EMILIO AGUINALDO COLLEGE SCHOOL OF NURSING AND MIDWIFERY

DOCUMENTATION
BY LEVEL IV GROUP B NCM 105 DURING PRIMARY CARE NURSING AT 6TH MAIN MEDICAL CENTER MANILA

JUNE 13, 2011

AMPARO LIM RN, RM, MAN CLINICAL INSTRUCTOR

GROUP B MEMBERS
ROSAL CLARINO CATHELYN EGOY ERON CECILIO JOVIC CRUZ DANILO DURAN JERRY DESCALZO PRINZ CUDAL LEVI DIZON NEILMER DAIZ ISAIAS TORRES

PROFILE

Name: Rosal B. Clarino Age: 22 Birthday: July 18, 1988 Address: 1115 Escoda St., Paco, Manila Hobbies: Jogging and Reading

Name: Jovic M. Cruz Age: 21 Birthday: July 30, 1989 Address: Blk 7 lot 1 Mandarin Homes, Imus, Cavite Hobbies: Cooking, Sleeping, Working out

Name: Danilo J. Duran Jr Age: 21 Birthday: October 24, 1989 Address: P-9 B17th 2nd St. VAB, Pasay City Hobbies: Basketball

Name: Jerry B. Descalso Age: 21 Birthday: March 21, 1990 Address: 167 Tabora, Gen. Emilio Aguinaldo, Cavite Hobbies: Basketball

Name: Isaias M. Torres, Jr. Age: 24 Birthday: July 24, 1989 Address: Bacao 1, Gen. Trias, Cavite Hobbies: Basketball, Going to the gym

Name: Levi Julius R. Dizon Age: 22 Birthday: June 10, 1989 Address: 26 San Rafael Ext., Mandaluyong City Hobbies: Basketball, Eating

Name: Prinz Nhilmar R. Cudal Age: 21 Birthday: November 21, 1990 Address: Germinal Dist., Bolinao, Panggasinan Hobbies: Skateboarding, Playing guitar

Name: Eron V. Cecilio Age: 22 Birthday: January 3, 1989 Address: Pandacan, Manila Hobbies: Watching movies, Listening to music and Playing with my pets

Name: Cathelyn C. Egoy Age: 22 Birthday: December 7, 1988 Address: Taguig Hobbies: Watching movies, Listening to music

Name: Neilmer Daiz Age: 22 Birthday: Address: Imus, Cavite Hobbies: Basketball

NARRATIVE REPORT

ROSAL CLARINO DAY 1 Our duty at the Medical Center Manila started at exactly six in the morning. The paraphernalias were checked including our grooming, which covers our uniform, hair, shoes and etc. We were given two patients each but for the last patient we would be sharing it with our student nurse buddy. I for instance got patient VV from 605-4 and Im sharing patient TM from 616-2 with my student buddy Eron Cecilio. I observed and assisted Mr. Henry Manibog, the staff nurse for patient VV and Ms. Ma. Andrea Cortez, the staff nurse for patient TM. I think our first encounter with our patients taking vital signs and providing bedside care was enough for the day. No wonder it is our first day, it was not quite challenging. Well, they promised that itll be our turn preparing and administering meds the following day. Patient VV is diagnosed of colloid adenomatous goiter on the right side while patient TM is diagnosed of cholelithiasis. I can say that my day was something since I gave bedside care to my patients who underwent thyroidectomy with frozen section for pt. VV and ultrasound of upper or whole abdomen for pt. TM, respectively. DAY II Its our second day at the Manila Medical Center, we started sharp six and I can sense the pressure of handling a patient independently. After shadowing the staff nurses yesterday, now, we are the staff nurses. That feels so good to hear but it has an equivalent anxiety effect among us, student nurses who will play the role of staff nurse for this day. Our main task is to perform all the basics of primary care and to administer due meds. I was appointed as the student nurse of patient LM at 616-4, a 68-year-old female diagnosed of sepsis secondary to CAP with UTI, liver cirrhosis secondary to NAFLD HPN stage II CAD. Dra. Gaspar-Trinidad made rounds at around ten and assessed the patient. She mentioned that the client had regained her urge to void. She ordered to stop the toilet training and remove the foley catheter. I am glad because I was the lucky one who for the first time experienced removing a foley catheter in an actual patient. It was a nice experience and I was able to recall and justify the processes taught among us in our skills laboratory. Thanks to Ms. Che Mendoza for personally assisting me during the process of my first catheter removal. I referred my client to her staff nurse Ms. Ma. Andrea Cortez when her BP goes beyond normal like 140/ 100 mmHg.

DAY III The third day of our related learning experience at the Medical Center Manila was a little rainy but then we continued with our clinical duty. We had a total of fifteen patients on that day. So first, we underwent the usual triad of checking attendance, paraphernalias and grooming; distribution of patients and endorsement; and the course of primary care. I should have two patients, the first one is patient TM, who was formerly under my care this week and secondly, a 19-year-old female, who just had NSD to a baby boy. The latter were scheduled to go home after submitting their baby for new born screening. Due to unexpected circumstances, our team was pulled out that day because we are attending an orientation in Pasay for our COPAR.

JULIUS LEVI DIZON July 4, 2011 After 2 weeks at the skills laboratory, we served our first day of duty at the Medical Center Manila. We handled 12 patients. Two of those are my patients. We conducted vital signs on time. There is this one nurse named Ms. Agnes Agbaglud, that helped me with my patients. Mam Lim refused to let us give medications since she observed that were quite shocked with the exposure again. So we observed the preparation and administration of all medications. But were the one who did the InputOutput recording and other interventions. So its a less pressure day for us. We tried to look for a patient that would be our main focus in our case study. We were able to get some names and cases and we asked for the approval of our selections but then Mam Lim denied it all because the cases are simple but we cant do anything since those are the only available cases. July 5, 2011 Mam Mendoza and Mam Lim got mad on us because were one minute late (6:01am). We moved on to perform properly. But we promised to them that it will never happen again. We performed vitals signs and gave medications on time. But we I observed one thing, Ive realized that on the patients chart, the patients med is due for administration by 11am but then on the medication card, its 10:40am. Its shouldnt be a big deal but then we should remember the rules. I got 2 patients again with the help of my classmate, Mr. Cudal and Mam Agabaglud. We tried again to look for our patient for case study again but its still a failure. Mam Lim denied since its all the same and simple. Then one patient came for admission from IMU. We chose her but then no more time for us for the assessment. July 6, 2011 Its our third day and unfortunately its our last. We did the first part of our vitals signs monitoring and meds administration. Then when its about time to do our assessment, we where pulled out from duty to attend our orientation in Pasay City for our COPAR.

ERON CECILIO Day 1 July 4, 2011 Monday, it is our first day in mcm 6th main ward. We do endorsement, rounds with the staff nurse, observe, morning care and take the vital signs of my patient, after that we do drug studies, ncp, dar and narrative report, 10 am to 10:30am lunch break, at 12noon we do vital signs again and talk to the patient and continue with our paper works. We are handled by our classmates in group D they are in head nursing, and we are their staff nurse. Day 2 July 5, 2011 Tuesday, it is our second day in mcm 6th main ward. We do endorsement, rounds with the staff nurse, observe, talk to the patient, do morning care, take the vital signs, after that we do drug studies, ncp, dar and narrative report, 10am to 10:30 am lunch break, at 12noon we do vital signs again and talk to the patient and continue with our paper works. Day 3 July 6, 2011 Wednesday, it is our third day in mcm 6th main ward. We do endorsement, rounds with the staff nurse, observe, talk to the patient, morning care, take the vital signs and give medications. At 10am we got pulled out in our duty because we have an orientation in pasay for our COPAR.

DANILO DURAN JR. DAY 1 Its our first day at Medical Center Manila 6th floor main. We arrive at the hospital at exactly 6 am in the morning. Our head nurse was also our classmate and they are the one will manage all what we should do. At first we have our opening prayer to guide us and give us knowledge of what we should do to our patient. After the prayer, they checked the attendance, our grooming and the paraphernalia each every one of us. After that, we listen attentively to the staff nurses for the endorsement. The head nurses assigned us for our respective patient. We prepare the medication of each patient and get their vital signs in the morning. At exactly 8am we give the medication of our patient. After giving the medication we read and analyze the status of the patient using their chart. After reading the chart, we go back to our table and do the requirements which include the drug study and the nursing care plan. I changed the IVF of my patient and regulate it well, and also check the IV line if it infused it well. After all, I talk to my patient and tell him about his status and give him some of advice about his diet. I also instruct him to have a rest and proper care of his wound. At exactly 2pm we passed all the requirements to the head nurses, and ready to go home. DAY 2 Our 2nd day at Medical Center Manila, we arrived at exactly 6am. We have our opening prayer, checking of attendance and paraphernalia. Vital signs at 8am and giving their medication. After doing all those things I already started doing my paper works and requirements. At exactly 11am I prepare the tools and materials that I will use to get the CBG of my patient. We do the said procedure at exactly 11:15 am; I explain the procedure to the patient and tell something why we should do that procedure. Her CBG is normal (109mg/dl). After doing the procedure I write the result to the chart of my patient, and continue the requirements that should be pass to our head nurse. DAY 3 Our 3rd and last day of our duty, as a routine we have our opening prayer, followed by the checking of attendance and grooming, and also the paraphernalia. The head nurse assigned us to our patient and we listen to the endorsement. We prepare the medication and give it to our patient but before giving the medication we should first check the vital signs of the client. After doing those things

we do the requirements, but unexpectedly our clinical instructor tells us that we are pull out and we must attend the orientation at Pasay City for our community participation.

ISAIAS TORRES DAY 1 On the day of 4th July 2011 we were in Medical Center Manila 6flr main 6am. It was my first rotation. Our clinical instructor is Mrs Lim she checked our paraphernalias and she also checked our grooming. Our head nurse called as to make some rounds. We visit our patient and my patient is EJ Roque in room 612 bed 1. He was suffering from acute gastritis. And after that we do morning care. We are taking vital signs and bed making. After getting done we are checked patient chart. It was very busy day. Our head nurse gave us make an examination it is not to hard thank you for them.

DAY 2

On the day 0f July 5 2011 Our second rotation in Medical Center Manila. We have new head nurse Mis Sumayao and Mis Tapec. They checked our paraphernalia, grooming and our shoes. The new head nurse called as to make so rounds to visit our patient. My patient is EJ Roque again in room 612 bed 1. He still suffering from abdominal pain. We did morning care first we taking vital signs and bad making. After that we proceed in patient chart to check some date and the new doctors order. We gave us our patient medication. Our clinical instructor helped us and teaching us for everything we want to know.

DAY 3 On this day July 6, 2011 our 3rd rotation in Medical Center Manila. We enter in hospital early to prefer our self for new activities because we have new a head nurse. First they checked our things and uniform and our shoes. Again we did rounds and visit our new patient taking their vital signs and bad making. After that we checked patient chart for new data and new doctors order. After that we gave the medication to our patient, our clinical instructor told us we need to attend orientation in Pasay thats why we dismiss early.

JOVIC CRUZ Day 1 It was July 4 2011 it is our first duty on mcm our head nurse for the day was our classmate. They first checked our materials for duty and paraphernalias and our duty uniform before going to our client after endorsing us our client we go then to our respective clients first Ive done my assessment of my client I established rapport to my client and do v/s taking and I regulated the iv of my client and charted it after that ive done some requirements like drug study and ncp .

Day 2 It was July 5 2011 this was our 2nd day here in mcm our head nurse for the day was sumayo and tapec they are our classmates first they inspect our materials and uniform then they endorse us with our client then after that Ive taken the v/s of my client and started to prepare my clients medication after that my c.i mam amparo lim accompanied me on giving my medication to the client after that ive done my drug study and other requirements for the day

Day 3 It was our 3rd day on the mcm first our head nurse is togonon and tandec they inspect us then endorse our patient to us then we have taken their v/s and give their medication when we are pulled out of our duty to go to pasay for copar orientation.

Cathelyn C. Egoy

First Day I was absent.

Second Day Our headnurse check our paraphenalias, also check for our grooming. Then, they endorsed for our patients. I have two patients one is a mother diagnosis of pregnancy uterine 38 4/7 weeks AOG cephalic in labor G1P0, and her son is my second patients. Vital signs taken and recorded at 8 am and 12 pm. Patient was educated to increase oral fluid intake, perineal hygiene/daily bath, breastfeeding. I observed for possible vaginal bleeding. Intake and output taken and recorded. While the baby boy was ordered for newborn screening. Baby was observed and cord care rendered, keep safe and maintained thermoregulated,vitals signs taken and recorded and both of them are stable. Proper techniques of breastfeeding, the advantage, baby wearing, carrying baby around on chest/back. We make our drug study, narrative, DAR, etc. and we had a quiz.

Third Day Our headnurse check our attendance,paraphenalias and grooming. They endorsed patients. I have 2 patients. Vital signs taken and recorded. We were pull out by our Clinical Insructor for having an orientation in COPAR at Dona Martha Lying In at Pasay.

JERRY DESCALZO DAY 2 We arrived at our duty on MCM 6th main exactly 6 in the morning. Our assigned head nurses for the day assigned us assigned staff nurses to our patients. After assigning, the head nurses checked our paraphernalias and our grooming. Then endorsement and patient rounds. Then at 8 am taking of vital signs, and preparation of medications of each patient. Before giving the medications, our clinical

instructor asks us what is that medicine for, for us not to look so incompetent in front of our patient. Then our clinical instructor told us that were having an orientation on our community rotation. Its on Pasay. Lots of discussion about rules and regulation, grooming, what will we expect on our duty there.

NEILMER DAIZ JUNE 4, 2011 It was the first day of our duty in Medical Center Manila. I arrived at 5:30am. Our head nurses at that day were Togonon and Ranjo. First was check the attendance and check the census by our head nurses. I assign at room 606-1. After the endorsement we take the vital signs of our patient and give the medication. At 10am have a break and comeback at 10:30am. After the break I prepared the medication for 11am meds, and after that I take the vital signs of our patient for 12nn and after taking the vital signs. Our head nurses told us to finish the drugs study and nursing care plan and after done everything we were dismissed at 2pm.

JUNE 5, 2011 It was the second day of our duty in Medical Center Manila. I arrived at 5:45am. Our head nurses of that day were Somayao and Tapec. First was check the attendance ang grooming by our haed nurses. At 7am is the start oof endorsement and I assign again at room 606-1. After the endorsement we take the vital signs of our patient and prepared the medication for 8am meds of our patient. And after that we have a break 10am and comeback at 10:30am. After the break we have to finish the drugs study and nursing care plan. At 11:30am we have to take the vital signs of our patient and give meds and after done everything we were dismissed at 2pm

JUNE 6, 2011 It was the 3rd day of our duty in Medical Center Manila. I arrived at 6am. Our head nurses was Togonon, Tandec and Roy, we start at checking the attendance and paraphernalias and after that our head nurses endorse the patient of 6th main, at that day our patient was 14. I was assign again at room 606-1 and 616-3. After the endorsement at 7am we take the vital signs and prepared the medication of our patient. After taking the vital signs and meds at 9:30am Ms. Lim our clinical instructor told us that we want to attend the orientation in our COPAR in Pasay City.