findings: Lips Integrity Symmetry Color Other Findings: _ Mouth Hygiene Number & Condition of Teeth Gums Mucosal Integrity Tongue Tonsils Palate Parotid Gland Hoarseness Other Findings: Neck Carotid Bruit Neck Veins Thyroid Trachea Rigidity/Tenderness Mass/Bruises Other Findings: Chest and Lungs Shape & Symmetry Nipple & Areola Mass/Lump Others: Form No.: TSU-COS-SF- Page 2 of 6 Assessment N AbN Area 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 Assessment Page 3 of 6 N Area AbN 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 N AbN Area 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 Assessment Page 5 of 6 N Area AbN 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) Motor and Posture Sensory Perception Reflexes a. Indicate Type of Reflex b. Pathologic Reflex: Yes No Other Findings: Patient’s ADL a. Bathing b. Dressing c. Elimination d. Mobility and Movement e. Nutrition and Feeding 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 CLINICAL CASE ANALYSIS Name of Patient Address Diagnosis Age: Date Admitted: Gender: NURSING HISTORY: PATHOPHYSIOLOGY: DIAGNOSTIC PROCEDURES: MEDICAL MANAGEMENT: Name of Student: Date Submitted: Form No.: TSU-COS-SF-04 C.I.’s Signature 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 EVALUATION SHEET FOR CASE PRESENTATION & DEFENSE CRITERIA STANDARDS PERFECT SCORE Systematic and logical presentation of report. 10 Correctness of processing and interpretation of data. 15 Clear and unambiguous presentation. 15 Conciseness (e.g. Presentation of essential information in relation to report.) 15 Use of visual aids facilitated comprehension of presentation. 5 Neat and proportional visuals. 5 Use of time Report was presented within the alotted time for the group. 10 Mastery and tact Ability of all presentors to answer relevant questions. 20 Dispassionate reactions to clarifications and criticisms. 5 Organization Content Visual aids TOTAL GROUP NUMBER 100 Name of Rater: Signature Over Printed Name 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 INVENTORY OF BASIC & INTERMMEDIATE NURSING SKILLS / PROCEDURES PERFORMED IN THE CLINICAL WARD (For BSN Level 3 & 4) Name: Section: Semester: SY: Date Performed with C.I.’s Signature Skills / Procedures 1st Rotation 2nd Rotation 3rd Rotation 4th Rotation 5th Rotation 6th Rotation Date Date Date Date Date Date C.I. C.I. C.I. C.I. C.I. Assessing Body Temperature Assessing Peripheral Pulse Assessing an Apical Pulse Assessing an Apical Radial Pulse Assessing Respirations Assessing Blood Pressure Handwashing Establishing & Maintaining a Sterile Field Donning & Removing Sterile Gloves (Open Method) Donning & Removing Sterile Gloves (Closed Method) Bed Bath Shampooing Hair of Client Confined to Bed Providing Perineal-Genital Care Brushing & Flossing Teeth Providing Special Oral Care Changing / Preparing an Unoccupied Bed Preparing a Surgical Bed Changing / Preparing an Occupied Bed Collecting Urine Specimen Collecting Specimen from IFC or Drainage Bag Administering Oral Medications Preparing Medications from Ampule Preparing Medications from Vials Mixing Medications Using One syringe Administering an Intradermal Injection Administering a Subcutaneous Injection Administering an Intramuscular Injection Adding Medications to Intravenous Containers Administering Intravenous Medication Using IV Push Administering Ophthalmic Medications Administering Otic Instillations Administering Vaginal Instillations Moving Client Up in Bed Turning Client to Lateral or Prone Position in Bed Logrolling a Client Form No.: TSU-COS -SF-01 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 3 C.I. Skills / Procedures 1st Rotation Date C.I. Date Performed with C.I.’s Signature 3rd 4th 5th Rotation Rotation Rotation Rotation Date C.I. Date C.I. Date C.I. Date C.I. 2nd 6th Rotation 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) Legend: To be placed inside the date box. 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: Inclusive Dates of Rotation Area of Clinical Experience Clinical Instructor (C.I.) Clinical Instructor’s Signature ***This document must be submitted to Level Coordinator during Clearance Signing. Date Submitted: Evaluated by: Clinical Instructor Noted by: Prof. Lorna C. Gamis RN, MAN CHAIRPERSON, DEPARTMENT OF NURSING Prof. Mary Jane N. Rigor, RN, MSN DEAN, COLLEGE OF SCIENCE 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 INVENTORY OF BASIC NURSING SKILLS / PROCEDURES PERFORMED IN THE CLINICAL WARD (For BSN Level 2) Name: Section: Semester: SY: Date Performed with C.I.’s Signature Skills / Procedures Assessing Body Temperature Assessing Peripheral Pulse Assessing an Apical Pulse Assessing an Apical Radial Pulse Assessing Respirations Assessing Blood Pressure Handwashing Establishing & Maintaining a Sterile Field Donning & Removing Sterile Gloves (Open Method) Donning & Removing Sterile Gloves (Closed Method) Bed Bath Shampooing Hair of Client Confined to Bed Providing Perineal-Genital Care Brushing & Flossing Teeth Providing Special Oral Care Changing / Preparing an Unoccupied Bed Preparing a Surgical Bed Changing / Preparing an Occupied Bed Collecting Urine Specimen Collecting Specimen from IFC or Drainage Bag Administering Oral Medications Preparing Medications from Ampule Preparing Medications from Vials Mixing Medications Using One syringe Administering an Intradermal Injection Administering a Subcutaneous Injection Administering an Intramuscular Injection Adding Medications to Intravenous Containers Administering Intravenous Medication Using IV Push Administering Ophthalmic Medications Administering Otic Instillations Administering Vaginal Instillations Moving Client Up in Bed Turning Client to Lateral or Prone Position in Bed Logrolling a Client Assisting Client to Sit on Side of Bed (Dangling) Transferring Client Between Bed and Chair 1st Rotation Date C.I. 2nd Rotation Date C.I. 3rd Rotation Date C.I. 4th Rotation Date C.I. 5th Rotation Date C.I. 6th Rotation Date C.I. Form No.: TSU-COS-SF-02 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 3 Date Performed with C.I.’s Signature 1st Rotation Date C.I. Skills / Procedures 2nd Rotation Date C.I. 3rd Rotation Date C.I. 4th Rotation Date C.I. 5th Rotation Date C.I. 6th Rotation Date C.I. 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 TO BE ACCOMPLISHED BY THE STUDENT: Inclusive Dates of Rotation Area of Clinical Experience Clinical Instructor (C.I.) Clinical Instructor’s Signature ***This document must be submitted to Level Coordinator during Clearance Signing. Date Submitted: Evaluated by: Clinical Instructor Noted by: Prof. Lorna C. Gamis RN, MAN CHAIRPERSON, DEPARTMENT OF NURSING Prof. Mary Jane N. Rigor, RN, MSN DEAN, COLLEGE OF SCIENCE Form No.: TSU-COS-SF02 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 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 LABOR ROOM / DELIVERY ROOM & NURSERY SLIP Name of Hospital / Agency: Shift: Date: Name of Student: Name of Patient: Middle Name First Name Last Name Time Started: Case Number: Age: Sex: (For the Newborn) Procedure Performed: LR/DR Nurse On Duty / Nursery Nurse on Duty First Name License Number: Signature: Middle Name OR Nurse Clinical Instructor Name: License Number: Form No.: TSU-COS-SF06 Last Name DR Nurse Signature : Signature: 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 Sir / Madam: This is to inform you that Mr. / Miss had a computed Midterm Grade of of BSN in the Subject / Concept . 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: Prof. Lorna C. Gamis, RN, MAN Chairperson, Department of Nursing Prof. Mary Jane N. Rigor, RN, MSN Dean, College of Science ===================================================================== =========== 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. Student’s Name: Parent’s/Guardian’s Signature Above Printed Name Date 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 Year Level Area RLE Group Inclusive dates 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 PATIENT EDUCATION FORM Name Year Level Name of Patient Date Admitted Area Inclusive dates of Rotation RLE Group Age Gender Diagnosis MAIN CONCEPT / TOPIC: Details of Patient Education Content: Patient’s Signature / Significant Other’s Signature Date Signed Date Submitted Form No.: TSU-COS-SF-09 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1 COLLEGE COPY TARLAC STATE UNIVERSITY COLLEGE OF SCIENCE DEPARTMENT OF NURSING RELATED LEARNING EXPERIENCE (RLE) NOTICE Date Sir / Madam: This is to inform you that Miss / Mr. BSN Level Section committed the following RLE policy violation: of Based on the existing RLE Policy and Guidelines, he / she is hereby given a disciplinary action of: Filed by: Clinical Instructor (SIGNATURE OVER PRINTED NAME) Shown and Served to Me: (STUDENT’S SIGNATURE OVER PRINTED NAME) Noted and Acknowledged: (PARENT’S / GUARDIAN’S SIGNATURE OVER PRINTED NAME) NOTED: Chairperson ================================================= PARENT’S / GUARDIAN’S and STUDENT’S COPY TARLAC STATE UNIVERSITY COLLEGE OF SCIENCE DEPARTMENT OF NURSING RELATED LEARNING EXPERIENCE (RLE) NOTICE Date Sir / Madam: This is to inform you that Miss / Mr. BSN Level Section committed the following RLE policy violation: of Based on the existing RLE Policy and Guidelines, he / she is hereby given a disciplinary action of: Filed by: Clinical Instructor (SIGNATURE OVER PRINTED NAME) Shown and Served to Me: (STUDENT’S SIGNATURE OVER PRINTED NAME) Noted and Acknowledged: (PARENT’S / GUARDIAN’S SIGNATURE OVER PRINTED NAME) 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 RUBRIC FOR WRITTEN REPORT/ASSIGNMENTS (Journals/Reaction/Learning Paper) PERFORMANCE AREA Content Development Organization and Structure Mechanical Convention Spelling, Grammar, Punctuation Logical Thinking a. Precision b. Depth c. Accuracy d. Logic Presentation Referencing MLA/APA Format HIGHLY PROFICIENT (5) -Content is accurate, focused and consistent -Exhibits content and development of idea -Unified with new and fresh insights -Clear Introduction, body and conclusion with effective transitions -Accurate Sequencing PROFECIENT (4) -Content is somewhat accurate and fairly clear, offers solid but less accurate reasoning -Contains some appropriate details and/or examples LIMITED PROFECIENCY (3) -Contents somewhat vague or only loosely related to the writing tasks -At times may be off topic or too broad with limited support POOR (2) -Content is unclear and irrelevant -Offers simplistic undeveloped support for ideas -Supports the purpose -Sequence of ideas could be improved -Poorly organized or demonstrates serious problems with progression of ideas -A written form of speech -Essentially Error Free -Has some mechanical error -Skillfully evaluates information gathered for observation, experience, reflection or reasoning -Adequately demonstrates reasonable relationship among ideas -Some signs of logical organization -May have abrupt or ecological shifts and ineffective flow of ideas -Repeated weaknesses in mechanics -Repeated pattern of flaws -Simplistic analysis of complex issue --Limited clarity and complexity of thought -Looks neat and professional -Accurate Citations -Looks neat but violates one or two formatting rules -Looks fairly neat but violate some formatting rule -Looks untidy and does not follow formatting rules Shown to me : -Mechanical errors are so severe that writing are hidden -Insufficient reasoning -Lacks of complexity of thought Clinical Instructor: Signature above printed name Signature above printed name RATING 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: RUBRIC FOR HEALTH TEACHINGS/ORAL REPORTS Dimension Organization (20 pts) Content (20 pts) Engagement (10 pts) Delivery (20 pts) Visual Aids/Handouts (20 pts) Promptness (10 pts) Shown to me: Very Satisfactory (20) Satisfactory (10) Poor (5) -Presentation is well organized with beginning, middle and end. There is a strong organizing theme with clear main ideas and transitions. -Starts on time -Information is complete and accurate. Clear evidence of research. -Loss train of thought does not stay with the proposed outline, or connections are all attempted but not made clean for audience. -Presentation shows organization under purpose and/or clear relationship as transitions -Research component is less evident than distinguished category or resources are present but less than adequate for assignment -Audience is involved but inadequate processing a response time is provided. -Audience is able to hear as a whole, but then there are times when volume is not quite adequate. -Time is appropriately used -Conclusion inadequate -Details and examples are lacking or -Visual are are adequate but does not inspire engagement with the materials -Submits just on time -A poor use of visual materials -No handouts provided -Presentation involves the audience allowing time for them to think and respond -Voice is easy to hear -Rates of speech are appropriate -Appropriate length, clear summary as provided -Audience is involved in synthesizing the discussion. -Visuals Aids are well done interesting and meaningful -Submits before the deadline not well chosen for the topics - Lacks evidence of research -Does not involved the audience -Presenter is difficult to hear -Rates of speaking are too slow or fast. -Presentation lacks conclusion or time is not appropriately used. Late submission Clinical Instructor: Rating 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: Inclusive Date of Evaluation: Area: RLE Group: RUBRICS FOR CHARTING DIMENSION ASSESMENT DIAGNOSIS PLANNING VERY GOOD (5) GOOD (3) NEEDS IMPROVEMENT (1) All subjective and Most subjective and Some subjective objective data is objective data is and objective data collected and recorded collected and is collected. There using the appropriate recorded using the is an terminology. Additional appropriate incomplete/absence data is collected terminology. of the use of inquiry through the use of Additional data is to collect inquiry flawlessly, collected through the information relevant applying knowledge use of inquiry to the disease and about the disease and flawlessly, applying current health the patient’s current knowledge about the condition. health condition. disease and the patient’s current health condition. The Nursing The Nursing The nursing diagnosis/collaborative diagnoses selected diagnosis selected problems selected reflect the adequate reflect that no effort reflect the accurate interpretation of the to interpret interpretation of the subjective and information was subjective and objective data applied resulting in objective data analyzed but are not a flawed plan of analyzed. Subjective always the best care. PES/PE/Risk and Objective are choice from the diagnosis format is listed appropriately as possible diagnosis usually not supporting data for the that could be complete or used nursing diagnoses. All interpreted from the format correctly. nursing diagnoses data. PES/PE/Risk used NANDA diagnosis format is Terminology. All actual used correctly. nursing diagnoses used 3 or 2 part statements (PES/PE format, Risk nursing diagnosis use 2 part statements) Measurable criteria Most of the outcome Some of the are identified all of criteria are outcome criteria the time and contain measurable and are identified to achieve verb and time identified to achieve goals will lead to the element. The criteria goals will lead to the resolution or control SCORE identified generally are individualized and will lead to the control of related factors that contribute to the nursing diagnosis resolution or control of the related factors that contribute to the nursing diagnosis. of the related factors that contribute to the nursing diagnosis purely by coincidence and poorly/erroneously developed. Interventions developed are incomplete. Inappropriate intervention may be included in the plan of care. INTERVENTION Specific interventions Specific interventions can easily be linked to can be linked to a specific outcomes. The specific outcome. interventions are The interventions are realistic and realistic and appropriate to the appropriate to the patient’s current patient’s current status. health status. The appropriate The appropriate Subjective and EVALUATION subjective and subjective and objective data is objective data is objective data is selected to reflect selected through selected most of the evaluation without review of the time, through review consideration of the interventions related to of the interventions outcome criteria. ongoing assessment. related to ongoing Subjective and The subjective and assessment that objective data may objective data that reflects adequate not be collected and measures the outcome analysis. lacks consideration is collected and of the outcome that is required to be analyzed correctly. measured. Data collection was not subjected to analysis. 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 WARD: Year and Section: Date: RLE Group: STUDENT NURSE-PATIENT INFORMATION SHEET STUDENT Clinical Instructor PATIENT ROOM DIAGNOSIS 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 SURGICAL CIRCULATING in Hospital, Municipality/City/Province Prepared by: Operating Room Form 1B Operating Room Circulating Form Printed Name and Signature of Student DATE PERFORMED AND TIME STARTED PATIENT’S INITIAL ONLY CASE NUMBER SURGICAL PROCEDURE PERFORMED O.R. NURSE ON DUTY (Name and Signature) SUPERVISED BY 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 SURGICAL SCRUB in Hospital, Municipality/City/Province Prepared by: Operating Room Form 1A Operating Room Scrub Form MAJOR OPERATION Printed Name and Signature of Student DATE PERFORMED AND TIME STARTED PATIENT’S INITIAL ONLY CASE NUMBER SURGICAL PROCEDURE PERFORMED O.R. NURSE ON DUTY (Name and Signature) SUPERVISED BY 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 SURGICAL SCRUB in Hospital, Municipality/City/Province Prepared by: Operating Room Form 1A Operating Room Scrub Form MINOR OPERATION Printed Name and Signature of Student DATE PERFORMED AND TIME STARTED PATIENT’S INITIAL ONLY CASE NUMBER SURGICAL PROCEDURE PERFORMED O.R. NURSE ON DUTY (Name and Signature) SUPERVISED BY 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 IMMEDIATE NEWBORN CORD CARE in Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: ICNB FORM IMMEDIATE CARE OF THE NEWBORN Printed Name and Signature of Student DATE PERFORMED AND TIME STARTED PATIENT’S INITIAL ONLY CASE NUMBER IMMEDIATE NEWBORN CARE PERFORMED O.R. NURSE ON DUTY (Name and Signature) (Not applicable for Birthing/Lying-in, Clinics/Homes) Indicate where performed (e.g. D.R., Nursery, NICU or Homes) (if Midwife on Duty, signature not required) SUPERVISED BY 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 ACTUAL DELIVERY in Hospital/Home/Lying-in, Municipality/City/Province Prepared by: DR FORM ACTUAL DELIVERY FORM Printed Name and Signature of Student DATE PERFORMED AND TIME STARTED PATIENT’S INITIAL ONLY CASE NUMBER (Not applicable for Birthing/Lying-in, Clinics/Homes) PROCEDURE PERFORMED O.R. NURSE ON DUTY (Name and Signature) (if Midwife on Duty, signature not required) SUPERVISED BY 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 Name: Section/Group: NURSING CARE PLAN ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION 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: DRUG STUDY NAME OF THE DRUG ROUTE, DOSAGE, & FREQUENCY MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS/ PRECAUTIONS SIDE EFFECTS NURSING RESPONSIBILITIES
