January 31, 2011 6.

Review the chart

SPINE WARD ORIENTATION - Check if all orders has
been carried out
- Carry out if not done
- Orders and notes (12mn-
12mn is one day)
7. Refill forms in the chart
- Nurse’s notes
- V/S Monitoring Sheet
- I&O Monitoring Sheet
- Therapeutic Sheet
- Orders, etc.

a. Proper Order of Chart

i. Case record
ii. Consent forms
iii. RIC Notes
I. Orthopedic Department iv. SIC Notes
1. Pedia v. Laboratories
2. Adult vi. Clinical Abstract
3. Trauma vii. Emergency Room
4. Hand Notes
5. Spine Unit viii. Admitting Order
ix. Regular Orders
*With the increased awareness to (Day1-Day [n])
scoliosis, Spine Unit was x. Nurse’s Notes
conceptualized to cater to patients xi. V/S Records
with spine problems. xii. Therapeutic Sheet
xiii. I&O Sheet
It was believed that a former xiv. OR/RR Records
patient of Orthopedic Department xv. Pharmacy Clearance
won the lottery and decided to xvi. Discharge
donate 5Million to UP-PGH for the 8. Housekeeping
construction of this unit. 9. Bed turning and log rolling
every 2hrs
In 2007, Spine unit can
accommodate 14 patients. At III. Usual Early Morning
present, it caters to 10 patients (8 Activities
regular beds and 2 isolation beds). - Anticox
- CBGs
II. Nursing Responsibilities of a - Medications
Spine Nurse - Bed turning (q2)
1. Bedside nurse - Kardex Update
2. Medications - End of Shift Report
3. V/S Monitoring
4. I&O Monitoring
5. Procedures (such as CBG)
IV. Medication Cards
*Prepare needs due shift

A. Common Abbreviations
OD – Once a day
BID – Twice a day
TID – Thrice a day
QID – Four times a day
PRN – As needed
HS – Hours of sleep
pBF- prebreakfast
pL- prelunch
pD – predinner
RTC – Round the clock

B. Time and Color Designation

Color Time
OD Whit 8AM
BID e 8AM, 6PM
TID Yello 8AM, 1PM, 6PM
QI w 8, 12, 4, 8
D Pink
PR Gree 8PM
N n Q12 (12mn/12nn ;
HS Whit 8am/8pm)
RT e Q8 (8am, 4pm, 12mn)
C Whit Q6 (6-12-6-12)
e Q4 (4-8-12-4-8-12)
Whit Q2 (2…)
e

Submitted to:
Mr. Eric Villa
Clinical Instructor

Submitted By: Group C1&C2

Montemayor, Elizer
Ocampo, Earvin
Perucho, Paola
Polumbarit, Seenjen
Quejada, Miravu
Quindipan, Lester
Ramos, Jen Marie
Ruiz, Christopher James
Sinson, Dianne
Zaguirre, Mikhaela Francisca
BS Nursing III-1