Brokenshire College

Davaoc City
Name of Student : _____________________________________ Year & Section

ADMINISTRATION OF MEDICATIONS ( Immunization Procedures Included - 65 )

Requirements : _________________________

A. Parenteral ( 25 )

# Name of Patient Age Diagnosis Attending Name of Route of Date & Ward / Area C.I.
Physician Medicine Adm. Time Given Signature
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

FRM-NSG-18B
REV. NO. 0 Page 1
 BROKENSHIRE COLLEGE
Davao City

Name of Student: __________________________________ Year and Section: __________ Procedure to be performed: Vital Signs Taking

(40 cases)
A.
Name of Patient Ward. / Rm. & Bed No. Age Diagnoses Attending Wt. T P R BP CI's Remarks
Area Physician signature
over
printed
# name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

FRM-NSG-18B Page 2
REV. NO. 0
 Name of Patient Ward. / Rm. & Bed No. Age Diagnoses Attending Wt. T P R BP CI's Remarks
Area Physician signature
over
printed
# name
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Date Submitted: _________________________________

Approved by: ____________________________________

(Level Clinical Coordinator) page 3
FRM-NSG-18B
REV. NO. 0
B.
Name of Patient Age Attending Physician Name od Medicine Route of Date & Time Ward / Area C.I.'s
# Admin. Given Signature
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

FRM-NSG-18B page 4
REV. NO. 0
 BROKENSHIRE COLLEGE
Davao City

Name of Student: __________________________________ Year and Section: __________ Procedure to be performed: Vital Signs Taking

(40 cases)
A.
Name of Patient Ward. / Rm. & Bed No. Age Diagnoses Attending Wt. T P R BP CI's Remarks
Area Physician signature
over
printed
# name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

FRM-NSG-18B Page 2
REV. NO. 0
 Name of Patient Ward. / Rm. & Bed No. Age Diagnoses Attending Wt. T P R BP CI's Remarks
Area Physician signature
over
printed
# name
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Date Submitted: _________________________________

Approved by: ____________________________________

(Level Clinical Coordinator) page 3
FRM-NSG-18B
REV. NO. 0
B.
Name of Patient Age Attending Physician Name od Medicine Route of Date & Time Ward / Area C.I.'s
# Admin. Given Signature
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

FRM-NSG-18B page 4
REV. NO. 0
 BROKENSHIRE COLLEGE
Madapo, Davao City

Name of Student : _______________________ Year and Section : _______________ Procedure done : Bedbath ( Partial & Complete ) ( 20 )

# Name of Patient Age Sex Diagnosis Attending Date Done Room & CI's signature over
Physician Ward Bed No. printed name Remarks
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Date Submitted : _______________________________

Approved by : _________________________________

FRM-NSG-18B ( page 5)
REV. NO. 0
 BROKENSHIRE COLLEGE
Davao City

Name of student : ____________________________ Year and section : _____________________

Procedure done : Perineal Care ( 5 ) : Range of Motion Exercises ( 10 )

# Name of Patient Age Sex Diagnosis Attending Procedure Date Ward

Physician Done Done Room Ci's Signature
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Date Submitted : ______________________________

Approved by : _________________________________ page 6

( Level Clinical Coordinator )
FRM-NSG-18B
REV. NO. 0
 BROKENSHIRE COLLEGE
Madapo, Davao City

Name of Student Year and Section : Procedure performed : Nursing Assessment ( NA ) = 10 ;

Nursing Care Plan ( NCP ) = 5; Family Nursing Care Plan
( FNCP ) = 5 ; and other ( if any )

# Name of Patient Age Procedure Diagnosis Attending Date Done Ward / Area CI's Signature and
( Initial only ) Physician Remarks
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Date Submitted : ___________________________________

Approved by : ___________________________________
FRM-NSG-18B Page 7
REV. NO. 0
 BROKENSHIRE COLLEGE
Davao City

Name of Student : Year & Section : Procedure Done : Bedmaking ( all types of bed ) ( 20 )
a. Close / Open Bed b. Occupied Bed c. OB Bed
d. Post-Op / Surgical Bed

# Name of Patient Age Diagnosis Attending Date Done Ward / Area Room / Bed CI's Signature
Physician No. Remarks
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

FRM-NSG-18B page 8
REV. NO. 0
 BROKENSHIRE COLLEGE
Davao City

Name of Student : ____________________________________________ Year and Section : _______________________________________________

A. Application of Heat / Warm ( 5 )

# Name of Patient Age Attending Physician Duration of Date & Time Ward & CI's
Name of Procedure Administration Given
1
2
3
4
5

B. Application of Cold ( 5 )

# Name of Patient Age Attending Physician Duration of Date & Time Ward & CI's
Name of Procedure Administration Given
1
2
3
4
5

Date Submitted : _________________________________________ Approved by : ______________________________________________

( Level Coordinator )

page 9
FRM-NSG-18B
REV. NO. 0
 BROKENSHIRE COLLEGE
Davao City
C. Topical ( 5 )
Name of Patient Age Diagnosis Attending Route of Date & Ward / Area C.I.'s
# Physician Admin Time Given Signature
1
2
3
4
5

D. Suppository ( 5 )
Name of Patient Age Diagnosis Attending Route of Date & Ward / Area C.I.'s
# Physician Admin Time Given Signature
1
2
3
4
5

E. Inhalation ( 5 )
Name of Patient Age Diagnosis Attending Route of Date & Ward / Area C.I.'s
# Physician Admin Time Given Signature
1
2
3
4
5

Date Submitted : _____________________________________________________________________________

FRM-NSG-18B
page 10 REV. NO. 0
 BROKENSHIRE COLLEGE
Madapo, Davao City

Name of Student : Year And Section : Other Procedures not specified but able to perform,
such as Catheterization, Suctioning,
Enema, CPR, Oxygen Administration, others

# Name of Name Age Diagnosis Attending Date Ward CI's signature and
Procedure of Patient Physician Done / Area Remarks
1
2
3
4
5
6
7
8
9
10

Date Submitted : _______________________________________

Approved by : _________________________________________
( Level Clinical Coordinator )

page 11

FRM-NSG-18B
REV. NO. 0