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UNIVERSITY OF THE VISAYAS

COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No. (032) 416-1538

RELATED LEARNING EXPERIENCE WORKBOOK

MEDICAL - SURGICAL NURSING

Name of Student: ______________________________________


Level & Section: _______________________________________
Note: To be submitted with clearance at the end of the semester.
Rev. 4, 06-2015

UNIVERSITY OF THE VISAYAS


COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No. (032) 416-1538

RELATED LEARNING EXPERIENCE MONITORING SHEET


Name of Student: ___________________________
Area: Medical - Surgical Ward
AREAS OF EVALUATION

Section: ________________________________
Date Covered: ___________________________
GRADE TOTAL WEIGHT

ATTENDANCE
1 Attendance

5%

PROGRESSIVE ASSESSMENT
1 Pre-test
2 Post-test

30%

TERM EVALUATIVE EXAM

25%

DEPORTMENT
1 RLE Attitudinal Scale
2 Major Offenses
3 Light Offenses

5%

PRACTICAL ASSESSMENT
1 PCNR
2 RLE Evaluative Record
3 Case Study
4 Nursing Conferences
5 Nursing Procedures
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.

35%

Signature of Student: ___________________________________________________


Signature over printed name/Date
Signature of Clinical Instructor: ___________________________________________
Signature over printed name/Date

COMMENTS

UNIVERSITY OF THE VISAYAS


COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No. (032) 416-1538

RELATED LEARNING EXPERIENCE ATTITUDINAL SCALE


Name of Student: ___________________________
Area: _____________________________________

Level and Section: ___________


Date Covered: ______________

Degree of Performance and Quality Classification


5 - Excellent
4 - Above Average
3 - Average
2 - Needs Improvement
1 - Poor

AREAS TO BE ASSESSED

RATING

1 Shows positive attitude towards role required in the area.

2 Accepts responsibility to pursue goals in the care of the client.

3 Demonstrates ability to establish rapport with clients.

4 Self-directed, motivated and willing to assume task assigned.

5 Requests for assistance when needed and willingness to


correct deficiencies.

6 Seeks feedback of work accomplished from supervisors


and instructors.

7 Initiates nursing actions with or without the direction of the


Clinical Instructors.

8 Demonstrates caring and compassionate attitude in client


management.

9 Accept values of others without imposing own value system.

10 Demonstrates respect of clients, supervisors, and peers.


TOTAL POINTS
EQUIVALENT GRADE

Signature of Clinical Instructor: ___________________________________________


Signature over printed name/Date

UNIVERSITY OF THE VISAYAS


COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No. (032) 416-1538

PATIENT CENTERED NURSE'S RECORD


Name of Student: ___________________________
Area: _____________________________________

AREAS OF ASSESSMENT
I.

II.

Level and Section: _____________________


Date Covered: ________________________

POINTS

ACTUAL
SCORE

History and Physical Assessment and


Systems Review

20 points

Anatomy and Physiology

20 points

III. Pathophysiology including interpretation


of Client's Laboratory / Diagnostic Values
IV. Medical-Surgical Management
V.

20 points
20 points

Nursing Management according to


Goals of Care

20 points

VI. Drug Study

10 points/drug

VII. Nursing Care Plan

20 points/ problem

TOTAL POINTS

AVERAGE GRADE

Signature of Clinical Instructor: ___________________________________________


Signature over printed name/Date

EQ
GRADE

MEDICAL SURGICAL ASSESSMENT


HEALTH HISTORY
Date ________ Time ______
Name of Client : _______________________________
Demographic Data: Date of birth ________ Age ___ Gender ____Marital Status ____ Sex: _________
Previous Illness/Hospitalization/Surgeries:_______________________________________________
____________________________________________________________________________________
Client/Family Medical History:
Addiction (drugs/alcohol) _____
Diabetes __________
Mental Disorders _______________
Arthritis ___________________
Heart Disease ______
Sickle Cell Anemia _____________
Cancer ____________________
Hypertension ______
Stroke ________________________
Chronic lung disease _________
Kidney disease _____
Other ________________________
Immunization/Exposure to Communicable Disease: _______________________________________
____________________________________________________________________________________
Allergies: ___________________________________________________________________________
____________________________________________________________________________________
Home Medications: __________________________________________________________________
____________________________________________________________________________________
Developmental Level: ________________________________________________________________
____________________________________________________________________________________
Psychosocial History: (Please indicate how much & how long)
Alcohol use: _________________________________________________________________________
Tobacco use: ________________________________________________________________________
Drug use: ___________________________________________________________________________
Caffeine intake: ______________________________________________________________________
Sociocultural History:
Family structure ______________________________________________________________________
Role in family _______________________________________________________________________
Cultural/ Ethnic group _________________________________________________________________
Occupation/Work Role ________________________________________________________________
Relationships with others _______________________________________________________________
Activities of Daily Living:
Nutrition: Type of Diet __________________________ Usual weight __________________________
Eating Patterns _______________________________________________________________________
Types of snacks ______________________________________________________________________
Food likes/dislikes ____________________________________________________________________
Fluid intake: Type ______________________________ Amount _______________________________

Elimination (usual patterns): Urinary _______________ Bowel _____________________


Sleep/Rest:
Usual sleep patterns ________________________________________________________________
Relaxation techniques/patterns _______________________________________________________
Activity/Exercise:
Usual exercise patterns _____________________________________________________________
Ability to perform self-care activities __________________________________________________
Date Admitted: _____________________ Time: _____________
How admitted: ( )Ambulatory ( )Wheelchair ( )Stretcher ( )Ambulance
( )Other:
Accompanied by: ____________________________
Chief Complaint / s: _______________________________________________________________
Admitting Diagnosis/Impression: _____________________________________________________
Final Diagnosis : __________________________________________________________________
Operation Performed: ______________________________________________________________
Attending Physician: _______________________________________________________________
Vital Signs: (Upon Assessment)
Temp: _____________ Resp: __________ Pulse: ____ BP: ____
Pain Rating Scale ___________________ Height _____________ Weight (Actual) ______
General physical / built: ____________________________________________________________
Mental Alertness:
( ) Oriented ( ) Disoriented ( ) Unresponsive
( ) Coherent ( ) Incoherent
Body Position During Assessment : __________________________
Hygiene and Grooming: ___________________________________

Musculoske
letal

Cardipul monary

Respiratory

Cardiovasculart

SYSTEMS ASSESSMENT
( ) Chest Pain
( ) Orthopnea
( ) Hypertension
( ) Pacemaker
( ) Apical Pulse

Rhythm: ( ) Regular
( ) Irregular
Type: ( ) Pounding
( ) Thready
( ) Weak

Cough
( )Productive
( )Non-productive
( )Dyspnea
( )Orthopnea

Radial ( ) Palpable
Pulses: ( ) Non- Palpable
( ) Others

Chest
( )Symmetrical
Appearance: ( )Asymmetrical

Edema: ( ) Present
( ) Pitting
( ) Non-Pitting
( ) Absent

Breathing ( )Labored
Pattern: ( )Non-labored

Breathing ( )Clear all lobes


Sounds: ( )Equal& Bilateral
( )Crackles
( )Rhonchi
( )Wheezes

1.Mobility Status: ( ) Ambulatory ( )Ambulatory with Assist ( )Bedrest ( )Transfer with Assist ( )Walker
2.Assistive Devices: ( )None ( )Cane ( )Wheelchair ( )Crutches ( )Prosthesis ( )Pillows # ______
Others: ______________________________________________________________________
3.Limitations
( )None ( )Weakness
( )Fatigue
( )Other __________________________________
______________________________________________________________________________
4. Do you have enough energy for desired activity? ( )Yes ( )No
Describe _________________________
_____________________________________________________________________________________________
5.Activities of Daily Living: I= Independent
A= Assist
D= Dependent
( )Feeding ( )Bathing
( )Grooming
Describe______________________________________
( )Toileting ( )Dressing ( )Other_____________________________________________________
( )Pain
( )Joint Stiffness
( )Swelling

( )Cramping
( )Spasms
( )Tremors

Muscle strength: (S=Strong W=Weak N=None)


Grips: ( )Right ( )Left
Pushes: ( )Right ( )Left

Nursing Diagnosis

Elimination

Genito
urinary

Gasro
Intestinal

Nutritional / Metabolic

Integumentary

Neurological

( )Headache / Pain
( )Motor Disturbances
( )Seizures
( )Numbness
( ) Tingling

1. Visual Impairment ( )None ( )Wears Glasses


( )Contacts
( )Blind ___Right ___Left
2. Hearing Impairment ( )None ( )Hard of Hearing
( )Deaf
___Right ___Left
( )Uses Hearing Aid
___Right ___Left
3.Speech Impairment
( )None
( )Cannot Express
( )Slurring ( )Cannot Understand
( )Mute
( )Tracheostomy
( )Slutters ( )Laryngectomy
( )Normal
( )Pale
( )Flushed
( )Cyanotic
( )Jaundiced
( )Other

Temperature: ( )Hot
( )Warm
( )Cool
Turgor ( )Good
( )Fair
( )Poor
( )Skin Intact

Level of ( )Alert
Consciousness: ( )Stuporous
( )Semicomatose
( )Comatose
( )Combative
( )Anxious
( )Confused

Oriented to: ( )Person


( )Place
( )Time
( )Event

4.Communication/Language Barrier: ( )Yes ( )No


5.Level of Education: ________________________
6.Pain/Discomfort:
Describe: ______________________________
A.Precipitating Factors:
Describe_______________________________
_______________________________________
B.How is pain controlled?
Describe _______________________________
_______________________________________

Describe: ( )Decubitus
( )Rashes
( )Wounds
( )Lesions

( )Bruises
( )Scars
( )None Visible
( )Other

1. Special Diet : ( )Yes ( )No


Describe:____________________________________________________________________________________
2.Frequency of Meals:
Describe: ____________________________________________________________________________________
3.Recent changes in appetite / eating / patters ? ( )Yes ( )No
Describe: ____________________________________________________________________________________
____________________________________________________________________________________
4.Have you experienced
( )Indigestion ( )Vomiting
( )Difficulty Chewing
( )Choking with meals
current / recent
( )Nausea
( )Sore Mouth ( )Difficulty Swallowing
( )Full Feeling in Throat
5.Recent Weight Loss / Gain ? ( ) Yes
( )No
Describe ____________________________________________________________________________________
General
( )Well Nourished Oral
( )Dry
Appearance: ( )Malnourished
Mucosa: ( )Moist
( )Obese

Urine Color: ( )Clear


( )Dark

( )Hematuria
( )Cloudy
( )Other

Bowel ( )Present
Sounds: ( )Absent

( )Bladder Distention
( )Foley Catheter

( )Ostomies
( )Gastrostomy
( )Nasogastric
( )Jejunostomy

( )Suprapubic Catheter
( )Urostomy
( )Dialysis Access

1. Bowel: ( )No Problems


( )Diarrhea
( )Pain
( )Blood in stool
( )Constipation
( )Incontinence
( )Hemorrhoids
( )Other
Describe ____________________________________________________________________________________
2. Bladder: ( )No Problems
( )Incontinence
( )Frequency
( )Burning ( )Nocturia
( )Retention
( )Dribbling
( )Dysuria
( )Urgency ( )Other
Describe ____________________________________________________________________________________
Male:

Reproductive

Pupil Size: ( )PERL


( )Other
Right ______
Left ______

( )Penile Discharge
( )Tenderness

Female:

LMP_______
Para_______
Gravida________
( )Contraceptive

( )Pain
( )Scrotal Mass

( )Inguinal Mass
( )Breast Lumps

Last Pap Smear______


( )Itching
( )Breast lumps
( )Abnormal Bleeding ( )PMS
( )Discharge

( )Penile Implant
( )STDs

Pain with:
( )Menstruation
( )Intercourse
( )Other

( )Other

Pregnant:
( )Yes
( )No

Role
Relationship
Coping/
Stress

1.Home Environment: ( )Lives with Spouse ( )Lives Alone ( )Lives with Family ( )Lives with Friend
2. Who do you rely on for emotional support? ( )Spouse
( )Family
( )Friend
( )Self
( )Other
3. How does your illness/hospitalization/affect your family/significant others?
Describe ________________________________________________________________________________________

1. Have you had any recent changes in your life (job, divorce,death,major surgeries,recent abuse)?
( )Yes ( )No
Describe __________________________________________________________________________
2. Do you feel you are dealing successfully with stresses associated with this change?
Describe _________________________________________________________________________________________
( )Difficulty staying asleep

( )Does not feel rested after sleep

2. What helps you sleep?


1. What concerns you most about your illness/hospitalization?
Describe _______________________________________________________________________________________
2. Does your illness and /or hospitalization affect your sexuality/body image? ( )Yes ( )No

Values/
Beliefs

Sleep/
Rest

( )Difficulty falling asleep

SelfPercep
tion

1.Sleep: ( )No Problem

1. Is religion important in your life?

( )Yes

( )No

( )Religion/Faith______________________________

Patients At risk to develop Pressure Sores: Identify any patient at risk to develop pressures by assessing
the seven clinical condition parameters & assigning a score. Patients with intact skin, but scoring 8 or
greater, should have the Nursing Diagnosis Potential Impairment of Skin Integrity.
Directions: Choose the number which best describes the patients status. Total the seven numbers.
Clinical Condition Parameters
General Physical Condition(Health
problem)
Good (minor)
o
Fair (major but stable)
1
Poor (chronic/serious not stable
2
Level of Consciousness (to commands)
Alert (responds readily)
0
Lethargic (slow to respond)
1
Semi-comatose (responds only to verbal
or painful stimuli)
2
Comatose (no response to stimuli) 3
Activity
Ambulant without assistance
Ambulant with assistance
Chairfast
Bedfast

0
2
4
6

Score

Clinical Condition Parameters


Mobility (extremities)
Full active range
Limited movement with assistance
Move only with assistance
Immobile

Score
0
2
4
6

Incontinence (bowel and /or bladder)


None
Occasional (less than 2x in 24 hours)
Usually (more than 2x in 24hours)
No control

0
2
4
6

Clinical Condition Parameters


Skin/Tissue Status
Good (well-nourished/skin intact)
Fair (poorly nourished/skin intact)
Poor (skin not intact)

Nutrition (for age & size)


Good (eats/drinks adequately
-3/4 of meal)
Fair (eats/drinks inadequately
- At least meal)
Poor (unable/refuses to eat/drink
-Less than meal)

Score
0
1
2

0
1
2

Total

Reference : Rick Daniels;Ruth N.Grendell;Fredrick R. Wilkins; Nursing Fundamentals Caring and


Clinical Decision Making;;Second Edition;Delmar Cengage Learning 2010.

INTERPRETATION OF CLIENT'S LABORATORY / DIAGNOSTIC RESULTS


Laboratory
Diagnostic

Date
Performed

Actual Result

Normal Value
(Reference)

Significance of the
Result

NURSING SYSTEM REVIEW CHART


Name of Client: ____________________________________________________________
Height: ___________ Weight: ____________
Vital Signs:
Temperature:
Pulse:
Respiratory Rate:

Date: __________________

Blood Pressure:

Instructions: Place an "X" mark on the area of abnormality. Indicate location of problem in the figure by placing an "X" mark and
and write your comments on the space provided for.
EENT
Impaired vision
Blind
Reddened
Drainage
Hard of hearing
Deaf
Edema
Lesion
Assess eyes, ears, nose, and throat abnormalities.
No problem

Pain
Gums
Burning
Teeth

RESPIRATORY SYSTEM
Assymmetrical

Tachypnea

Apnea

Rales

Cough

Barrel chest

Bradypnea

Shallow

Rhonchi

Sputum

Dyspnea

Orthopnea

Labored

Wheezing

Pain

Cyanotic

Dimished breath sounds

Assess respiatory rate, rhythm, depth, pattern, breath sounds,


and comfort
CARDIOVASCULAR
Arrhythmia

Tachycardia

Numbness

Diminished pulses

Edema

Fatigue

Irregular

Bradycardia

Murmur

Tingling

Absent pulses

Pain

Assess heart sounds, rate, rhythm, blood pressure


circulation, fluid retention, and comfort.

No problem

GASTROINTESTINAL
Obese
Distention
Mass
Dysphagia
Rigidity
pain
Assess abdomen, bowel habits, swallowing, bowel
sounds, and comfort
No problem
GENITO-URINARY AND GYNE
Pain

Urine color

Vaginal bleesing

Hematuria

Discharges

Noctoria

Assess urinary grequency, control, color, odor,


comfort, beeding, and discharges.
No problem
NEURO/NERVOUS SYSTEM
Paralysis
Stuporous
unsteady
Letheargic
Comatose
Seizures
Confused
Vertigo
Tremors
Vision
Grip
Asses motor function, sensation, LOC, strength, grip
gait, coordination, orientation, speech.
No problem
MUSCULOSKELETAL and SKIN
Appliance
Stiffness
Itching
Petechiae
Hot
Drainage
Prosthesis
Swelling
Lesion
Poor turgor
Cool
Deformity
Wound
Rash
Skin color
Flushed
Atrophy
Pain
Ecchymosis
Diaphoretic
Moist
Assess mobility, motion, gait, alignment, joint function
skin color, texture, turgor, integrity.
No problem

UNIVERSITY OF THE VISAYAS


College of Nursing
Banilad, Mandaue City 6014
A. ANATOMY AND PHYSIOLOGY

B. PATHOPHYSIOLOGY
Name of Client: ___________________________________________________________________________
1. Diagnosis/Impression: Definition:
_____________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2. Schematic Diagram: Trace the psychopathophysiology (Inductive type from etiology to prognosis).

C. MEDICAL-SURGICAL MANAGEMENT
IDEAL MANAGEMENT

ACTUAL MANAGEMENT

D. OUTLINE OF NURSING MANAGEMENT: ( Give all ideal Nursing Management according to Goals of
Care)

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DRUG STUDY
Name of Client: ___________________________________ Diagnosis: __________________________________ Bed No. __________ Date: ______________
Name of Drug
Generic and
Brand Name

Date
Ordered

Classification

Dose
Frequency
Route & Time

Mechanism of
Action

Specific
Indication

Reference:

Side Effects

Nursing Responsibilities

NURSING CARE PLAN

Name of Client: ________________________________


Assessment

Nursing Diagnosis

Scientific Basis:

Reference:

Client Goal

Score: _________ Grade: ______________


Diagnosis: ____________________ Bed No. ____________ Date: _________________________
Outcome Criteria

Nursing Intervention

Rationale

Actual Evaluation