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OB Notes

The document outlines policies and procedures for a clinical rotation at Cong. Simeon Toribio Memorial Hospital, including requirements for assessments, care plans, drug studies, health teaching, and case studies for students, as well as guidelines for vital signs, charting, medication administration, waste management, and grading. Students will be assigned patients and implement morning care, assessments, care plans, and health teaching under supervision during their rotation in areas like the emergency room, obstetrics ward, and nursery.

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Mikaela Fuentes
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Download as PDF, TXT or read online on Scribd
33 views

OB Notes

The document outlines policies and procedures for a clinical rotation at Cong. Simeon Toribio Memorial Hospital, including requirements for assessments, care plans, drug studies, health teaching, and case studies for students, as well as guidelines for vital signs, charting, medication administration, waste management, and grading. Students will be assigned patients and implement morning care, assessments, care plans, and health teaching under supervision during their rotation in areas like the emergency room, obstetrics ward, and nursery.

Uploaded by

Mikaela Fuentes
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY OF BOHOL- TAGBILARAN CITY

CONG. SIMEON TORIBIO MEMORIAL HOSPITAL

Circle Time is at 7:45 am at the Hospital


Ground. • NURSE’S Notes
Nurse’s Prayer and Special Instructions o Focus
o Data
OB-ER o Action
• Arriving of patients in the Triage Room- o Response
Rapid Antigen Test will be performed
• We will take the Vital Signs B FORMS/ CHARTS
• Will be referred for Admission. • Lab Requests
• If patient is an OB case, ER will call DR • Discharge Summary
team to assess degree of labor. Checking • NURSERY RECORD
for the Cervical Dilatation. o Apgar Scoring and New Ballard
• With other cases we will, assist with the Scale
procedures done in the ER. • TPR
• Doctor’s Order
PROCEDURES WE CAN ASSIST: • Medication Sheet
• Discharge Instructions
1. Vital Signs • Crede’s Prophylaxis
2. Assist in IV Insertion • Hep B (0.5ml) IM
3. Assist in Skin Test • Vitamin K (0.1 ml) IM
4. Assist in Injections/ Or we can inject • Blood Sugar
5. Assist in Wound Dressing • BCG
6. Assisting in ECG • Newborn Screening
7. Assisting in O2 administration.
DO’s and DON’T’s
COMMON ER CASES 1. No Cellphones
1. Vehicular Accidents. 2. Nails should be cut short.
2. Vomiting and Diarrhea 3. No colored hair.
4. Observe Data Privacy (No Maritess)
OB- WARD 5. No Pictures and Videos.
6. Data and Patient Information will be
• Will do Morning Care given by the authorized person only.
• Will do Vital Signs of assigned patients 7. No information about the hospital and
Q4 (1oam and 2pm) the cases you handled will be given to
• Will plot the Vital signs in the TPR anybody.
sheet. 8. When talking about patients, use
• Will Create FDAR Charting but we will initials, do not use full names. We will
not do the charting yet. also use initials in the case study.
• Charting will be checked 2 hours before 9. Mask is Mandatory in all the areas.
the end of the shift.
• We will help with medication
administration. REQUIREMENTS:
• Patient Assessment (Will need a copy of
M FORMS/ CHARTS the Assessment Form)
• Labs • Nursing Care Plan
• ER Record • A Drug Study
• Discharge Summary from ER • Health Teaching Plan
• Clinical Case Record • Case Study
• Obstetrical Record • Individual Conference
• Blood Pressure Record • Post-Test during the Post Conference.
• Temperature Record • Notebook (Lesson Plan 80 leaves)
• DOCTOR’S Order (CARED) covered with the class color with the
o Carried proper label.
o Administered
o Requested NEEDED PARAPHERNALIA
o Endorsed • Penlight
o Discontinued • BP and Stet
• Medication Sheet • Tape Measure
UNIVERSITY OF BOHOL- TAGBILARAN CITY

CONG. SIMEON TORIBIO MEMORIAL HOSPITAL

• Ruler
• Needle and Thread
• Bandage Scissor MEDICINE ADMINISTRATION
• Pencil Case with 3 colored pens and
writing materials ORANGE Q8
• Small Medicine Tray (each) PINK TID 8am-1pm-6pm
• Masks YELLOW BID 8am-6pm
• 70% alcohol each WHITE OD, Q6, Q12
GREEN HS
• A box of clean gloves by group
BLUE Q4
WEEK 1 DAY 1
Meticulous Waste Management
• Assigning of Patient
• Morning Care
DRY WASTE- WHITE
• Assessment, Vital Signs taking
• Formulation of NCP WET WASTE- GREEN
• Individual Conference
DAY 2 INFECTIOUS WASTE- YELLOW
• Submission of Requirements
• Morning Care
• Vital Signs IMPORTANT REMINDERS
• Charting
• Implementation of the Plan • Will open the RLE Clearance on
• Individual Conference PRECON
DAY 3 • Absent during PreCon – 1 day absent
• Implementation of the Plan • Absent on Post Con – 2 days absent
• Group Health Teaching • 3 consecutive tardiness of 15 minutes
• Individual Conference each- 1 day absent
• 30 minutes late- 1 day absent
Week 2 DAY 1 • 1 day excused absence- 1 day
• Assigning of Patient replacement
• Morning Care • 1 day unexcused absence- 2 days
• Assessment, Vital Signs taking replacement
• Formulation of NCP • 10 days absent – DROPPED
• Individual Conference • 50% absent in an area – REPEAT
DAY 2 EXPOSURE
• Submission of Requirements
• Morning Care
• Vital Signs GRADING:
• Charting
• Implementation of the Plan Performace- 50%
• Individual Conference Written Requirements- 30%
DAY 3 Evaluation(POST CON) - 20%
• Implementation of the Plan TOTAL: 100%
• Group Health Teaching
• POST TEST/ POST CON

PENS
Black- AM shift
Prepared By:
Blue- PM Shift
Red-NOC
JANICE BUSTAMANTE- ATON, RN,MAN, IBCLC
PATIENT COLOR CODING
PEDIA- YELLOW
OB- PINK
MEDICAL- BLUE
SURGICAL- RED
NEWBORN- WHITE

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