IBE, Susanna Martha B.

Ward 1

2014-57561 May 10, 2018

A. PATIENT-CENTERED OBJECTIVES

Long-term Objectives
1. Attain optimal physiologic function.
2. Exhibit no signs and symptoms of infection, injury, and potential complications of disease.
3. Have no evidence of contractures and further skin breakdown.
4. Exhibit readiness in self-health management upon discharge at the health facility.

Short-term Objectives
At the end of the shift, the patients will:
1. Manifest no episodes of worsening condition during assessment period.
2. Exhibit vital signs within recommended ranges upon the duration of the shift.
3. Breathe deeply to expectorate secretions and maintain a patent airway.
4. Achieve improvements in bowel elimination patterns.
5. Verbalize relief from pain and enhancement of comfort.
6. Receive holistic care from the staff nurse, significant other/s, and other members of the health
care team.

B. NURSE-CENTERED OBJECTIVES

Long-term Objectives
1. Apply critical skills in nursing care using integrated knowledge.
2. Provide holistic, safe, and quality nursing care as a staff nurse to 6-8 patients with the aid of
the nursing process in the provision of care.
3. Perform patient admission correctly and efficiently.
4. Establishes clear communication with nursing and other disciplines regarding patient care.
5. Delegates tasks when necessary, considering the person’s ability and skill.
6. Conducts a group teaching guided by a teaching plan that reflect all its essential component.
7. Document nursing care and client outcomes in an accurate and comprehensive manner.
8. Work effectively through inter-professional collaboration including the patient’s family.
9. Actively participate in administrative and other ward activities.
10. Exhibit professional and personal qualities of a staff nurse.

Short-term Objectives
At the end of shift, the student nurse will:
1. Receive new orders from PM and night shift and update plan on care based on these.
2. Perform initial assessment accurately and comprehensively on newly admitted patients.
3. Performs complete and correct orientation to patient and family regarding ward personnel,
physical set-up, hospital and ward policies and various services.
4. Carries out admission orders correctly and efficiently.
5. Utilize correct nursing diagnosis using pertinent assessment data.
6. Utilize a comprehensive total nursing care plan for assigned patients.
7. Communicates with head nurse/nursing personnel regarding patient care needs and plan of
care during endorsements and nursing rounds.
8. Document nursing care given for the shift in patients’ chart using prescribed forms and
recording system.
9. Update Kardex entries completely.
IBE, Susanna Martha B. Ward 1

2014-57561 May 10, 2018

HIGHLIGHTS AND INSIGHTS (MAY 9, 2018)

HIGHLIGHTS:
 First time to eat with all the nurses (after their ward meeting)
INSIGHTS:
During the shift, there were times where I found myself already done with all the tasks
needed to be done. This is the reason why I am pondering if I should have taken 7 patients
already for today. But, I feel also that because I chose to retain the 6 patients that I was able
to pace myself better and have enough time to review from the charts of some of my patients
as part of assessment. For tomorrow, I will be taking an additional patient which will make
my total count up to 7, which is the ideal number for nurse to staff ratio inside a ward. I am
actually excited since I am loving what I am doing and I feel really good to see my patient
improve over time because he/she is under my care. 