Adventist Medical center – Iligan City

Nursing Service Department

Operating Room/Delivery Room

AFFILIATION GUIDELINES
Uniform:
1. Students must wear their complete prescribed uniform.
2. OR/DR scrub suits must be worn in the theater only.
3. Smock gown must be worn whenever students go out of the OR theater.
4. Caps and mask must be removed. Students are required to wear their white uniform
whenever they need to go outside hospital premises.
5. Prescribed OR/DR footwear must be replaced with their clinical footwear whenever they go
outside the OR theater.
6. Students must bring their own OR/DR footwear and oblige with the following color-coding
scheme:

YELLOW slippers – for UNSTERILE Area

GREEN slippers – for STERILE Area

7. Students must wear their white uniform upon reporting to OR/DR whether for duty or for on-
call completion of OR/DR cases.
8. Failure to follow the above mentioned guidelines means NO DUTY.

OTHERS:

1. No labor watch, no assisting in DR cases

2. Signing of OR/DR cases by the staff-on-duty is within 24 hours only after each surgical and/or
obstetric procedure.
3. During NOC shift, students are allowed to take 30-minute to 1 hour nap only.
4. Students are strictly not allowed to use cellphones, laptops, MP3, MP4 and other electronic
gadgets if a student violates this rule.
5. Circulating students should assist during the preparation of surgery and should not leave the
OR theater during the entire procedure and monitored patient in the recovery room.
6. Scrub nurse should make sure that the used instruments are properly cleansed after each
procedure.
7. Schedule for logbook checking of OR/DR cases:

Monday – Thursday 4:00 PM – 6:00 PM

Friday 4:00 PM – 5:00 PM

OPERATING ROOM/POST ANESTHESIA CARE UNIT

SIMULATION
Objectives:
At the end of the simulation, the student shall be able to:
1. Perform surgical scrubbing correctly
2. Perform hand drying, closed gowning and gloving correctly.
3. Master the skills in doing gowning and gloving another person.
4. Remove the gown and gloves correctly.
5. Apply with confidence the different responsibilities of the scrub nurse and circulating nurse
during preoperative, perioperative and postoperative phase using situational analysis.
6. Perform open gloving with less supervision
7. Prepare the OR setup correctly.
8. Differentiate correctly the sutures and needles with its uses.
9. Identify perfectly the different surgical instrument
10. Fill up the OR forms in different Operating Room (OR) facility including Post Anesthesia Care
Unit (PACU) forms.

OPERATING ROOM/PACU SIMULATION

Time Budget
8:00 am – 8:30 am
8:30 am – 12:00 pm
1:30 pm – 5:30 pm
Day 1
Devotional and Checking of
Attendance
1. OR Forms
2. Surgical Scrubbing
3. Drying of Hands and Arms
4. Closed Gloving and
Gowning
5. Open Gloving
6.
Identification/Classification
of Instruments
7. Different Sutures and Uses
OR Setup and Preparation
(OR table, Spinal Tray, Prep
Tray)
8. Methods of Sterilization
and Indications of Sterility
9. PACU Simulation
10. Filling of PACU Forms
11. Responsibilities of PACU
Nurse
1. Orientation to OR
Requirements, Grading
System and Performance
Evaluation
2. Quiz
3. Moving Exam
4. Supervised Practice
Day 2 – 3
Devotional and Checking of
Attendance
Return Demonstration
I. Responsibilities of a Scrub
Nurse
a. Surgical Scrubbing
b. Drying of Hands and Arms
c. Closed Gloving and
Gowning
d. Prepare Towels for
Draping.
e. Arrange Instrument,
Sutures, Needles and
Sponges
f. Mount the blades on knife
handles using needle holder
g. Gowning and Gloving
Another Person
h. Initial counting of sponges,
needles, instruments and
other sharps with the
circulating nurse.
i. Removing the gown and
gloves
II. Responsibilities of a
Circulating Nurse
a. OR Setup and Preparation
b. Position patient for
induction of anesthesia
c. Skin preparation
(Abdominal)
Simulation
Scenario/Situational Analysis

OR/DR/PACU/NICU
Objectives: After 4 weeks of duty the student shall have:

Skills:
1. Assesses with confidence in the client’s health care needs and problems through data
collection.
2. Followed steps correctly on how to admit the client in the operating room.
3. Demonstrated and mastered skills in doing ways of using monitoring device
4. Applied correctly the principles of sterilization techniques in the preparation and use of all
materials in the perioperative environment to prevent transmission of biological contaminants.
5. Prepared OR/DR suites before and after delivery and surgery respectively with less
supervision.
6. Prepared packs and sets for sterilization correctly.
7. Assisted with beginning confidence in surgical procedures and handles delivery.
8. Demonstrated immediate care of newborn
9. Applied the different roles and nursing duties of the circulating and scrub nurse with
confidence during preoperative, intraoperative and postoperative phases.
10. Performed preoperative preparations correctly like surgical scrubbing, gowning and gloving.
11. Assisted correctly in placing the client in the desired surgical position, taking into
consideration the nursing responsibilities.
12. Selected the appropriate instruments and/or equipment for the intended surgical
procedure correctly.
13. Applied perfectly the different nursing responsibilities of a PACU nurse.

Knowledge:

1. Created and implemented the nursing care plan for pre-operative, intra-operative, and post-
operative clients successfully.
2. Stated and memorized by heart the different principles of sterile techniques and discussed
the rationale.
3. Described and followed the roles and functions of each member of the surgical team with
less supervision during preoperative, intraoperative, and postoperative phases.
4. Identified correctly the different classes of instruments and equipment used in the OR/DR.
5. Identified correctly the appropriate needles to be used per tissue layer; and described the
different sutures used as to specific purposes.
6. Described and performed with confidence the pharmacologic and non-pharmacologic
methods used to promote relief of pain.
7. Executed the nursing responsibilities with beginning confidence when caring for surgical
client, and in so doing, utilized the nursing process, whose phases are assessment, planning,
intervention and evaluation.
8. Described correctly the operating room attire.
9. Described correctly the various positions used during surgeries.
10. Enumerated perfectly the different types of anesthesia and adjunctive drugs used in general
anesthesia.
11. Explained correctly the different methods of anesthesia, its actions and identified the drugs
for the adverse effects, different complications and related stages of anesthesia.
12. Discussed the responsibilities of clients receiving general, balanced, local and regional
anesthesia with confidence.
13. Created and implemented the nursing care plan successfully.
14. Identified the instruments and equipment used in the NICU correctly.
15. Identified correctly the duties and responsibilities of the nurse in the OR/DR/NICU/PACU.
16. Defined sterilization and explained correctly the different methods of sterilization and
described the indicators of sterility.
17. Discussed correctly the assessment of a client admitted in PACU as to patent airway and
vital signs.
18. Described perfectly the dressing and drains attached to the client.
19. Researched on the current issues related to surgical case assigned by the clinical instructor
and presented it successfully for learning.
20. Mastered the knowledge learned in formulating a teaching plan for postoperative clients.

Attitudes:

1. Appreciated and applied successfully the different functions and responsibilities in varied
settings.
2. Complied faithfully with the standard operating procedures.
3. Valued the importance of accurate data collection and documentation.
4. Valued the principles and processes I the operating room as evidenced by hi/her
performance of the core nursing competencies.
5. Listened attentively to the concerns of the client who will deliver or undergo surgery.
6. Integrated successfully the spiritual care as part of the healing ministry.
7. Recognized perfectly the importance of informed consent.
8. Showed genuine sensitivity to cultural differences.
9. Be aware and carefully handling responsibilities related to medico-legal cases.
10. Complied perfectly with the standard operating procedures.
11. Appreciated the importance of accurate data collection and documentation.
12. Internalized with confidence the new knowledge learned.

OR/PACU ACTIVITIES
Shifts Day 1 Day 2 Day 3 POST
AM PM NOC OR/DR OR/DR OR/DR CONFERENCE
6:30 – 2:30 – 10:30 Preconference Diagnostic Tests
6:45 2:45 – Devotional Week 1
10:45 Checking of 1. Urinalysis and
requirements, 24 hour urine
uniform, collection
paraphernalia 2. Stool Exam
Final include occult
announcement blood
and reminders 3. Typhi dot/
Widal test/
6:45 – 2:45 – 10:45 Orientation to Tubex test
8:00 4:00 – the OR setup, 4. CBC, platelet
12:00 policies, referral 5. Culture and
and hospital Sensitivity Test
routines (CI or with Antibiotic
NOD) Assists with Assists with Removing
Review the OR/PACU/ OR/PACU/ Device (ARD)
duties and NICU/ DR NICU/DR 6. Sputum
responsibilities activities activities Exam/AFB
or OR/PACU 7. Purified
nurse and NICU Protein
nurse Derivative
Reorientation to (PPD)/ Mantoux
OR/PACU forms Test
Review on 8. Fasting blood
surgical sugar
instruments 9. Random
8:00 – 4:00 – 12:00 Assists with Assists with Assists with blood sugar
11:30 6:30 – 2:30 OR/PACU/ OR/PACU/ OR/PACU/ 10. Glycosylated
NICU/ DR NICU/ DR NICU/ DR hemoglobin, 11.
activities activities activities 2 hours
11:30 – 6:30 – 2:30 – 1st batch meal 1st batch 1st batch postprandial
12:00 7:00 3:30 break meal break meal break glucose test
12:00 – 7:00 – 3:30 – 2nd batch meal 2nd batch 2nd batch 12. Oral glucose
12:30 7:30 4:30 break meal break meal break tolerance test
12:30 – 7:30 – 4:30 – Assists with Assists with Assists with (OGTT)
1:30 9:30 6:00 OR/PACU/ OR/PACU/ OR/PACU/ Week 2
NICU/ DR NICU/ DR NICU/ DR 1. Albumin/
activities activities activities Globulin Ratio
1:30 – 9:30 – 6:00 – Post- Post- Post- (A/G ratio)
3:00 11:00 7:00 conference, conference, conference, 2. Cardiac
Review or Review or Review or Enzymes
OR/PACU/DR/NI OR/PACU/D OR/PACU/DR 3. Lipid Profile
CU Routine 4. Liver enzymes
5. Thyroid Panel
 Team R/NICU /NICU 6. Trop T and
Conference Routine Routine Trop I
Emphasis Team Team 7. Myoglobulin
1st week Conference Conference 8. Prothrombin
1. Review the Emphasis Emphasis time
principles of 2nd week 3rd week 9. Arterial Gas
sterile 1. Types of 1. Common Analysis (ABG)
technique surgical positioning 10. Serum
2. Review the specimens devices and Electrolytes
basic 2. Care and clinical Week 3
instrument set handling of implications 1. X-ray (all
3. Standardized surgical 2. Drug types)
instrument sets instruments review 2. CT Scan (all
4. Applications 3. (follow drug types)
of dressings and Manageme study format) 3. MRI (all
tape nt of tubes 3. types)
5. Transporting and drains Assessment 4. Upper GI
and moving and 4. of client Series/Barium
lifting the Preoperativ admitted in Enema
patient e health PACU 5. Lower GI
References: teaching 4. Contents Series/Barium
Preoperative plan of Enema
Nursing: implementa postoperativ 6. Ultrasound
Principles and tion e report from (all types)
Practice by the 7. Bone Scan
Susan S,. following: 8. Cystoclysis
Fairchild a. 9. Paracentesis
Operating Room Anesthesiolo 10.
Nursing gist Thoracentesis
Perioperative b. Surgeon Week 4
Practice by c. Circulating 1. Pap Smear
Pamela nurse 2. Colonoscopy/
Pagunsan – Proctosigmoidos
Villacrabs copy
3. Endoscopy
QUIZ (20 pts) QUIZ (20 4.
pts) Cholangiogram
5. Lumbar
Puncture
6.
Echocardiograp
hy
QUIZ (20 pts) 7. Liver Biopsy
8. Stress Test
9. Holter
Monitor
10. Cardiac
Catheterization

Note: Please identify what are the latest trends of these procedures worldwide, nationwide and
locally. Include some reliable references. (See Diagnostic Test Performance Evaluation Tool)

Diagnostic Test
a. Objectives
b. Definition of Terms
c. Introduction/ Definition
d. Indications/Contraindications
e. Normal Values/ Significant results/ Interpretation
f. Equipment used/Procedure
g. Nursing responsibilities: Pre-test, during, Post-test
h. Possible Complications (if any)
i. Drug Study
j. Validity of the Test
k. Latest update on the study

FIRST SEMESTER
OR/DR/NICU/PACU REQUIREMENTS
Day 1 Day 2 Day 3 Day 4
Week 1
To be pass during For students with For students with Diagnostic test
preconference in a surgical case surgical case: Presentation
long bond paper 1. Operating Room 1. Surgical Case Study
1. Define Anesthesia Information Sheet For students who
2. Enumerate the 2. Equipment has no surgical case:
different types of Functionality Test 1. Nursing care plan
anesthesia 3. Surgical Case Study (Intra-operative
3. explain the 4. Sponge, problem)
different methods of Instrument and 2. Discharge plan
anesthesia Needle Accounting 3. Annotated
4. Explain the action Sheet Readings (please use
of the following 5. Pre-operative Visit reading in our
a. General anesthesia Checklist College Library as the
b. Balanced For students who reference and must
anesthesia has surgical no have the signature of
c. Local and Regional surgical case: the Librarian)
anesthesia 1. Health Teaching The discharge plan
5. Describe the Plan should have the
methods of 2. One (1) Nursing following emphasis:
administration of: care Plan a. Work
a. General anesthesia (preoperative b. Rest
b. Balanced problem) c. Exercise
anesthesia 3. Identify the drug d. Wound
c. Regional and Local used for: e. Medication
anesthesia a. general anesthesia f. Follow-up
6. Enumerate the b. balanced
adjunctive drugs anesthesia
used in general c. local and regional
anesthesia anesthesia
7. Discuss the nursing 4. Identify the
responsibilities for adverse effects of
clients receiving: administration
a. General anesthesia techniques in:
b. Balanced a. general anesthesia
anesthesia b. balanced
c. Regional and Local anesthesia
Anesthesia c. Local and regional
anesthesia
5. Give the different
complications of:
a. general anesthesia
b. balanced
anesthesia
c. local and regional
anesthesia
Week 2
To be pass during For students with For students with
preconference in a surgical case: surgical case:
long bond paper 1. Operating Room 1. Surgical Case Study
1. Members of the Information Sheet For students who
surgical team and 2. Equipment has no surgical case:
their functions Functionality Test 1. Nursing care plan
2. Operating room 3. Surgical Case Study (Intra-operative
attire: 4. Sponge, problem)
a. Purpose Instrument and 2. Discharge plan
b. Policies regarding Needle Accounting 3. Annotated
OR attire Sheet Readings (please use
c. Basic OR attire 5. Pre-operative Visit reading in our
d. Attire for sterile Checklist College Library as the
team For students who reference and must
e. Protective gear has surgical no have the signature of
3. Types or degree of surgical case: the Librarian)
trauma 1. Health Teaching
Note: to be included Plan
in the 1st day quiz 2. One (1) Nursing
care Plan (intra
operative problem –
1st priority)
3. Surgical scrub
a. Purpose
b. Important
reminders
c. Preparations prior
to scrub
d. Length of scrub
e. Methods of
surgical scrub
4. Gowning and
gloving
a. Purpose
b. General
considerations
5. Surgical
Instruments
a. Cutting and
dissecting
b. Bone cutters and
debulking tools
c. Grasping and
holding
d. Clamping and
occluding
e. Exposing and
retracting
f. Suturing
instruments
Week 3
To be pass during For students with For students with
preconference in a surgical case: surgical case:
long bond paper 1. Operating Room 1. Surgical Case Study
Possible postop Information Sheet For students who
complications: 2. Equipment has no surgical case:
a. Definition Functionality Test
b. Risk factors 3. Surgical Case Study 1. Nursing care plan
c. Manifestations/ 4. Sponge, (Intra-operative
Vital signs Instrument and problem)
d. Nursing Needle Accounting 2. Discharge plan
management Sheet 3. Annotated
e. Medical 5. Pre-operative Visit Readings (please use
management Checklist reading in our
1. Hypotension For students who College Library as the
2. Bleeding has surgical no reference and must
3. Hypovolemic shock surgical case: have the signature of
4. Atelectasis 1. Health Teaching the Librarian)
5. Thrombophlebitis Plan
6. Paralytic ileus 2. 1 Nursing care Plan
7. Dehiscence (post-op patient – 1st
8. Evisceration priority)
Note: to be included 3. Eight (8) Surgical
in the 1st day quiz Positions
a. Indications
b. Example of surgical
procedure
c. Draw
4. Wound Closure
a. Interrupted
suturing
b. Continuous
● describe
● purpose
● example
● draw
Week 4
To be pass during For students with For students with
preconference in a surgical case surgical case:
long bond paper 1. Operating Room 1. Surgical Case Study
1. Abdominal Information Sheet For students who
Incisions (draw and 2. Equipment has no surgical case:
label) Functionality Test 1. Nursing care plan
2. Setting up the 3. Surgical Case Study (Intra-operative
instrument table 4. Sponge, problem)
3. Handling Instrument and 2. Discharge plan
instruments during Needle Accounting 3. Annotated
surgical procedure Sheet Readings (please use
4. Types of sutures 5. Pre-operative Visit reading in our
and its uses Checklist College Library as the
For students who reference and must
has surgical no have the signature of
surgical case: the Librarian)
1. Dismantling the
instrument table
2. Surgical
Preparation
3. Draw how to skin
prep the following:
a. Abdomen
b. Chest/breast
c. Lateral/
thoracotomy
d. Rectoperineal/
vaginal
 e. Knee/ lower leg
f. Hip/lower leg
extremity

SECOND SEMESTER
OR/DR/NICU/PACU REQUIREMENTS

Day 1 Day 2 Day 3 Day 4

1st Week
To be pass during 1. Operating Room 1. Newborn Physical
preconference: Information Sheet Assessment Guide Annotated
1. Surgical Preparation 2. Surgical Case Study 2. OB Case Study Readings
Guidelines – draw 3. Checklist for Pre-
how to skin prep the operative Note: If the student has
following body parts preparation no case, follow the
in preparation for 4. Pre-anesthetic requirments below:
surgery Patient 1. Give the Indication
a. Abdomen Questionnaire and Nursing
b. Chest/Breast 5. Pre-operative Responsibilities of the
c. Lateral/Thorac Health Teaching following Common
otomy Plan Surgical Positions:
d. Rectoperineal/ a. Supine (Dorsal)
Vaginal Note: If the student has Position (8)
e. Abdominal/Va no case, follow the b. Trendelenburg
ginal requirements below: Position (6)
f. Knee/Lower 1. Purposes of c. Reverse
leg Informed Consent Trendelenburg
g. Hip/Lower (Operative Permit) Position (9)
Extremity 2. Discuss the 3 areas d. Fowler’s Position (9)
2. Kinds of Sutures in the Operating e. Lithotomy Position
3. Methods of Suturing Room (17)
3. Discuss the 3 f. Prone Position (8)
Phases of Surgical g. Kraske (Jackknife)
Experience and the Position (10)
scope of Nursing h. Lateral Position (5)
Activities
4. Circumstances
Requiring Permit or
Surgical Consent
and Circumstances
where Consents
may not be Needed
5. Pre-operative
Health Teaching
Plan
2nd Week
To be passed during 1. Operating Room 1. Newborn Physical
preconference: Information Sheet Assessment Guide Annonated
1. Classifications of 2. Surgical Case Study 2. OB Case Study Reading
Surgical Needles 3. Equipment
2. Give the list of Functionality Test Note: If no OB/Newborn
instruments use in 4. Pre-op Visit Checklist
Case
a. Orthopedic 5. 1 Nursing Care Plan 1. Common Surgical
surgeries Procedures with
b. Major Note: If no Surgical Terminology
Laparotomy Set Case a. Abdominal
c. Surgical Scissors 1. GIT preparations: Surgery
d. Suture Set a. Day Before b. Gastrointestinal
e. Cutting Surgery Surgery
Instruments b. On the Day of c. Neck Surgery
f. Tissue Forceps Surgery d. Breast Surgery
g. Clamping c. After Surgery e. Gynecologic and
Instruments 2. Two Methods of Obstetric Surgery
h. Grasping Hemostasis with f. Genitourinary
Instruments Example Surgery
i. Retractors 3. Complications of the g. Thoracic Surgery
j. Dilation & following Anesthetic h. Neurologic Surgery
Curettage and give the i. Ophthalmic
Instrument Rationale Surgery
a. General j. Orthopedic
b. Epidural Surgery
c. Spinal
d. 1 NCP (Newborn
Problem)
3rd Week
To be passed during 1. Operating Room 1. Newborn Physical Experience
preconference Information Sheet Assessment Guide journal
1. Types of wounds 2. Surgical Case Study 2. OB Case Study 2.annotated
2. Methods of surgical 3. Equipment readings
wound healing Functionality Test Note: if no OB/newborn 3.performa
3. Phases of first 4. Pre-op Visit Checklist case nce
intention healing 5. 1 Nursing Care Plan 1.discuss normal evaluation
4. Factors Influencing (Surgical Case) adaptations to pregnancy tool
Normal Wound (by systems) a. scrub
Healing Note: If no Surgical 2.delivery room nurse
5. Complications of Case medications (3) b.
wound healing 1. Advantages and (generic, brand, circulating
6. Discuss the four Disadvantages of indicaction, mechanism nurse
types of anesthesia Various Types of of action, side effects, c. without
Anesthesia nursing responsibilities) case
2. The four stages of 3.discuss the principles of
General Anesthesia newborn care
with Description,
Related Nursing
Interventions and
Rationales
3. Methods of
Sterilization with
Example (3)
4. 1 NCP (OB Case)
Postpartum
Problem
 SURGICAL INSTRUMENT

I. CUTTING AND DISSECTING INSTRUMENTS

A. SCALPELS

Size of Scalpel Description = 2 Size of Scalpel Drawing/Picture Purposes = 2 pts

Blade pts Handle = 1 pt = 1 pt
No. 10
No. 11
No. 12
No. 15
No. 20, 21, 22, 23

B. KNIVES

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

C. SCISSORS

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

BONE CUTTERS AND DEBULKING TOOLS

Types Description = 2pts Drawing = 3 pts Purposes = 2 pts

Chisels
Osteotomes
Gouges
Curette
Bone Cutter
Rongeur
Saws
Drills
Rubber Cutter
Rasps
Files

GRASPING AND HOLDING

A. Tissue Forceps

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

Smooth/Thumb
Pickup Forceps
Toothed/Rat-
Toothed Forceps
Allis forceps
Babcock

B. Stone Forceps

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

C. Tenaculums
 Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts
Single-tooth
Uterine tenaculum
Jacob multi-toothed
Tenaculum

D. Bone Holders

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

CLAMPING AND OCCLUDING INSTRUMENTS

A. Homeostatic Forceps

Types Description = 2 pts Drawing = 2 pts Purposes = 2 pts

Hemostat
Crushing Clamps

B. Non-crushing Vascular Clamps

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

EXPOSING AND RETRACTING INSTRUMENTS

A. Hand-Held Retractors

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

Solid Blade
(Richardson)
Prolonged/Rake
(Volkmann)
Double-Ended (US
Army)
Deaver

1. Malleable Retractor

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

2. Hooks

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

3. Self-Retaining Retractors

Types Description = 2 pts Drawing = 3 pts Purposes = 2 pts

SUTURING INSTRUMENTS
NEEDLE HOLDERS

Types Description Drawing Purposes

Cross-hatched
serrations on jaws
Smooth jaws
 SURGICAL POSITIONS

Name:__________________________________________________
Date:_____________________ Blocking/Area:___________________________

Surgical Position Drawing How It It Is

Performed
1. Supine
1.1. Face and neck procedures
1.2. Shoulder and anterolateral procedure
1.3. Vaginal procedures
1.4. Operations in the groin or lower extremity
1.5. Breast, axillary, upper extremity or hand
2. Trendelenburg’s position
3. Reverse Trendelenburg’s position
4. Fowler’s position
5. Sitting position
6. Lithotomy position
7. Prone position
8. Modified prone position
9. Kraske position
10. Knee-chest position
11. Lateral position
12. Kidney position
13. Lateral Chest position
14. Anterior Chest position
15. Sim’s position
16. Dorsal Recumbent position
Reference: _______________________________

KINDS OF SUTURES/NEEDLES
Suture/Needle Type Color Frequent Usage
Reference: __________________________________

METHODS OF SUTURING

Technique Drawing Common Usage

Reference: _________________________________
 STAGES OF GENERAL ANESTHESIA
Stage Description Patient Reaction / Nursing Rationale
Biologic Response Implications /
Responsibilities

Reference: ________________________

COMMON SURGICAL PROCEDURES

Name:_________________________________ Date:__________ Blocking/Area:___________

Surgery Definition Position Incision Skin Packs/ Anesthesi

Site Prep Instruments/ a Used
Supplies
Needed
Explore Laparotomy
Appendectomy
Cesarean Section

Herniorrhapy
Open
Cholecystectomy
Hemorrhoidectomy

Crainiotomy

Reference: _________________________
 NEWBORN PHYSICAL ASSESSMENT GUIDE

Name: _____________________________________ Gender: _________________

Birth Date: ____________________ Time: ___________________
Type of Delivery: ____________________________ Presentation: _____________
Length of Labor: ________________ APGAR Score: _____________
Rank in the Family: 1 minute after birth __________
5 minutes after birth __________
Educational Attainment: _____________________________________________________
Mother’s Age: ______________ Occupation: ____________________________________
Father’s Age: _______________ Occupation: ____________________________________

Pre-natal History
a. Pre-natal care: adequate, inadequate or none (specify)
b. Supervised by: doctor, nurse, midwife or “hilot”
c. Maternal Illness: include medical and surgical
d. Medication/Treatment taken

General Appearance (Describe)

a. Muscle tone
b. Weight at birth and during your care
c. Height – crown to heel
d. Infant state and behavior

Vital Signs
a. Temperature (rectally)
b. Respiratory rate and character
c. Pulse rate
d. Blood pressure if taken

SKIN
a. Color (Describe and if there are abnormalities in some parts, note the periphery)
b. Birthmarks – check for location, size and characteristics
c. Condition – check if there are abnormalities such as edema, papules, ulcers or diaper
rashes, include also the smoothness, intactness, texture, opacity (visibility of blood
vessel) and desquamation.
d. Hydration and consistency (pinch skin between thumb and forefinger over abdomen or
inner thigh). Check for turgor subcutaneous fat deposits (cheek and buttocks). Check for
any weight loss.
e. Vernixcaseosa – amount, color, distribution, and odor if there is.
f. Lanugo – amount and distribution
g. Mila

HEAD AND NECK

a. Circumference
b. Inspect for head shape and symmetry, also for hair its distribution and texture
c. Palpate fontanelles (anterior and posterior) and describe also; include if there are
abnormalities
d. Face – shape, symmetry, etc.
e. Check the eyes for size (equality of pupils, reaction of pupils to light, blink reflex, sharp
movements, and for any abnormalities).
f. Nose – shape, symmetry, patency, and breathing
g. Ears – size, shape, position or placement amount of cartilage
h. Mouth – placement of face, check lips for color, movement, rooting and sucking
reflexes, gums, tongue, oral thrush, and others that are present.
i. Neck – measure the length; mobility, and palpate lymph nodes and trachea position.
CHEST
a. Assess for shape, symmetry, circumference, respiratory movement
b. Inspect and palpate for the clavicle, ribs, nipples, breast
c. Auscultate for HR, rhythm and breathe sounds

ABDOMEN
Assess the size, contour and shape, circumference, inspect the umbilical cord for 2 arteries and
1 vein, color and condition if dry or still wet. Auscultate for bowel sounds, note amount,
number and characteristics of stool and behavior during elimination, movement of abdomen
during respiration.

GENITALS
Female: General appearance, presence of labia and clitoris and for any discharge
Male: Assess for metal opening, scrotum, or size, symmetry, and any abnormalities reflexes
(erection)

EXTREMITIES
General inspection and palpation on:
a. Arms: Degree of flexion, ROM, muscle tone, color, intactness and appropriate
placement of joints on shoulder, elbows, wrist and fingers, extra digits and grasp reflex
b. Legs: Intactness, length in relation to arms, number of toes, color
c. Hips: Examine for any discoloration
d. Back: Inspection and palpation of spine, check for any abnormality.

BEHAVIOR AND NEUROLOGICAL REFLEXES: Assess for the following if present (check if present;
put an “x” if absent) – indicate how it is elicited
a. Plantar Grasp
b. Hand Grasp
c. Babinski Reflex
d. Tonic Neck
e. Moro
f. Rooting
g. Sucking and Swallowing
h. Blink
 PATIENTS OPERATING ROOM
INFORMATION SHEET

I. Patient’s Name: _________________________________ Room: ________ Date: __________

Age: ____________ Gender: ___________ Civil Status: __________________
Surgeon: _______________ First Assistant: _______________ Second Assistant: ____________
Anesthesiologist: _______________________________ Anesthesia: ______________________
Scrub Nurse: ____________________________ Circulating Nurse: ________________________
Pre-op Diagnosis: _______________________________________________________________
Post-op Diagnosis: ______________________________________________________________
Operation proposed and performed: ________________________________________________
Time Started: ___________________________ Time Ended: ____________________________
Type of Operation: ______________________________________________________________

II. A. SPONGE COUNT

Initial Count First Count Second Count

Count Added On table On floor Total On table On floor Total

4x4
Bighots
Cherry
balls
Cotton
balls
Etc.

B. Medications/Anesthesia
a. Trade name
b. Generic name
c. Dosage given
d. Time given
e. Route
f. Nursing implications

C. Intra-OP IVF
a. Type
b. Amount consumed

D. Supplies and their uses

E. Sutures used in specific tissue/organ and layers of skin
 SURGICAL CASE STUDY

Name: _________________________________________________ Date: ________________

I. Assessment (5 pts.)

A. Personal Data
Patient’s name:
Age:
Gender:
Civil status:
Date/Time of visit:
Room number:
Address:
Attending physician:
Surgeon:
First assistant:
Second assistant:
Anesthesiologist:
First scrub:
Second scrub:
Circulating nurse:
PACU nurse:

B. Past medical and surgical history (5 pts.)

Includes the previous medical and surgical diagnosis and treatment

C. Pre-operative Diagnosis

D. Type of Surgery (Specify and describe)

II. Pre-operative Preparation of Patients (35 pts.)

A. Psychologic Preparation (5 pts.)

1. Psychologic needs
2. Pre-operative teachings
B. Physiologic Preparations (15 pts.)
Indicate the laboratory results of the diagnostic tests performed prior to surgery.

Diagnostic Test Normal Value Results Significance

C. Physical Preparations (10 pts.)

1. Few days before

a. Intravenous therapy (type and amount of fluid/blood)
b. Medications (make a drug study reflect the generic and trade name, general
action, mechanism of action, side effects, adverse reactions and nursing
implications.)
2. Immediate Pre-operative Period (a day before surgery)
a. NPO (time stated and the duration of NPO status)
b. Informed consent (describe the steps of securing it)
c. Physical preoperative preparation
3. Define surgical procedure briefly (5 pts.)

III. Intra-operative Nursing (25 pts.)

 1. Table set-up, position assumed by the patient
2. Linen packs prepared and laparotomy Drape
3. Instrument sets prepared
4. Final skin preparation (describe the procedure)
5. Equipment being used
Type of anesthesia (describe this procedure)

IV. Immediate Post-operative Care Duties and Responsibilities (25 pts)

V. PACU (25 pts)
Use monitoring sheet in PACU (25 pts.)
 OB CASE STUDY (DR)

PERSONAL DATA

Name: _______________________________________________
Age: _______________________________________________
Place of Birth: _______________________________________________
Religion: _______________________________________________
Race: _______________________________________________
Ethnic Background: _______________________________________________
Civil Status: _______________________________________________
Date of Admission: _______________________________________________
Time of Admission: _______________________________________________
OB Index: _______________________________________________
Age of Gestation: _______________________________________________

MENSTRUAL HISTORY
LMP _______________________________________________
EDD (Calculate) _______________________________________________
Menarche Age ____________ Interval _________ Duration ________
Symptoms: _____________________

OBSTETRICAL HISTORY
DATE DURATION/CHARACTER GENDER OF WEIGHT OF REMARKS
OF LABOR BABY BABY

MEDICAL/SURGICAL HISTORY
Disease/Illness: __________________________________________________
Previous Accident/s: ______________________________________________
Previous Surgery/ies: _____________________________________________

HISTORY OF PRESENT ILLNESS

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

PHYSICAL EXAMINATION

Vital Signs: BP _______ PR _______ Temp ______ WT _______

SYSTEMS FINDINGS
EENT
LUNGS
BREAST
HEART
ABDOMEN
VAGINA/PERINEUM
EXTREMITIES
FETUS Lie
Presentation
Position
Estimated Fetal Weight
LABORATORY RESULTS (See Format Below)

DIAGNOSTIC NORMAL RESULT INTERPRETATION NURSING

TEST/S VALUES IMPLICATIONS

STAGES OF LABOR

FIRST STAGE

Time Started_____ Time Ended ______ Duration ________ Hrs/Min

Membrane Ruptured
_______ Spontaneous __________ Yes/No oxytocic stimulation
_______ Artificial __________ Time
Complications _____________________________________________________
Drugs given _______________________________________________________
Analgesic _______________________________________________________

SECOND STAGE

Time of birth __________ Time started ___________ Time ended: __________

Duration _________ Hrs _________ Minutes
Complications _______________________________________
Type of delivery ______________________________________
Indication (if not spontaneous) __________________________
Position of delivery __________ Episiotomy __________ Laceration _________
Tubal ligation _________ Yes _________ No
Complications during delivery ______________________________

TIME BP PULSE DRUGS GIVEN

Observe the preparation for delivery:

List all the instruments in the prime-set with their corresponding use. Include references.
Note and record the anesthetic agents/drugs administered.

DRUG GENERAL INDICATION MECHANISM SIDE NURSING

ACTION OF ACTION EFFECTS & IMPLICATIONS
ADVERSE
REACTIONS

Generic
Name:

Note the intravenous solution or blood given including amount and blood type.

________________________________________________
________________________________________________
NEONATE

Gender ______________ Weight _____________ Height ___________ Single/Multiple ____

APGAR Score ___________ Respiration _________ Spontaneous/Artificial ______________
Chest circumference __________ Head circumference __________ Eyes __________
Premature _____ Full Term __________ Born Alive __________ Still Born ____________
Delivered by: _______________ OB Gyne
_______________ Anesthesiologist
_______________ Assistant

THIRD STAGE

Time Started _______ Time Ended: ________ Duration: __________ Hrs/Mins

Placental Delivery
_________ Spontaneous ____________ Manual Removal
_________ Complete ____________ Incomplete

Uterine Exploration __________ Yes ___________ No

Time _____________
Mechanism _____________
Abnormalities ______________
Oxytocic drugs given ______________________ Condition of cervix _______________
Anesthesia/Analgesic given ________________________________________________
Complications ___________________________________________________________
Sutures ________________________________________________________________
Total duration of labor ____________________________________________________
Total blood loss _________________________________________________________

FOURTH STAGE

Note the condition of the mother.

Record the vital signs

Note the condition of the uterus (relaxed or firm)
Record lochial discharges, amount, odor, and type
Note height of fundus
Note condition of episiotomy wound, and presence of after pains.
 PRE-OPERATIVE HEALTH TEACHING PLAN
Name of Patient: ______________________________ Room Number: _______ Date: ______
Attending Physician/Surgeon: _____________________________________
Anesthesiologist: _______________________________________________
Surgery: _________________________________________ Date of Surgery: ______________

Objectives: (at least 3)

1.
2.
3.

Materials Needed:

1.
2.
3.

General Health Teachings Specific Health Teachings

Possible Topics ( Only applicable to the

patient)

Fears and Anxieties

Surgical Procedures
Preoperative Routines ( e.g. NPO, enemas,
blood samples, showering, bath)
Invasive Procedures (IV line, catheters)
Post-op exercises- coughing, turning, deep
breathing
Incentive spirometer- how to use, how to tell
when used correctly
Lower extremity exercises ( postoperative leg
exercises)
Stockings and pneumatic compression
devices
Early ambulation
Splinting
Pain Management

Evaluation: ____________________________________________________________
____________________________________________________________

Date Performed: ____________________ Evaluated by: ______________________

 CHECKLIST FOR PRE-OPERATIVE PREPARATION

Name of Patient: ________________________ Room Number: _____ Hospital Number: ______

Surgery to be performed: _______________________ Surgeon: _________________________
Anesthesia to be used: __________________________ Anesthesiologist: __________________
Date of Surgery: ______________________

_____________1. Satisfactory Business Arrangement has been made.

_____________2. Surgical and Anesthesia Consent Signed.
_____________3. Special Consent.
Eye nucleation
Sterilization
_____________4. Laboratory work done.
Bleeding time, clotting and coagulation
RBC, WBC, Differential
Type and Crossmatch
_____________5. Blood Available:
Serial number
Amount in CC
_____________6. Skin Prep done:
Umbilicus cleaned very well
Site of spinal anesthesia cleaned very well
_____________7. Enema as ordered
_____________8. Identification band adhesive or wrist:
Complete name
Doctor
Room Number
_____________9. Care of Hair
Hairpins and old woman’s comb removed
Long hair braids in two
Remove all underwear including panty of female patient
____________10. Jewelry removed and give it to relatives for safekeeping
____________11. Prostheses Removed:
Denture
Eye
Leg or Arm
Lipstick and nail polish from thumb is removed
____________12. Urine Removed
____________13. Place indwelling catheter in the following cases:
Cesarean
Pelvic Laparotomy (female)
All kidney cases
Note: Use Foley Catheter of no. 14 & 16, never a small one unless the patient is a child.
____________14. Premedication given
____________15. Instruct patient’s relatives how to find the gallery as one is allowed inside the
O.R. except O.R. personnel.
 PREOP VISIT CHECKLIST

A. Pre-op teaching to all surgery patients.

Exception:
1. Emergency admission for Emergency Surgery
2. Patients with apparent inability to understand instructions without family
member
3. Patients admitted directly to O.R.

B. Pre-op teaching to include the following

YES NO
1. Reinforcement of physician explanation of surgical procedures
2. Explanation on how to deep breath and cough
a. Demonstrate and return demonstration
b. Incentive spirometer
3. Explanation of Oxygen drainage tubes, intravenous fluids and specific reasons for
having these
4. Patient informed regarding how often blood pressure, pulse and temperature
will be taken
5. Explanation of pain medicine given. Patient informed of need to request pain
medicine when needed
6. Patient informed about what will take place night before surgery. (enema, bath,
prep, sleeping pill, etc.)
7. Patient informed about what will take place early morning of surgery. (bath, vital
signs, and gown)
8. Patient shown how to turn from side to side. Turning encouraged every 2 hours
for 24 hours or longer after surgery. Patient encouraged to move himself (except
spinal surgery)
9. Patient shown how to move foot in circle and how to flex his leg slowly but often
10. Pre-op medication explained to the patient and reason for giving
11. Patient instructed in need to void prior to pre-op
12. Patient instructed to stay in bed after pre-op medication given and side rails be
kept up.
13. Explanation of “Nothing by Mouth” which usually is in effect after midnight
14. Patient instructed on how to record I&O and purpose
15. Patient instructed in self perineal care and catheter care if applicable
16. Patient instructed in removal of the following:
a. Dentures
b. Jewelry: watch, earrings, rings and necklace
c. Contact lens and eye glasses
d. Fingernail and toenail polish
e. Wigs, Hairpieces and hair pins
f. Hearing aid
g. Extra clothing

17. Specific information given to relatives on where to wait and when & where to
see the doctor

I have received the above pre-op instructions and I understand them.

__________________________ __________________________
Patient’s Name & Signature Nurse’s Name & Signature
 EQUIPMENT FUNCTIONALITY SHEET

Date ____________ Time ________

Name: ___________________________ Age: ___ Sex: ___ Room: _____ Hospital No. ________
Surgeon: _______________ First Assistant: ____________ Anesthesiologist: _______________
Planned Surgical Procedure: ______________________________________________________
_____________________________________________________________________________
Type of Anesthesia: ______________________ Date of Surgery: ___________ Time: ________

_____ OR Light
_____ OR Table
_____ Cardiac/Patient Monitor
_____ Anesthesia Machine
_____ Suction Machine (Oral)
_____ Suction Machine (Abdominal)
_____ IV Pump
_____ Syringe Pump
_____ Laparoscope
Others:
________________________
________________________
________________________
________________________
________________________

___________________________
Name and Signature of OR Nurse
 INSTRUMENT AND NEEDLE COUNT
INSTRUMENT AND NEEDLE COUNT
Needle Initial Adde Total Second Count Third Count Fourth Count Final Count Remarks
Count d
On On Total On On Total On On Total On On Total
table floor Table Floor Table Floor Table Floor

Adson w/
teeth
Adson
w/o
teeth
Allis
Army
Navy
Retractor
Bandage
Scissors
Babcock
Blade
Holder
De Bakey
Heaney
Kelly
(Curve)
Kelly
(Straight)
Kocher
(Curve)
Kocher
(Straight)
Mayo
scissors
Metz
Mosquit
oes
Needle
holder
Peans
(Curve)
Peans
(Straight)
Suture
Scissors
Thumb
Forceps
Tissue
Forceps
Towel
Clips
Others:

Needle
Blade

We hereby declare that the sponge, instrument, and needle counts are complete and accounted for.

_____________________ _______________________ _____________________

Surgeon Scrub Nurse Circulator
(Signature Over Printed Name) (Signature Over Printed Name (Signature Over Printed Name)
 SPONGE, INSTRUMENT AND NEEDLE
ACCOUNTING SHEET

Name: ___________________________________ Age: _____ Sex: _____ Date: ___________

Surgeon: __________________ First Assistant: ____________ Second Assistant: __________
Scrub: __________________________________ Circulator: ___________________________
Procedure: Specimen:
___ Major
___ Minor

SPONGE COUNT
Sponges Initial Adde Total Second Count Third Count Fourth Count Final Count Remarks
Count d
On On Total On On Total On On Total On On Total
table floor Table Floor Table Floor Table Floor

4x4
4x16
Big Hotz
Cottonoi
ds
Peanuts
Prep
Balls
Cherry
Balls
Others:

Note: (any relevant endorsement e.g. vaginal pack)

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
 CASE SHARING PERFORMANCE EVALUATION

Case: _________________________ Evaluator: ________________ Date: _________

Section: _________________________ Group: _____________________

Individual-40%
I. Delivery
a. Organization. Systematic and logical presentation of 15
the report
b. Clarity of voice, goof diction, grooming and poise 5
II. Content
a. Correctness of processing and interpretation of data 15
b. Clear and unambiguous presentation 5
c. Conciseness of presentation 5
d. Appropriate data presented 10
III. Audio-visual aids
a. Use of audio-visual aids to facilitate comprehension 5
IV. Mastery and Tact
a. Ability to answer relevant questions 20
b. Attitude toward criticism and suggestions 10
TOTAL 100
GROUP-40%
I. Delivery-30%
a. Utilization of appropriate, useful strategies to catch 20
audience interest, sustain attention and encourage
participation
b. Organized and well-outlined, comprehensive 50
presentation
c. Collaboration of members, provision of data and 20
participation in the Q and A, coaches each other
d. Time limit observance (1 and ½ hour) 10
e. Use of appropriate and relevant visual aids 10
f. Bibliography-annotated references used 10
Total 120
II. Content-60%
Introduction of the Case 10
Definition of Terms 5
Normal Anatomy and Physiology 20
Physical Assessment and Review of Systems 30
Diagnostic Tests 15
Risk Factors and Pathophysiology 30
Pharmacology/Medications 10
Nursing Care Plans (Appropriately prioritized) 50
Medical/Surgical Management 10
Discharge Plan and Health Education Plan 20
Prognosis 5
References 5
Recent Updates and Researches 10
TOTAL 230
III. Group Attitude Towards 10
Questions/Criticisms/Comments-10%
Total
FINAL COPY-20%
Individual 40%
Group 40%
 CASE SHARING GUIDELINES
GROUPINGS

Case Sharing Groupings is outlines on the Level 3 Bulletin Board. The CS group is consists of 10-
12 members.

ASSIGNMENT OF A CASE SHARING TOPIC

There will be 3 weeks of Case Sharing. One group will present in a day.

CONTENT OF THE CASE SHARING

1. Case Sharing Objectives (at least 5 objectives)

2. Introduction (Case/Clinical diagnosis)
3. Definition of Terms
4. Assessment
5. Physical Assessment and Review of Systems
6. Diagnostic Tests
7. Normal Anatomy & Physiology (based on the involved systems determined by the case)
8. Risk Factors and Pathophysiology
9. Nursing Management
10. Nursing Care Plans (Prioritized)
11. Health Education Plan
12. Discharge Plan
13. Medical Management/Surgical Management (Treatments, Medications, Procedures)
14. Prognosis
15. Bibliography (of at least 7-10 books, recent copyright. The internet references will be
considered supplementary references)

PRESENTATION

1. During the Presentation, each group will be given the tasks. One group will present the
case topic provided, and another group is assigned to be the TIME KEEPER and STAGE
COORDINATOR. This group will remind the presenting group of the remaining time and
budget of their presentation. They are also in charge in putting up the visual aids, maintain
the order of the stage, and attend the needs of the presenting group.

2. One group will be assigned as the CRITIQUE GROUP. The Critique Group will be in charged
in asking questions (together with Clinical Instructors), making constructive criticisms of the
work of the presenting group.

FINAL COPY FOR PRESENTATION

1. Submit a typewritten or computer-encoded manuscript of the case presentation on the

day before scheduled presentation (5 PM). The presenting group should provide 6 copies
of the final manuscript. Each clinical instructor (4) attending the presentation should have a
copy. One copy will be given to each of the 3 Critique Group. Failure to do so means that
presenting group will automatically get a grade of zero (NO EXCUSES WILL BE
ENTERTAINED). FOR STRICT IMPLEMENTATION.

2. The Critique Group should study, scrutinize, criticize the output of the group and prepare
mind challenging questions a night prior to the presentation.

3. Submission of the final manuscript of the case presentation should be 1 week after the
presentation. Failure to do so, the group will receive a grade of zero for the final copy.
Late submission will not be accepted.
4. Manuscript submitted to the clinical instructors should be neat & tidy. Please check for any
typographical errors. Manuscript for the presentation will be written in a long bond-paper.

5. Practice for a dry run of the presentation will be done among the group. Expect for various
thought-provoking questions from the panel members

6. Prepare useful, clean & presentable visual aids.

7. Use appropriate & relevant strategies in the presentation of the case. Extravagant
presentation that is out of context of the diagnosis being discussed, is highly discouraged.

CASE SHARING GRADING

1. The presentation will be graded according to established CS Performance Evaluation Tool.

2. The CP Final Grade depends upon the group and individual performance. Forty percent
(40%) of the Final Grade will come from the individual performance and 40% will come
from the group performance and 20% will come from the final copy.

3. Do approach/consult any of the attending CI’s for any suggestions, comments or initial
corrections of the output 1 week before the scheduled presentation. However, a night
before the presentation, there must be NO consultation and correction done. The CI’s will
use that time in preparing for the actual presentation. Thorough discussion about the case
must be done among the group before the presentation. Intermission numbers, ice
breakers, teaching strategies (play, drama, role playing, and games) must be rehearsed
ahead of time. Thought-provoking questions will be expected from the panel members.

4. On the day of the presentation, the group will submit a written program for the
presentation.
 MINI MENTAL STATUS EXAMINATION FORM

Name of Patient: __________________________________________ Date: _____________

DSMR IV TR Diagnosis/Impression: ______________________________________________
Age: ____ Gender: ______ Civil Status: _____ Attending Physician: ____________________

Areas of Mental Function Maximum Actual Evaluation Activity

Evaluated Score Score
Orientation to Time 3 May ask:
 What day is today?
 What month is it today?
 What year is today?
Orientation to Place 1 May ask:
 Where are you now?
Attention and Immediate 3 May ask:
Recall  Repeat these words now, bell,
book, and candle (1 point per word)
 Remember there words and I will
ask you to repeat them in few
minutes
Abstract Thinking 3 May ask:
a. What does the saying “No use
of crying over spilled milk”?
Recent Memory 3 May ask:
b. Say three words I asked you to
remember earlier
Naming Objects 2 Point to any object example “eyeglasses”
and ask what is this? Repeat with other
item. (2 points possible)
Ability to follow simple 2 May ask:
verbal commands c. Tear this paper in one half and
throw it in the trash can
Ability to follow simple 2 Write a command on a piece of paper (e.g.
written commands Touch your nose), give the paper to the
patient and say “Do what it says on this
paper. (1 point for correct action)
Ability to use language 3 Ask the patient to write a sentence (3
correctly points if sentence has a subject, a verb,
and has a valid meaning)
Ability to concentrate 4 “Say the month of the year in reverse,
starting with December.” (1 point each for
every correct answers from November
through August, 4 points possible)
Understanding spatial 5 Draw a clock; put in all the numbers; and
relationships set the hands on 3 o’clock. (clock circle- 1
point; numbers in correct sequence- 1
point; numbers placed on clock correctly- 1
point; two hands on the clock- 1 point
hands set at correct time- 1 point) (5
points possible)
Total Score

Scoring: 21-30 – normal; 11-20 – mild cognitive impairment; 0-10 – severe cognitive
impairment

Assessed by: _____________________________ Date: _____________ Time: ____________

 COMPREHENSIVE MENTAL STATUS
EXAMINATION

Patient’s Name: ______________________________________ Date: _____________

Age: _____ Gender: _____ Status: _________
DSMR IV TR Diagnosis/Impression: ___________________________________________
Attending Physician: ________________________________ Ward: ________________

I. Presentation
A. General Appearance
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

B. General Mobility
a. Posture and Gait:

b. Activity

i. Normoactive
ii. Psychomotor Retardation
iii. Hyperactive
iv. Agitated

c. Behavior
Friendly Impulsive Angry Embarrassed Negativistic

Evasive Seclusive Indifferent Withdrawn

d. Nurse Patient Interaction

Cooperative Uncooperative

Initially All Throughout

e. Quality

Warm Distant Hostile Suspicious

Talkative Dependent

Others: ____________________________________________

C. Speech Patterns

a. Character
Spontaneous Deliberate Pressured Blocking

b. Organization of Talk

Relevant Loose Association Tangentiality Irrelevant

Flight of Ideas Neologism Others: ___________________

 c. Accessibility
Good Self Absorbed Defensive Fair

Mute Inaccessible

D. Emotional State and Reaction

1. Mood
Euthymic Depressed Euphoric Labile Irritable
Guilty Anxious Fearful Sad Despairing

2. Affect
Appropriate Inappropriate

3. Quality
Flat Blunt Restricted Labile

4. Rate of Mood (1-10) _________

5. Describe: _________________________________________________________
____________________________________________________________________
____________________________________________________________________

E. Thought Content

 Central Theme; What is important to the client?

________________________________________________________________________
__________________________________________________________________

 Self-Concept; How does the client view himself or herself?

_____________________________________________________________________
_____________________________________________________________________

 Delusion?
Type: ________________________________________________________________
_____________________________________________________________________

 Suicidal or Homicidal Ideas

_____________________________________________________________________
_____________________________________________________________________

 Preoccupation and Rumination

_____________________________________________________________________
_____________________________________________________________________

 Obsessions/Paranoia/Phobias/Ritual
_____________________________________________________________________
_____________________________________________________________________

 Perceptual Disturbances
i. Hallucinations: _______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
ii. Depersonalizations or Derealizations: ____________________________________
_____________________________________________________________________
iii. Illusions: ___________________________________________________________
iv. Others: ____________________________________________________________
F. Neurovegetative Functions

a. Sleep

Normal Insomnia Hypersomnia

b. Appetite: ___________________________________________________________

c. Diurnal Variation: ____________________________________________________

d. Weight: ___________________________________________________________

e. Libido: ____________________________________________________________

G. General Sensorium and Intellectual Status

A. Orientation
i. Time: __________________________________________________________
ii. Person: ________________________________________________________
iii. Place: _________________________________________________________
iv. Level of Consciousness: ___________________________________________
_________________________________________________________________
v. Calculation: _____________________________________________________
_________________________________________________________________
vi. Concentration: __________________________________________________
_________________________________________________________________
vii. General Information: _____________________________________________
_________________________________________________________________
viii. Abstract Thinking: _______________________________________________
__________________________________________________________________
__________________________________________________________________
ix. Judgment: _______________________________________________________
__________________________________________________________________
__________________________________________________________________
x. Memory:
1. Immediate: ___________________________________________________
_______________________________________________________________
2. Recent: ______________________________________________________
_______________________________________________________________
3. Remote: ______________________________________________________
_______________________________________________________________
xi. Insight: _________________________________________________________
__________________________________________________________________
xii. Adaptive Use of Coping/Ego Mechanisms: ____________________________
__________________________________________________________________
__________________________________________________________________

Assessed by: ___________________________________ Date: ___________ Time: _________

DAILY OBJECTIVES

Daily Objectives:

A.
B.
C.
D.
E.

Note: Should be submitted during preconference

 THERAPY FORMAT

THERAPY: ____________________________ DATE CONDUCTED: ________________

GROUP NUMBER: _____________________ PLACE CONDUCTED: ________________

Objective Time Alloted Materials Outline Resource Evaluation

Needed Mechanics Person

Note: CI must check this form a night before therapy. Students must make the activity
interesting. Allow creativity artistic prowess, and resourcefulness to come in to play. Reserve
more icebreakers and games just in case needs one
 PSYCHIATRIC NURSING PROCESS RECORDING
FORMAT
Name: ________________________________________ Age: ______ Date: _____________
Diagnosis: _______________________________ Attending Physician: __________________

I. TIME AND SETTING

Time of interaction:

Setting of interaction: (written or drawing with description)

II. OBJECTIVES

STO (based on the daily objectives)

LTO (formulate 5 objectives for the whole exposure. E.g. Within 3 weeks…)

III. DESCRIPTION OF THE PATIENT

IV. NURSE –PATIENT-INTERACTION (write in column with documentation of Analysis)

INTERACTION INTERPRETATION ANALYSIS WITH REFERENCE

NURSE:

PATIENT:

NURSE:

PATIENT:

V. EVALUATION OF STO

Note:
 Should be recorded daily
 Monday and Tuesday NPI will be submitted Wednesday during Preconference
 Wednesday and Thursday NPI will be submitted Friday during Preconference
 PSYCHIATRIC-MENTAL HEALTH NURSING
CARE PLAN FORMAT

Cues Nursing Interventions Rationale Evaluation

Outcomes
Subjective: Short Term Nurse Patient
Goals: Relationship
(Independent)

Objective: Long Term Milieu Management:

Goals: (Dependent)

Psychopharmacology
Theory: (Collaborative)
 PSYCHIATRIC NURSING STUDY FORMAT

I. INTRODUCTION

II. OBJECTIVES

III. INFORMANT

Name, relationship to the patient, intimacy, and length of acquaintance. Interviewer’s

impression of informant’s reliability. What place or situation does the current interview took
place and whether the current disorder is the first episode of that type for that patient. Sources
of interview took place, the sources of information.

A. ANAMNESIS: (past personal history) History of the patient’s life from infancy to the present
to the extent that can be recalled, gaps in history as spontaneously related by the patient,
emotions associated with these life periods- pain, stressful, and conflictual. Each health history
and developmental milestone. Anchor these theories.
a. Prenatal/Perinatal History
b. Infancy
c. Toddler
d. Preschooler
e. School Age
f. Adolescent: social, relationships, school history, cognitive and motor development, emotional
and physical problems and sexuality
g. Early Adulthood
h. Middle Adulthood
i. Late Adulthood: occupational history, marital relationship history, education history, religion,
social activity, current living situation, legal history

B. ONSENT OR HISTORY OF PRESENT ILLNESS: A comprehensive and Chronological picture

of the events leading up to the current moment in the patient’s life or background and
development of the symptoms or behavioral changes culminating in the patient’s life activities
and personal relations – changes in personality, memory, speech, psychological symptoms.
a. What was the onset of the current episode?
b. What were the immediate precipitating event events or that triggers?
c. Why did the patient come to the doctor at this time?
d. What were the patient’s life circumstances at the onset of the symptoms or behavioral
changes?
e. How did they affect the patient so that the presenting disorder manifest?
f. The evolution of the patient’s symptoms should be determined and summarized in an
organized and systematic way. Symptoms not present should also be delineated.
g. What past precipitating events was part of the chain leading up to the immediate events?
h. In what way has the patient’s illness affected his/her life activities (Work, Relationships)?
i. What is the nature of the dysfunction (changes in personality, memory, speech)?
j. Are there psychological? If so, they should be described in terms of location, intensity and
fluctuation. If there is no relationship between physical and psychological symptoms it should
be noted.
k. A description of the patient’s current anxieties, whether they are generalized and non-
specific (free floating) are specifically related to particular situations.
l. How does the patient handle those anxieties?
m. How did this all begin?
C. HISTORY OF PAST ILLNESS: Emotional or mental disturbances, psychosomatic disorders,
mental conditions and neurological disorder.
If the symptoms extent of incapacity, type of treatment received, name of hospital, length of
each illness, effects of prior treatment and degree of compliance should be explored and
recorded chronologically.
 Pertinent childhood illness or facts concerning growth and development.
 In chronological order; operations, other hospitalizations, significant injuries, and significant
illnesses not resulting to hospitalizations.
 Specific injury should be made concerning head injury and neurological illness.

D. GENOGRAM AND FAMILY HISTORY: Elicited from patient and from someone else
because quite different descriptions may be given of the same people and events; ethnic,
national and religious traditions; other people in the home, description of them – personality
and intelligence and what become of them since the patient’s childhood; descriptions of
different households live in; present relationship between patient and other people who were
in the family; role of illness in the family; history of mental illness and treatment.

Family history of medical, neurological, psychiatric and substance abuse.

Family history: Details of parents’ siblings; details of family psychiatric illness or other medical
conditions e.g. epilepsy, delinquency, alcoholism, drug use, suicide or attempted suicide. This
should be in particular focus on the atmosphere in childhood and any early stresses, including
death and separation.
1. Is there a family history of alcohol and other substance abuse or antisocial behavior?
2. Provide description of personalities and the intelligence of the various people living in them
patient’s home from childhood to the present and description of the various household lived in.
3. Define the role of each person has played in the patient’s upbringing and the current
relationship with the patient.
4. What have been the family ethnic, national and religious traditions?
5. Family’s attitude towards the patient and insight of the patient’s illness
6. Does the patient feel that the family members are supportive, indifferent or destructive?
7. What is the role of the illness in the family?
8. What are the patient’s attitude toward her/his parents and siblings?
9. Ask the patient to describe each member of the family.
10. What does the patient mention first?
11. Whom does the patient leave out?
12. What does each of the parents do for a living?
13. What do the siblings do?
14. How does that compare with that the patient is currently doing and does the patient feel
about it?
15. Whom does the patient feel he/she is most like in the family?

IV. PSYCHODYNAMIC FOMULATION

(With documentation) Causes of the patient’s psychodynamic breakdown, influences in the
patient’s life that contributed to the present illness, environmental, genetic and personality
factors relevant in determining patient’s symptoms, primary and secondary gains, outline of the
major defense mechanism used by the patient.

V. PROGRESS NOTES

VI. A. MENTAL STATUS ASSESSMENT (refer to Mental Health Manual)

Medicare requires a listing of the five axis for psychiatric patients according to DSM-IV-R. Thus
at the end of the case study restate your assessment in this format (Axis I-V) according to DSM
criteria. If you do not make a diagnosis in an axis but may possibly do so in the future, state,
“none formulated” on that axis. Remember, if you happen to state “ruled out” or “deferred”, at
some point during the hospitalization you must go back to the issue and change it from
“deferred” to have a specific diagnosis or “no diagnosis”. Axis I are the Clinical Syndromes. Axis
II are primarily Personality and Developmental Disorders. Axis III are Physical Disorders. Axis IV
are Psychosocial Stressors. Axis V denotes Global Assessment of Functioning.

B. LABORATORY DATA:
In addition to medical test, one should record the result of any psychometric test.

C. PSYCHOMETRIC AND NEUROPSYCHOLOGICAL TESTS (Test can be done by

psychologist in the hospital)

VII. NURSING CARE PLAN AND TREATMENT PLAN:

Modalities of treatment recommended, role of medication, inpatient or outpatient, treatment,

frequency of sessions, probable duration of therapy, type of psychotherapy, individual, group
or family therapy, symptoms of problems to be treated.

VIII. PROGNOSIS

Opinion as to the probable future course, event and extent and outcome of the illness; goals of
therapy.

Prognosis Documentation
Onset of Illness (if chronic/acute)
Precipitating Factors (if present/absent)
Family Support (if strong/weak/poor/absent)
Depressive feature (if present/absent)
Mood and Affect (if appropriate/
Inappropriate)
Willingness to take medications

Note: Prognosis can be either be Good, Fair, or Poor. Summarize by making a conclusion in the
overall prognosis of the client based on the criteria above. Cite documentation about the
prognosis of the disease according to the book. Write the reference.

IX. RECOMMENDATIONS
A. PATIENT
B. FAMILY
C. NURSE
D. PHYSICIAN
E. COMMUNITY

X. REFERENCES
XI. APPENDIX
 CASE STUDY FORMAT

Contents:
Title Cover
Table of Contents
The Authors
Acknowledgment
Dedication
Objectives of the Study
 Patient Centered
 Student Centered
Introduction
Definition of the Case, Types, History, Etiology, Epidemiology, Prevalence (Global and
National), Recent Studies and Findings
Chapter I: Assessment
A. Psychiatric Nursing History
a. Vital Information
b. Informants
c. Chief Complaints
d. Personal Identification
e. History of Present Illness
f. History of Past Illness
g. Allergies
h. Medication and Drug Study
i. Family History
j. Personality
k. Psychosexual History
l. Current Social Situation
m. Assets
n. Dreams, Fantasies and Value System
B. Anamnesis
C. Genogram
D. Mini Mental Status Examination (Include daily MMSE and compare for each day)
E. Mental Status Examination (Include weekly MSE and compare for each week)
F. Physical Assessment (Perform it weekly)
G. Spiritual Assessment
H. Diagnostic Studies (From admission until the week of care)
I. Nurses Progress Notes (From orientation phase until termination phase)
Chapter II: Diagnosis and Analysis
A. Psychodynamics
B. Psychodynamics Concept Map
C. Life Chart (refer to sample given)
D. Diagnostic and Statistical Manual of Mental Disorder
Chapter III: Planning and Implementation
A. Nursing Care Plan
B. Psychotherapies
C. Nurse Process Recording (NPI only the significant interaction)
Chapter IV: Psychopharmacology
Chapter V: Discharge Plan (M.E.T.H.O.D.S.)
Chapter VI: Evaluation (Prognosis and Recommendations)
Appendices (Pictures, Letters, etc)
Glossary
Bibliography
 Make a scrapbook
Note:

 Chief Complaint: Exactly why the patient came to the psychiatrist, preferably in the
patient’s own words; If this information does not come from the patient, note who
supplied it. The patient’s explanation, regardless of how bizarre or irrelevant it should
be recorded verbatim in the section of the chief complaint.

 Personal Identification: brief, non-technical description of the patient’s appearance and

behavior as a novelist may write

 Personality: the patient’s illness and attitudes and beliefs, moral values, standards and
reaction to stress

 Psychosexual History: e.g. how the patient acquired sexual information, varieties and
frequency of sexual practice and fantasy, marital history with details of engagement,
marriage and pregnancies and their outcome. In females there should be careful inquiry
about psychiatric disturbance during and after pregnancy.

 Current Social Situation: where does the patient live – neighborhood and particular
residence of the patient; is home crowded; privacy of family members from each other
and from other families; sources of family income and difficulties obtaining it; who is
caring for the children.
Biological father/mother/brothers/sisters; state their age, health, education,
occupations, psychological functioning and job history. Please include the adaptive or
step parents and others. Upbringing (family constellation, socioeconomic status,
religion). School and occupational history (grade completed and age stopped, for what
reason, ability, performance and behavior in school). Type of work and job, and its
history. Sexual and marital history (details of not only sexual experience, but also of the
family dynamics and patient’s may be of importance. Premorbid personality of patient
before the onset of an acute psychiatric illness. Describe briefly his premorbid activities,
interest, general mood and social patterns.

 Assets: Medicare requires statements regarding the patient’s assets. Briefly mention
patient’s attributes such as talents, compliance, supportive people in the patient’s life,
insurance status, education and job status, housing wealth that may contribute to the
patient’s treatment.

 Dreams, Fantasies and Value Systems: If patient has nightmares, what are their
repetitive themes? Can a patient describe a recent dream and discuss its possible
meanings? Fantasies and daydreams are another value source of unconscious material.
What are the patient’s fantasies about the future? If the patient could make any change
in his or her life, what would it be? What are the patient’s most common favorite
current fantasies? Does the patient experience daydreams? Are the patient’s fantasies
grounded in reality or is the patient unable to tell the difference between fantasy and
reality? Ask the patient’s system of values both social and moral, including values that
concerns work, money, play, children, parents, friends, sex, community concerns and
cultural issues. For instance, are children seen as a burden or a joy? Is work experienced
as a necessary evil, an avoidable chore or an opportunity? What is the patient’s concept
between right and wrong?

 Spiritual Assessment: Ask the patient; What importance does religion or spirituality
have in your life? Do your religious or spiritual beliefs influence the way you take care of
yourself or illness? How? Who or what supplies you with hope?

 Cultural Assessment: Ask the patient; With what cultural group do you identify? Have
you tried any cultural remedies or practices for your condition? If so, what do you use
any alternative or complimentary medicine/herbs or any practices?
 BEHAVIOR PATTERN ANALYSIS

Points
A. Vital Information
1. Demographic Data/Other Petinent Data
Name of Patient Age
Address Religion 10
Civil Status Date of Admission
Diagnosis Attending Physician
2. Brief Discussion of the disorder or the diagnosis of your client 10
3. Chief Complaints 5
4. History of Illness 10
5. Family History 10
6. Personal History 10
B. Behavior Patterns Interpretation with Reference
Enumerate all the signs and symptoms or the manifestation of client, classifying
them according to the items below, state the signs and symptoms then describe how 20
the client manifested it. Lastly, document the signs and symptoms by explaining its
psychodynamics; indicate the reference (e.g. delusion of grandeur {describe the clients
behavior then explain the cause of the grandiose delusion} )
1. Appearance and Behavior
a. 5

b.
2. Emotional State
a. 5

b
3. Thought and Perceptual Disturbances
a. 5

b.
4. Speech and Stream of Talk
a. 5

b.
5. Cognition, Memory and Orientation
a. 5

b.
C. Evaluation/Evaluate client based on:
a. Behavior Patterns (signs and symptoms of the client) 10
b. LTO (based on the LTO formulated in the NPI
Total points 110