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Don Mariano Marcos Memorial State University

South La Union Campus


INSTITUTE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Tel. 072.682.0663/ichams.dmmmsu-sluc.com
Embracing World–class Standards NURSING DEPARTMENT Care to Learn, Learn to Care

CLINICAL TEACHING PLAN


MEDICAL WARD 1
University Philosophy : Total human development with appropriate competencies
University Vision : A premium and globally competitive university
University Mission : Provides relevant quality instruction, research and extension
University Goal : To lead in transforming human resources into productive, self-reliant citizens and responsible leaders

Institute Goals : 1. To provide quality graduates in the medical and health allied fields.
2. To provide effective community health care services in the field of medical and health allied courses.
3. To offer courses relevant to the health needs and situation of the times.
4. To reach out to the less privileged but deserving high school graduates who cannot afford to enroll in the private schools
in the region
Program Outcomes
1. Apply knowledge of physical, social, natural and health sciences and humanities in the practice of nursing.
2. Provide safe, appropriate and holistic care to individuals, families, population group and community utilizing nursing process.
3. Apply guidelines and principles of evidence based practice in delivery of care.
4. Practice nursing in accordance with existing laws, legal, ethical, and moral principles.
5. Communicate effectively in speaking, writing, and presenting using culturally appropriate language.
6. Document to include reporting up-t-date client care accurately and comprehensively.
7. Work effectively in collaboration with inter-, intra-, and multi-disciplinary and multi-cultural teams.
8. Practice beginning management and leadership skills in the delivery of client care using a system approach.
9. Conduct research with and experienced researcher.
10. Engage in lifelong learning with a passion to keep current with national and global developments in general, and nursing and health developments in particular.
11. Demonstrate responsible citizenship and pride of being a Filipino.

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Objectives
After 1 week of clinical exposure, students will be able to:
 Be oriented to the clinical set-up, the nursing and midwifery personnel, the medical staff and existing rules and regulations of the area
 Gain more skills, knowledge and attitude in providing health care to patients
 Apply nursing and health care theories learned in the actual situations in the clinical area
 Promote and provide a competent standard quality health care to all patients by ensuring themselves to adhere to the ethical standards prescribed in the
nursing code
 Promote and adhere to the midwifery process specifically and correctly, to achieve the specific goals for the patients
 Acquire skills, knowledge and acceptable attitude in the care of the family and community

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ACTIVITIES COURSE CONTENT
Day 1 Definition:
6:45-7:00 Checking of attendance. Checking of uniform and paraphernalias.
The choice of formula by tube feeding is influenced by the status of GI tract and the nutritional needs of the
Discussion of activities for the day. Assigning of patient’s
patient. Formula characteristics that are considered include the chemical composition of the nutrient source
7:00-8:00 Endorsement, rounds, medication preparation.
(protein, carbohydrates, fat) caloric density, osmolality, fiber content, vitamins, minerals, electrolytes, and
8:00-8:30 Initial vital signs taking and bedside care. Establish Nurse- Patient
cost. Enteral formulas contain 70% to 85% free water and are not designed to meet total fluids needs (Seres,
Interaction
2016).
8:30-9:00 Checking of patient’s chart
9:00-9:15 First batch snack break Administration Methods:
9:15-9:30 Second batch snack break
9:30-11:00 Discussion and Question and answer about patient’s case per The tube feeding method chosen depends on the location of the tube in the GI tract, patient tolerance,
student (1st batch). Plotting of TPR sheet convenience, and cost. Large-bore (larger than 12Fr) gastric tubes can be uncomfortable and their
11:00-11:30 Sample charting/ Drug study usefulness for tube feedings is limited: however, they may be used for administration of feedings for several
11:30-12:00 First batch lunch break days (Brantley & Mills, 2012). Small-bore tubes manufactured for tube feedings are better tolerated:
12:00-12:30 Second batch lunch break however, they require diligent monitoring and frequent flushing to remain patent.
12:30-1:00 Continuation of Nurse Patient Interaction, bedside care procedures BE ALERT for the following assessment findings:
1:00-1:30 Discussion and Question and answer about patient’s case per
student (2nd batch)  Tube placement, patients position (head od bed elevated 30-45 degrees), and formula flow rate.
1:30-2:00 Continuation of NPI, V/S taking and plotting in the monitoring sheet.  Patient’s ability to tolerate the formula; observe for fullness, bloating, distention, nausea, vomiting,
2:00-2:30 Closing of chart and stool pattern.
2:30-3:00 Post- conference, Topic discussion: NGT Feeding  Clinical responses, as noted in laboratory findings (blood urea nitrogen, serum protein, prealbumin,
electrolytes, kidney function, hemoglobin, hematocrit).
 Signs of dehydration (dry mucous membranes, thirst, decreased urine output).
 Amount of formula actually taken in by the patient.
 Elevated blood glucose level, decreased urinary output, sudden weight gain, and periorbital or
dependent edema.
 Infection control practices: Replace any formula given by an open system every 4-8 hours with fresh
formula; change tube feeding container and tubing every 24 hours.
 Check gastric residual volume before each feeding or in the case of continuous feedings, every 4
hours; return the aspirate to the stomach.
 Intake and output.

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Day 2 Definition:
6:45-7:00 Checking of attendance. Checking of uniform and paraphernalias.
If the patient’s body must remain in alignment after spinal surgery, use the logrolling technique when turning
Discussion of activities for the day. Assigning of patient’s
him to protect him from injury and discomfort and to prevent complications. Logrolling requires at least two
7:00-8:00 Endorsement, rounds, medication preparation.
people (three for a large patient). The two-person technique is:
8:00-8:30 Initial vital signs taking and bedside care. Establish Nurse- Patient
Interaction  Wash your hands. Provide privacy and explain the procedure to the patient.
8:30-9:00 Checking of patient’s chart  Perform a baseline assessment of his neurologic status, including his mental status, movement, and
9:00-9:15 First batch snack break sensation.
9:15-9:30 Second batch snack break  Use a turning sheet whenever possible, making sure it extends from above his shoulders to below
9:30-11:00 Discussion and Question and answer about patient’s case per his hips. Cross his arms over his chest to protect them from injury.
student (1st batch). Plotting of TPR sheet  Position yourself and your colleague facing the patient. Lower the side rail and place a pillow
11:00-11:30 Sample charting/ Drug study between his legs.
11:30-12:00 First batch lunch break  To synchronize your movements with your colleague’s, count, “One, two, three, go.” Gently turn the
12:00-12:30 Second batch lunch break patient so he rolls like a log-head, shoulders, spine, hips, and knees turning simultaneously.
12:30-1:00 Continuation of Nurse Patient Interaction, bedside care procedures
 Support his back, buttocks, and legs with pillows to maintain a side-lying position.
1:00-1:30 Discussion and Question and answer about patient’s case per
 Raise the side rails and reassess his neurologic status and comfort level.
student (2nd batch)
 Document the procedure and his response in the medical record.
1:30-2:00 Continuation of NPI, V/S taking and plotting in the monitoring sheet.
2:00-2:30 Closing of chart  Don’t try to logroll the patient without enough help. Besides injuring you could hurt yourself.
2:30-3:00 Post- conference, Topic discussion: LOG ROLLING  Don’t move the patient until both people are prepared to move in unison.
-Rotational Quiz  Don’t twist the patient’s head, spine, shoulders, knees, or hips while logrolling.

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Day 3 Definition:
6:45-7:00 Checking of attendance. Checking of uniform and paraphernalias.
Cardiac monitoring is a form of electrocardiography (ECG) that enables continuous observation of the heart’s
Discussion of activities for the day. Assigning of patient’s
electrical activity. It’s an essential assessment tool in emergency department and is used to continually
7:00-8:00 Endorsement, rounds, medication preparation.
monitor the patient’s cardiac status to enable rapid identification and treatment of abnormalities in rate,
8:00-8:30 Initial vital signs taking and bedside care. Establish Nurse- Patient
rhythm, or conduction.
Interaction
8:30-9:00 Checking of patient’s chart A TEST WITH 12 VIEWS.
9:00-9:15 First batch snack break
9:15-9:30 Second batch snack break The 12 lead ECG measures the hearts electrical activity and records it as waveforms. It’s one of the most
9:30-11:00 Discussion and Question and answer about patient’s case per valuable and commonly used diagnostic tools; however, it isn’t 100% diagnostic and is used in conjunction
student (1st batch). Plotting of TPR sheet with other tests. The standard 12 leads ECG uses a series of electrodes placed on the patients extremities
11:00-11:30 Sample charting/ Drug study and chest wall to assess the heart from 12 different views (Leads). The 12leads include three bipolar limb
11:30-12:00 First batch lunch break leads (I,II and, III), three unipolar augmented limb leads (aV R, aVL,and aVF), and six unipolar precordial limb
12:00-12:30 Second batch lunch break leads (V1 to V6). The limb leads and augmented leads show the heart from the frontal plane. The precordial
12:30-1:00 Continuation of Nurse Patient Interaction, bedside care procedures leads show the heart from horizontal plane
1:00-1:30 Discussion and Question and answer about patient’s case per UP, DOWN AND ACROSS
student (2nd batch)
1:30-2:00 Continuation of NPI, V/S taking and plotting in the monitoring sheet. Scanning up, down, and across the heart, each lead transmits information about a different area. The wave
2:00-2:30 Closing of chart forms obtained from each lead vary depending on the location of the lead in relation to the wave of electrical
2:30-3:00 Post- conference, Topic discussion: ECG stimulus, or depolarization, passing through the myocardium.
FROM TOP TO BOTTOM
The six limb leads record electrical activity in the hearts frontal plane. This plane is a view through the middle
of the heart from top to bottom. Electrical activity is recorded from the anterior to posterior axis.

AND, FINALLY, HORIZONTAL


The six pericordial leads provide information on electrical activity in the heart’s horizontal plane, a transverse
view through the middle of the heart, dividing it into upper and lower portions. Electrical activity is recorded
from a superior or an inferior approach.
PERICORDIAL LEAD PLACEMENT

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To record the 12 lead ECG, place electrodes on the patient’s arms and left leg and place a ground led on the
patient’s right leg. The three standard limb leads (I, II and III), and the three augmented leads (aV R, aVL,and
aVF) are recorded using this electrodes.
Then to record the pericardial chest leads, place electrodes as follows:
 V1- fourth intercostal space, right sternal border
 V2- fourth intercostal space, left sternal border
 V3- mid way between V2 and V4
 V4- fifth ICS, left midclavicular line
 V5- fifth ICS, left anterior axillary line
 V6- fifth ICS, left mid axillary line

RIGHT PERICORDIAL LEAD PLACEMENT


Right pericardial leads can provide specific information about the function of the right ventricle. Place the six
leads on the right side of the chest in a mirror image of the standard pericorial lead placement, as follows:
 V1R – fourth ICS, left sternal border

 V2R – fourth ICS, right sternal border

 V3R – half way between V2R and V4R

 V4R – fifth ICS, right midclavicular line

 V5R – fifth ICS, right anterior axillary line

 V6R - fifth ICS, right mid axillary line.

POSTERIOR LEAD PLACEMENT


Posterior leads can be used to assess the posterior side of the heart. To ensure an accurate reading, make
sure the posterior electrodes V7, V8 and V9 are placed at the same horizontal level as the V6 lead at the fifth
intercostal line. Place the V7 at the posterior axillary line, lead V9 at the paraspinal line, and lead V8 halfway
between leads V7 and V9

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Day 4 Definition:
6:45-7:00 Checking of attendance. Checking of uniform and paraphernalias.
A reduction below normal in the number of erythrocytes, the quantity of hemoglobin, and the volume of
Discussion of activities for the day. Assigning of patient’s
erythrocytes (hematocrit). Results from decreased erythrocyte production, increased erythrocyte destruction,
7:00-8:00 Endorsement, rounds, medication preparation.
or acute or chronic blood loss.
8:00-8:30 Initial vital signs taking and bedside care. Establish Nurse- Patient
Interaction TYPES OF ANEMIA:
8:30-9:00 Checking of patient’s chart
1. Iron Deficiency Anemia - most common type of anemia; 10% to 30% of all adults in the united states
9:00-9:15 First batch snack break
have iron deficiency anemia. Causes include insufficient intake, chronic blood loss, excessive
9:15-9:30 Second batch snack break
menstrual bleeding, iron malabsorption, or increased needs for iron such as that which occurs in
9:30-11:00 Discussion and Question and answer about patient’s case per
pregnancy.
student (1st batch). Plotting of TPR sheet
2. Thalassemia - decreased production of hemoglobin due to abnormal hemoglobin synthesis.
11:00-11:30 Sample charting/ Drug study
Autosomal recessive genetic disorder commonly found in persons whose origins are near the
11:30-12:00 First batch lunch break
mediterranean sea. May be thalassemia minor or thalassemia major
12:00-12:30 Second batch lunch break
 a) thalassemia minor or trait has one thalassemic and one normal gene with mild clinical
12:30-1:00 Continuation of Nurse Patient Interaction, bedside care procedures
1:00-1:30 Discussion and Question and answer about patient’s case per manifestations and requires no treatment.
student (2nd batch)  b) thalassemia major has two thalassemic genes causing a severe condition.
1:30-2:00 Continuation of NPI, V/S taking and plotting in the monitoring sheet. 3. Megaloblastic Anemia - defective erythrocyte (megaloblast) structure caused by impaired dna
2:00-2:30 Closing of chart synthesis caused by cobalamin (vitamin b12) or folate deficiency. The erythrocytes are large with
2:30-3:00 Post- conference, Topic discussion: ANEMIA fragile membranes that rupture easily.
Rotational Quiz  Pernicious Anemia - The gastric mucosal lining atrophies after years of gastritis. Intrinsic
factor (iF), which is secreted by the parietal cells of the gastric mucosa and is essential for
cobalamin absorption, becomes defective or stops functioning.
 Folic acid deficiency - description: folic acid is required for dna synthesis in erythrocyte
formation.
4. Aplastic Anemia - a life-threatening stem cell disorder with many possible etiological mechanisms
characterized by a hypoplastic, fatty bone marrow and pancytopenia. Cause is most often immune
mediated but can be congenital (Fanconi’s anemia) or acquired from radiation, chemical exposures
such as from solvents like benzene, viral or bacterial infections, pregnancy, or, usually, idiopathic.

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Day 5
6:45-7:00 Checking of attendance. Checking of uniform and paraphernalias.
Definition:
Discussion of activities for the day. Assigning of patient’s
7:00-8:00 Endorsement, rounds, medication preparation. In many cultures, the breast plays a significant role in a woman’s sexuality and self-identity. A breast
8:00-8:30 Initial vital signs taking and bedside care. Establish Nurse- Patient disorder, whether benign or malignant, can cause great anxiety and fear of potential disfigurement, loss of
Interaction sexual attractiveness, and even death. Nurses, therefore, must have expertise in the assessment and
8:30-9:00 Checking of patient’s chart management of not only the physical symptoms but also the psychosocial symptoms associated with breast
9:00-9:15 First batch snack break disorders.
9:15-9:30 Second batch snack break
Male and female breasts mature comparably until puberty, when in females estrogen and other hormones
9:30-11:00 Discussion and Question and answer about patient’s case per
initiate breast development. This development usually occurs from 10 to 16 years of age, although the range
student (1st batch). Plotting of TPR sheet
can vary from 9 to 18 years. Stages of breast development are described as Tanner stages 1 through 5.
11:00-11:30 Sample charting/ Drug study
11:30-12:00 First batch lunch break  Stage 1 describes a prepubertal breast.
12:00-12:30 Second batch lunch break  Stage 2 is breast budding, the first sign of puberty in a female.
12:30-1:00 Continuation of Nurse Patient Interaction, bedside care procedures  Stage 3 involves further enlargement of breast tissue and the areola (a darker tissue ring around the
1:00-1:30 Discussion and Question and answer about patient’s case per nipple).
student (2nd batch)  Stage 4 occurs when the nipple and areola form a secondary mound on top of the breast tissue.
1:30-2:00 Continuation of NPI, V/S taking and plotting in the monitoring sheet.
 Stage 5 is the continued development of a larger breast with a single contour.
2:00-2:30 Closing of chart
2:30-3:00 Post- conference, Topic discussion: BREAST CANCER The breasts are located between the second and sixth ribs over the pectoralis muscle from the sternum to
the midaxillary line. An area of breast tissue, called the tail of Spence, extends into the axilla. Fascial bands,
called Cooper’s ligaments, support the breast on the chest wall. The inframammary fold (or crease) is a ridge
of fat at the bottom of the breast. Each breast contains 12 to 20 cone-shaped lobes, which are made up of
glandular elements (lobules and ducts) and separated by fat and fibrous tissue that binds the lobes together.
Milk is produced in the lobules and then carried through the ducts to the nipple.
Physical Assessment: Female Breast
A female breast examination can be conducted during any
general physical or gynecologic examination or whenever the
patient reports an abnormality. The American Cancer Society
(ACS) recommends that women at average risk for breast
cancer undergo a clinical breast examination at least every 3

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years while in their 20s and 30s and then annually thereafter (Smith, Cokkinides & Brawley, 2008).

Inspection
Examination begins with inspection. The patient is asked to disrobe to the waist and sit in a comfortable
position facing the examiner. The breasts are inspected for size and symmetry. A slight variation in the size
of each breast is common and generally normal. The skin is inspected for color, venous pattern, thickening,
or edema. Erythema (redness) may indicate benign local inflammation or superficial lymphatic invasion by a
neoplasm. A prominent venous pattern can signal increased blood supply required by a tumor. Edema and
pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel
appearance (peau d’orange), a classic sign of advanced breast cancer. Nipple inversion of one or both
breasts is not uncommon and is significant only when of recent origin. Ulceration, rashes, or spontaneous
nipple discharge requires evaluation.

Palpation
The breasts are palpated with the patient sitting up (upright) and lying down (supine). In the supine position
the patient’s shoulder is first elevated with a small pillow to help balance the breast on the chest wall. Failure
to do this allows the breast tissue to slip laterally, and a breast mass may be missed. The entire surface of
the breast and the axillary tail is systematically palpated using the flat part (pads) of the second, third, and
fourth fingertips, held together, making dime-size circles. The examiner may choose to proceed in a
clockwise direction, following imaginary concentric circles from the outer limits of the breast toward the
nipple.

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Diagnostic Evaluation:
1. Breast Self-Examination -The nurse plays an important role in BSE education, a modality used for
the early detection of breast cancer. BSE can be taught in a variety of settings—either on a one-to-
one basis or in a group. It can also be initiated by a health care practitioner during a patient’s routine
physical examination.
2. Mammography - Mammography is a breast-imaging technique that has been shown to reduce
breast cancer mortality rates. It can detect non palpable lesions and assist in diagnosing palpable
masses. The procedure takes about 15 minutes and can be performed in a hospital radiology
department or independent imaging center. Two views are taken of each breast. The breast is
mechanically compressed from top to bottom (cranio caudal view) and side to side (mediolateral
oblique view). Women may experience some fleeting discomfort because maximum compression is
necessary for proper visualization.
3. Galactography - is a diagnostic procedure that involves injection of less than 1 mL of radiopaque
material through a cannula inserted into a ductal opening on the areola, which is followed by a
mammogram. It is performed to evaluate an abnormality within the duct when the patient has bloody
nipple discharge on expression, spontaneous nipple discharge, or a solitary dilated duct noted on
mammography.
4. Ultrasonography - (ultrasound) is used as a diagnostic adjunct to mammography to help distinguish
MEDICAL WARD 1 LEVEL IV |Page 10
fluid-filled cysts from other lesions. A thin coating of lubricating jelly is spread over the area to be
imaged. A transducer is then placed on the breast. The transducer transmits high-frequency sound
waves through the skin toward the area of concern. The sound waves that are reflected back form a
two-dimensional image, which is then displayed on a computer screen. No radiation is emitted
during the procedure.
5. Magnetic Resonance Imaging - Magnetic resonance imaging (MRI) of the breast is rapidly gaining
in popularity. This highly sensitive test has become a useful diagnostic adjunct to mammography. A
magnet is linked to a computer that creates detailed images of the breast without exposure to
radiation. An intravenous (IV) injection of gadolinium, a contrast dye, is given to improve visibility.
The patient lies face down and the breast is placed through a depression in the table. A coil is
placed around the breast, and the patient is placed inside the MRI machine. The entire procedure
takes about 30 to 40 minutes.

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Day 6
6:45-7:00 Checking of attendance. Checking of uniform and paraphernalias.
Discussion of activities for the day. Assigning of patient’s
7:00-8:00 Endorsement, rounds, medication preparation. Definition:
8:00-8:30 Initial vital signs taking and bedside care. Establish Nurse- Patient
Interaction Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue
8:30-9:00 Checking of patient’s chart damage (Merskey & Bogduk, 1994). It is the most common reason for seeking health care (Shi, Langer,
9:00-9:15 First batch snack break Cohen, et al., 2007). Pain occurs as the result of many disorders, diagnostic tests, and treatments; it disables
9:15-9:30 Second batch snack break and distresses more people than any single disease. Because nurses spend more time with patients in pain
9:30-11:00 Discussion and Question and answer about patient’s case per than other health care providers do, nurses need to understand the pathophysiology of pain, the physiologic
student (1st batch). Plotting of TPR sheet and psychological consequences of acute and chronic pain, and the methods used to treat pain.
11:00-11:30 Sample charting/ Drug study  Pain management is considered such an important part of care that it is referred to as “the fifth vital
11:30-12:00 First batch lunch break sign” to emphasize its significance and to increase the awareness among health care professionals
12:00-12:30 Second batch lunch break of the importance of effective pain management (American Pain Society, 2003). Identifying pain as
12:30-1:00 Continuation of Nurse Patient Interaction, bedside care procedures the fifth vital sign suggests that the assessment of pain should be as automatic as taking a patient’s
1:00-1:30 Discussion and Question and answer about patient’s case per blood pressure and pulse.
student (2nd batch)
1:30-2:00 Continuation of NPI, V/S taking and plotting in the monitoring sheet. Types of Pain
2:00-2:30 Closing of chart Pain is categorized according to its duration, location, and etiology. Three basic categories of pain are
2:30-3:00 Post- conference, Topic discussion: PAIN MANAGEMENT generally recognized: acute pain, chronic (nonmalignant) pain, and cancer-related pain.
Rotational Quiz
1. Acute Pain - Usually of recent onset and commonly associated with a specific injury, acute pain
indicates that damage or injury has occurred. Pain is significant in that it draws attention to its
existence and teaches people to avoid similar potentially painful situations. If no lasting damage
occurs and no systemic disease exists, acute pain usually decreases as healing occurs. For
definitional purposes, acute pain can last from seconds to 6 months.
2. Chronic Pain Chronic pain is pain that lasts for 6 months or longer, although 6 months is an arbitrary
period for differentiating between acute and chronic pain, as previously noted. An episode of pain
may assume the characteristics of chronic pain before 6 months have elapsed, or some types of
pain may remain primarily acute in nature for longer than 6 months.
3. Cancer-Related Pain - Pain associated with cancer may be acute or chronic. Pain resulting from
cancer is so ubiquitous that when cancer patients are asked about possible outcomes, pain is
reported to be the most feared outcome (Munoz Sastre, Albaret, Maria Raich Escursell, et al., 2006).

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Pain in patients with cancer can be directly associated with the cancer (eg, bony infiltration with
tumor cells or nerve compression), a result of cancer treatment (eg, surgery or radiation), or not
associated with the cancer (eg, trauma). However, most pain associated with cancer is a direct result
of tumor involvement.
Nursing Care - The role of the nurse in pain management is to perform pain assessment, identify goals
for pain management, provide patient teaching, perform physical care, help relieve pain by administering
pain-relieving interventions (including both pharmacologic and nonpharmacologic approaches), assess
the effectiveness of those interventions, monitor for adverse effects, and serve as an advocate for the
patient when the prescribed intervention is ineffective in relieving pain.

Reference: Medical-SurgicalNursing12.pdf

Prepared By: Girlie A. Frigillana SN Noted By:

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Noted By: Mrs. Sheldy M. Peralta RN, MAN

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