SYSTEM NORMAL ABNORMAL REMARKS

VITAL SIGNS TEMPERATURE: 36C The child’s vital sign are

PR= 80 within normal range
RR= 26 according to her age.
BP= 90/60
SKIN  Light brown  Presence of scar on The child has a healthy skin
 Uniform in color her sural but does have a scar on her
 No rashses right sural because of burn
 Skin is moist from the motor exhaust.
HAIR  No masses and There is no abnormal
scalp lesion findings in the hair.
 Absence of
infection
NAIL  Pinkish nails  Clubbing nails The child has a clubbing
 Capilliary refill test nails associated to
returns in less than congenital heart disease.
2 seconds
HEAD  No nodules and There is no abnormal
masses findings in the head.
 Asymmetrically
and round without
lesions
EYES  Eyes are There is no abnormal
symmetrical findings in the eyes.
 Eyebrows
symmetrically
aligned
 Eyes has no
discoloration
EARS  Symmetrically and There is no abnormal
color is the same as findings in the ears.
the color of the
face.
 No nodules
NOSE  Pink mucosa There is no abnormal
 No nasal discharge findings in the nose.
 No nodules and
lesion
MOUTH  Have complete There is no abnormal
teeth findings in the mouth.
 Lips is moist
 Has no nodules and
lesions
 No bad breath
CHEST AND RESPIRATORY  Irregular beats of Irregular beats and crackles
SYSTEM the heart has been heard on the
 Presence of patient’s chest and
crackles respiratory system.
Patient’s Profile
Patient Rizlyka Urua is a 10-year-old girl who was born February 20, 2009. She is the daughter of Mr.
and Mrs. Romulo Urua Jr. and currently lives at Amulung, Cagayan. He is a Filipino and believes in the
teaching of Roman Catholics. She was admitted at Cagayan Valley Medical Center Tuguegarao last January
23,2020 and with chief complaint of chest pain, difficulty of breathing and headache when she experienced that
pain they immediately go to CVMC.

History of Present Illness

Prior to the patient hospitalization there were no other health complaints except for her easily getting
tired or fatigue.

History of the Past Illness

According to the father of patient Rizlyka the child has a full immunization. The patient doesn’t have
experienced having chicken pox, and measles.

Family Health History

The patient’s grandfather has a history of heart disease and hypertension. And her nephews on her
mother side experiences asthma.

Environmental History
According to the assessment of patient Rizlyka she has a sedentary lifestyle. Her only exercise is when
she walks going to her school and going home. They’re rarely buy vegetables to eat because they plant their
own veggies in their backyard.

Interpersonal Factors
Patient Rizkyla spoken language is Ilocano and she doesn’t have a cultural belief that connected to her
condition now.

Current Health Information

According to the father of patient Rizlyka the factors that affect her health is she always junkfoods and
rarely eats fruits and vegetables. Another factor is that when she is playing with her peers she easily get tired.
NAME: Jhoanna Mae Romias
DATE: January 23, 2020
AREA: Pedia Ward, Cagayan Valley Medical Center
CLINICAL INSTRUCTOR: Mrs. Rona Cruz

LEARNING FEEDBACK DIARY:

This was not my first time exposure in hospital and render nursing care to my patient and enhance my

skills in the hospital. Our general objective is to conduct patient care as well as to gain more knowledge at the

Pedia Ward. On the other hand, my specific objective was to apply my knowledge and skills regarding nursing

measures and procedures related and needed by the patient such as getting and recording the vital signs.

Though I am a bit nervous to interact because our patient this time has a special case. I took this opportunity to

challenge myself and take courage because in the near future I will be handling not one patient but more than

one.

Our clinical instructor Mrs. Cruz endorsed the patients individually and let us assess our patient one on

one to determine what is the diagnosis of the patient. I introduced myself and my purpose on my patient to gain

trust and cooperation which is not hard because she’s willingly to cooperate. I did my best in doing my

responsibilities as a student nurse. One thing I learned is to improve and be a competent nurse in the future.

Despite the status or the disease of the client, we as health care providers must always treat our patient

equally, respect them and be able to provide health care needs needed by the patient to alleviate their pain

and cure their illness.

Comparing to my past duties in hospital, I had gained confidence to interact to my patient to establish

rapport. I was able to get the necessary details needed for the Vital sign record, Physical assessment and

Patient’s Health History. Because my patient cooperated well, I was able to provide a proper and accurate

physical assessment for her. I am looking forward for more challenging duties and activities in the future. And

to give care to other patient.

NAME: Jhoanna Mae Romias
DATE: January 24, 2020
AREA: Pedia Ward, Cagayan Valley Medical Center
CLINICAL INSTRUCTOR: Mrs. Rona Cruz

LEARNING FEEDBACK DIARY:

For today’s duty, our clinical instructor gave each one of us three patients to take care of. She let us stay

in the bedside of our patient. She orders us to take the vital signs of our patients every 2 hours and refer to her

if there are any abnormalities observed. She also let us formulate one nursing care plan to our patient that is to

be pass at the end of the duty.

Taking care of the newborn patients is not an easy task to do. Taking their vital signs is challenging

especially if the baby is not cooperating. One of the parents that I am taking care of is a first time parent. I

teach him on how to properly care the cord of the baby. I told him to expose the baby’s cord to avoid it in

getting moist and to avoid infection. I also told him to stop cleaning the cord with alcohol.

I have learned that having patient and passion in what you are doing, you can easily do or accomplish

your goal.
NAME: Jhoanna Mae Romias
DATE: January 29, 2020
AREA: Pedia Ward, Cagayan Valley Medical Center
CLINICAL INSTRUCTOR: Mrs. Rona Cruz

LEARNING FEEDBACK DIARY:

For this day of duty, our clinical instructor didn’t give us a patient. She gave this day for us to find cases

that will serve us our case presentation. She let us take a look at the patient’s charts. Finding special cases to

present is challenging because some cases at pedia ward are common cases and some are in the isolation

room so we were not able get information from them. Our instructor helps us to find and decide which case we

will study and also other staff nurses suggest some cases that are good for case study.

As we go through, we discover different diagnosis such as hirschsprung’s disease. At first we chose

this as our case but we still come up with a decision that we will just get the simple one yet rare to pedia

patients which is the hypertension stage 2. We interviewed the patient and gather necessary information.

In this day of duty, I have learned that patient, courage and teamwork is needed to come up with a

good outcome for our output.

NAME: Jhoanna Mae Romias
DATE: January 30, 2020
AREA: Pedia Ward, Cagayan Valley Medical Center
CLINICAL INSTRUCTOR: Mrs. Rona Cruz

LEARNING FEEDBACK DIARY:

On our 4th day duty in the ward, I was given a task to handle three patients on my own. I have to get

and monitor their vital signs throughout the duty. Doing it alone gives me the comfort and strength to stand up

on my own and realized that I also got what it takes when I’m alone. Each of us was given a patient of our own.

My friend also asked me to help her on encouraging her patient to have suctioning for her own good. For me,

this was my biggest achievement for me for this day because we helped the patient to do the right decision for

her own good. We properly educated her on her condition and to the procedure that she’s about to undergo.

Our clinical instructor is a good motivator, a good disciplinarian. She gives a lot of pointers. She is

always there to teach and guide us in everything. Sometimes she can be very strict but she can still crack a

joke that makes us feel better. She also let us make nursing care plan again on one of our patient to improve

our skill and critical thinking and also widen our knowledge on how to care for our patient properly.

For this day of our duty, I have learned to be independent in taking care of my patients. I have also

realized that having enough knowledge is one of the most important thing when you are on duty because it is

necessary to share knowledge to your patients especially when they are not aware or not well educated in their

situations.
NAME: Jhoanna Mae Romias
DATE: January 31, 2020
AREA: Pedia Ward, Cagayan Valley Medical Center
CLINICAL INSTRUCTOR: Mrs. Rona Cruz

LEARNING FEEDBACK DIARY:

Knowing the persons who belong to the nursing team of the school is important because as a health

care system, harmonious working relationship is needed to facilitate productive and effective teamwork.

Eventually, the needs of the patients are met thus fulfilling the ultimate goal of the system, which is delivery of

healthcare services. But before achieving this goal, there should be also respect, honesty, and dedication to

the things that we are doing and knowing our responsibilities and role as a health care provider by heart.

Touching others people lives and being able to cater to their needs is an achievement that no other

thing can replace. The feeling of fulfilment I have me makes me believe that as long as I love what I’m doing

there can be a thousand of people or even hundreds or thousand people in this world that I can offer my

undying service.

It was my last day duty in pedia ward for this semester which I came to familiarized more and witness

how challenging to be one of the health care provider. In our five-day duty in the ward, I realized my obligation

to always bear things in mind. My skills were also enhanced. The duty was full of chismisan (bonding session).

Our clinical instructor is willing to share things that we don’t know yet. She is always there to remind us things

we seldom do on duty but we know that it is for our own good to become a competent nurse someday.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Activity After 8 hours of  Monitor vital  To After 8 hours of
“Madali po akong intoleranc duty the patient signs. determine duty the patient
mapagod kahit e related will be able to if there is was able to play
malapit lang yung to fatigue. manage changes in with the other
nilalakad ko at sa activities within BP, PR and patient and was
tuwing naglalaro individual limits. RR. able to balance
kami” as verbalized  Plan care to  This is to rest periods.
by the patient. carefully balance reduce
rest periods with fatigue to
“Sumasakit yung activities. the
dibdib ko kapag patient.
napapagod ako”  Assess physical  To know if
mobility status. there is
OBJECTIVE: any
 Experiences changes to
difficulty in the
breathing patient’s
 Pain scale: 9 condition
out of 10. specifically
10 as the on physical
highest  Promote comfort aspect.
 Clubbing of the measures and  To
nail provide relief enhance
from pain. ability to
participate
 Provide positive in
atmosphere activities.
while  This helps
acknowledging minimize
the difficulty of situation.
the situation for
the patient.