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Head Nursing

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General Objectives

Within 2 days of clinical duty as student head nurse at MJ Santos Hospital (Pedia
Ward), I will be able to:

1. Obtain a variety of ideas with the necessary things to get acquainted regarding the
assigned institution.
2. Develop the qualities expected to each student head nurse.
3. Formulate a daily management plan prior to the actual clinical duty.
4. Participate in the usual endorsement done by the hospital staff nurse from the night shift.
5. Initiate a pre and post conference with my staff nurses.
6. Assign patients accordingly to each staff nurses.
7. Discuss the case and special endorsements for each patient taken.
8. Facilitate nursing rounds as well as assessing patient’s condition prior to actual handling.
9. Conduct a bedside conference with my staff nurses to be certain with their patient’s
condition.
10. Utilize previous learning regarding the appropriate rendition of care towards the patient.
11. Check the daily written requirements as well as paraphernalias of my staff nurses.
12. Add on or make corrections to the sample SOAPIE / METHOD charting of my staff
nurses.
13. Assess the knowledge of my staff nurses regarding their patient’s oral medications prior
to administration.
14. Render appropriate informations and necessary inputs during the endorsement with the
next shift.
15. Evaluate the learnings of my staff throughout the span of clinical exposure.
WEEKLY RECORDING OF ACTIVITIES

Census: 36
Date: July 31, 2008 Total Number of Handled Patients: 6
Ward: Pedia Ward Patients with FBC: 0
Shift: 8:00 – 4:00PM Patients with NGT: 0
Head Nurse: Sheila Marie Adorador Patients with IVF: 6
Staff Nurses: Patients with O2: 0
Charge Nurse: Vivina Tero
Medication Nurse: Melanie Mae Nazi
V/S Nurse: John Ryan Oñate
IVF Nurse: Brenn Maagad

Staff Nurses Patient Assignment Endorsement

John Ryan Oñate Room 321 I CC: cough, fever


Lamoste, Necole  with d5IMB 500 @ 40 cc/hr
 on full diet; lugaw for diet
 afebrile
 6 months under Dr. Royeca

Vivina Tero Room 321 J CC: fever, cough, [+] Tubex Test
Lamoste, Jelou  with D5IMB 500 cc @ 35-40 cc/hr
 on DAT, no choco, no dark colored
food
 afebrile
 3 y.o., under Dr. Royeca

Melanie Mae Nazi Room 329 A CC: fever, [+] Tubex Test
Ledesma, Thea  11 y.o
 under Dr. C. Aala
 with D5.3Nacl 1L @ 80 cc/hr
 diet for age
 for 12L ECG
 continue meds
 TF IVF D5.3Nacl 500 cc@ 40 cc/hr

Room 329 D CC: fever for 3 days


Ebrado, Mark  3 y.o.
 under Dr. V. Yu
 with D5LR 500 cc @ 70 cc/hr
 on DAT
 afebrile
 Hct, Platelet taken

Brenn Maagad Room 329 B CC: fever & cough


Saura, Danesa  7 y.o.
 under Dr. V.Yu
 with D5IMB 500 cc @ 50 mgtts/min
 on Full Diet

Room 329 C
CC: fever, LBM, vomiting
Patuasic, Sunshine
 1 y.o.
 under Dr. V. Yu
 with D5IMB 500 cc @ 40 gtts/min
 on DAT
 still for SE
 record frequency & characteristic of
stool
 refer for persistent vomiting
WEEKLY RECORDING OF ACTIVITIES

Census: 29
Date: August 1, 2008 Total Number of Handled Patients: 7
Ward: Pedia Ward Patients with FBC: 0
Shift: 8:00 – 4:00PM Patients with NGT: 0
Head Nurse: Sheila Marie Adorador Patients with IVF: 7
Staff Nurses: Patients with O2: 1
Charge Nurse: Brenn Maagad
Medication Nurse: Vivina Tero
V/S Nurse: Melanie Mae Nazi
IVF Nurse: John Ryan Oñate

Staff Nurses Patient Assignment Endorsement

John Ryan Oñate Room 321 I • Dr. Solomon


Tolibas, Xyrelle • 1 y.o.
CC: cough, fever & DOB
 with D5.3Nacl 500 cc @ 40 cc/hr
 CBC referred
 For U/A, CTZ(APL) O2 3L/min

Room 321 J
• Dr. Royeca
Lamoste, Jelou
• 3 y.o.
CC: fever, cough, [+] Tubex Test
 with D5IMB 500 cc @ 30 cc/hr
 on DAT, no choco, no dark colored
food

Melanie Mae Nazi Room 323 F • Dr. M. Villanueva


Abcede, Zian • 13 y.o.
CC: fever with epistaxis 4 days PTA
 full diet
 with D5LR 500 cc @ 15 gtts/min
 for U/A, CBC blood typing
Room 329 A • Dr. C. Aala
Ledesma, Thea Corine • 11 y.o
CC: fever, [+] Tubex Test
 with D5.3Nacl 500 cc @ 40 cc/hr
 diet for age

Vivina Tero Room 329 B • Dr. V.Yu


Saura, Danesa • 7 y.o.
CC: fever & cough
 with D5IMB 500 cc @ 50 cc/hr
 Full Diet

Room 329 D
• Dr. V. Yu
Ebrado, Mark
• 3 y.o.
CC: fever for 3 days on DAT
 with D5LR 500 cc @ 70 cc/hr
alternate with D5.3Nacl @ SR time
tape IVF

Brenn Maagad Room 329 C Patuasic, • Dr. V. Yu


Sunshine • 1 y.o.
CC: fever, LBM, vomiting, on DAT
 with D5IMB 500 cc @ 40 cc/hr
 BM monitoring
ENDORSEMENT PLAN
July 31, 2008

Room 321 I
Room 329 C
Patient: Lamoste, Necole
Attending Physician: Dr. Royeca Patient: Patuasic, Sunshine
Age: 6 months Attending Physician: Dr. V. Yu
CC: cough, fever Age: 1 y.o.
Diet: Full diet, lugaw for diet CC: fever, LBM, vomiting
IVF: without IVF Diet: DAT
Special Endorsement: IVF: D5IMB 500 cc @ 40 gtts/min
 MGH Special Endorsement:
 Home meds given  TPR every 4 hrs

 Instructions given by Dr.  Still for SE; result refer after


Royeca  Record frequency &
characteristic of stool
 Refer for persistent vomiting
 BM once

Room 329 A

Room 321 I
Patient: Ledesma, Thea Corine
Attending Physician: Dr. C. Aala Patient: Lamoste, Jelou
Age: 11 y.o. Attending Physician: Dr. Royeca
CC: fever, [+] Tubex Test Age: 3 y.o.
Diet: diet for age CC: cough, fever, [+] Tubex Test
IVF: D5.3Nacl 1L @ 80cc/hr Diet: DAT, no dark colored food
Special Endorsement: IVF: D5IMB 500 @ 35-40 cc/hr
 Seen and examined by Dr. Aala Special Endorsement:
with orders:  Seen & examined by Dr. Royeca
 for 12L ECG [done]; reading with order:
by Dr. Gambe  TF D5IMB 500 cc @ 30 cc/hr
 continue meds
 IVF TF D5.3Nacl 500 @ 40
cc/hr
Room 329 B

Patient: Saura, Danesa


Attending Physician: Dr. V. Yu
Age: 7 y.o.
CC: cough, fever
Diet: Full diet
IVF: D5IMB 500 @ 50 mgtts/min
Special Endorsement:
 Seen & examined by Dr. V. Yu
with order:
 TF D5IMB 500 @ SR

Room 329 D

Patient: Ebrado, Mark


Attending Physician: Dr. V. Yu
Age: 3 y.o
CC: fever for 3 days
Diet: DAT
IVF: D5LR 500 cc @ 70 cc/hr
Special Endorsement:
 Hct, platelet, result still to refer
 TF D5.3Nacl 500 @ 70 cc/hr
alternate with D5LR @ SR
ENDORSEMENT PLAN
July 31, 2008

Room 321 I

Patient: Tolibas, Xyrelle Room 321 J


Attending Physician: Dr. Solomon
Age: 1 y.o. Patient: Lamoste, Jelou
CC: cough, fever, DOB Attending Physician: Dr. Royeca
Diet: FTW Age: 3 y.o.
IVF: D5.3Nacl 500 cc @ 40 cc/hr CC: cough, fever, [+] Tubex Test
Special Endorsement: Diet: DAT, no dark colored food
 Seen & examined br Dr. Solomon with IVF: D5IMB 500 @ 30 cc/hr
orders: Special Endorsement:
 Clarithromycin (Klaricid) 125  Seen & examined by Dr. Royeca
mg/5ml suspension 3 ml BID with order:
 done chest x-ray (APL);  TF D5IMB 500 cc @ 40 cc/hr
referred result to Dr. Solomon  Please give the latest dose of
 done U/A, result still to refer Rocephin IV @ 8pm Ceftriaxone
(Rocephin) – last dose

Room 323 F
Room 329 A
Patient: Abcede. Zian
Attending Physician: Dr. M. Villanueva Patient: Ledesma, Thea Corine
Age: 13 y.o. Attending Physician: Dr. C. Aala
CC: fever with epistaxis 4 days PTA Age: 11 y.o.
Diet: full diet CC: fever, [+] Tubex Test
IVF: D5LR 500 cc @ 15 gtts/min Diet: diet for age
Special Endorsement: IVF: D5.3Nacl 1L @ 40cc/hr
 TPR every 4 hours Special Endorsement:

 For CBC and blood typing  Continue meds

 Meds:  TF IVF D5.3Nacl 1L @ 20

o Paracetamol mgtts/min

o Ascorbic Acid (Eviscee)


 Chart frequency & characteristic
of stool
 Refer for frequent vomiting
Room 329 B

Patient: Saura, Danesa


Attending Physician: Dr. V. Yu
Age: 7 y.o.
CC: cough, fever
Diet: Full diet
IVF: without IVF
Special Endorsement:
 MGH

Room 329 D

Patient: Ebrado, Mark


Attending Physician: Dr. V. Yu
Age: 3 y.o
CC: fever for 3 days
Diet: DAT
IVF: without IVF
Special Endorsement:
 MGH

Room 329 C

Patient: Patuasic, Sunshine


Attending Physician: Dr. V. Yu
Age: 1 y.o.
CC: fever, LBM, vomiting
Diet: DAT
IVF: D5IMB 500 cc @ 40 cc/hr
Special Endorsement:
 Nebulize with ½ nebule
ipatropium salbutamol (Duavent)
+ 1 ml NSS every 8 hours
 TF IVF D5IMB 500 cc @ 40
cc/hr

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