WEEK 1

Item Points
GOSO
Clinical Teaching Plan
Patient’s Health Profile
Head to Toe Physical Assessment
Humpty Dumpty Fall Prevention Assessment
Developmental Stages or Milestones
Diagnostic, Laboratory Procedures and Nursing
Responsibilities
Medical Management and Nursing Responsibilities
i. Intravenous Fluid Therapy & NR
ii. Pharmacotherapy & NR
Vital Signs Monitoring
TPR Sheet
Nursing Process Record
Evidence – Based Nursing Research (Reflection Paper)
Total

Clinical Instructor

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 1|Page

 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

HRN : Date: _
Hospital _______________________________ Shift:
Clinical Instructor: Area: _

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECIFIC OBJECTIVES
ST
1 DAY 2ND DAY
Knowledge
1. 1.

2. 2.

Skills
1. 1.

2. 2.

Attitude
1. 1.

2. 2.

CLINICAL TEACHING PLAN

Activities
Time 1ST Day 2ND Day
 PATIENT’S HEALTH PROFILE

Instructions: Kindly fill out the information below through interview of the patient
or his/her significant others. Be sure to write it legibly and accurately.

I. Biographical Data

HRN : Age:
Birth Date : Sex:
Civil Status : Religion:
Address : Height:
Educational Attainment : Weight:
Ethnic Group : Vital Signs
Date & Time of Admission : BP:
Attending Physician : RR:
Medical Diagnosis : PR:
Temp:

II. Client’s History

A. General Health Status:

B. Chief Complaints:

C. History of Present Illness

D. Family Health History (Narrative):

Paternal History
Maternal History

E. Personal History:

a. Prenatal and Birth History

Mother’s Age: _ _ G: P: (T: , P: , A: , L: )
Birth Weight:
Type of delivery:
( ) NSVD ( ) CS due to: _
Age of Gestation: _
( ) Term ( ) Preterm
Place of Delivery:
( ) Hospital ( ) LHC ( ) Others: _
Complication/s at Birth: Yes ( ); No ( )
If yes, please specify: _ __ _

b. Feeding History
( ) Breastfeeding ( ) Milk formula Duration:
Age solid foods introduced: __
Vitamin supplement: _ _

F. Hospitalization History:

G. Childhood Illness: (Past illnesses)

[ ] Allergies [ ] Childhood Disease [ ] Asthma [ ] Chicken pox
[ ] Measles [ ] Mumps [ ] Tonsillitis
[ ] Operations: _ _ [ ] Others:

H. Immunizations:

BCG Hepa B DPT OPV/PV

Hib Measles MMR PCV
Typhoid Hepa A Varicella
Others
 HEAD TO TOE PHYSICAL ASSESSMENT

Instructions: Kindly accomplish this matrix. Be sure to include the normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. (Only for body parts/systems that are applicable)

Areas to be 1ST DAY 2ND DAY

Assessed

General
Survey/Mental
Status

Integumentary

Head & Face

Neck

Eyes

Ears
 Ears

Nose & Sinuses

Mouth & Throat

Lungs & Thorax

Breasts &
Axillae

Heart

Abdomen
Gastrointestinal/
Nutrition
(BMI: Ideal Body
Weight, Height,
Waist to Hip
Ratio)

Musculoskeletal

Genitourinary

Neurologic
Date: _
Patient’s Name:
Age/Sex:

Instruction: Encircle the appropriate score that corresponds to the parameter

being assessed.
PARAMETER CRITERIA SCORE
Less than 3 years old 4
AGE 3 to less than 7 years old 3
7 to less than 13 years old 2
13 years old and above 1
GENDER Male 2
Female 1
Neurological Diagnosis 4
Alterations in Oxygenation (Respiratory
Diagnosis, Dehydration, Anemia, 3
DIAGNOSIS Anorexia, Syncope/Dizziness, etc.)
Psych/Behavioral Disorders 2
Other Diagnosis 1
Not aware of limitations 3
COGNITIVE Forgets limitation 2
IMPAIRMENTS Oriented to own ability 1
History of falls or infant-toddler placed in 4
bed
Patient uses assistive device or
ENVIRONMENTAL infant-toddler in crib or 3
FACTORS furniture/lighting (tripled room)
Patient placed in bed 2
Outpatient area 1
Within 24 hours 3
RESPONSE TO Within 48 hours 2
SURGERY/SEDATI More than 48 hours/none 1
ON/ANESTHESIA
Multiple usage of:
Sedatives (including ICU patients sedated &
paralyzed)
Hypnotics
MEDICATION Barbiturates 3
USAGE Phenothiazines
Anti-depressants
Laxatives/diuretics
Narcotics
One of the meds listed above 2
Other medications/None 1
TOTAL
Interpretation:
Score Interpretation Note
12 and above High Risk for Fall The highest score to be garnered is 23 points.
7 – 11 Medium Risk for Fall
6 and below Low Risk for Fall
 DEVELOPMENTAL STAGES/MILESTONE
Developmental Theories
Instruction: Provide brief descriptions of the various developmental tasks of your patient in accordance to the different developmental theories.
(Pertains only to the child’s age)
Stages FREUD ERIKSON PIAGET KOHLBERG HAVIGHURST
(Psychosexual) (Psychosocial) (Cognitive) (Moral Reasoning) (Developmental Tasks)

Stage
Description

Developmental
Tasks
Performed and
Observed
Behaviors

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 9|Page

 DIAGNOSTICS, LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC /LABORATORY INDICATIONS & PURPOSES RESULTS/ NORMAL VALUES NURSING RESPONSIBILITIES
PROCEDURES INTERPRETATION
DIAGNOSTIC /LABORATORY INDICATIONS & PURPOSES RESULTS/ NORMAL VALUES NURSING RESPONSIBILITIES
PROCEDURES INTERPRETATION
 MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose Nursing Responsibilities
II. Pharmacotherapy & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 DIET & ACTIVITY MANAGEMENT & NURSING RESPONSIBILITIES

Type of Diet/Activity General Description Indication or Purposes Restricted Nursing Responsibilities

Foods/Activities
 MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and intake
and output sheet accordingly.

A. Vital Signs Monitoring

Shift: _

Date & Temp HR/PR RR BP O2 Sat

Time

B. Intake & Output Monitoring

Shift: _

Date & Intake Output

Time
IVF IVTT PO Others Total Urine Stool Others Total

TOTAL INTAKE TOTAL OUTPUT

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 17 | P a g e

 TPR SHEET
(Please attach here)
 Instructions: Fill – out the table below with the appropriate nursing diagnosis and make your nursing care plan utilizing the nursing process.
NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 19 | P a g e

 NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _
 NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _
 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a Research Article related to the case of your patient
and give your own reflection/insights.

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 22 | P a g e

 __

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 22 | P a g e

 LEARNING FEEDBACK DIARY

Learnings Problems Encountered Actions Taken Realization

Self

Peers

Patient’s
Area

Clinical
Instructor

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 23 | P a g e

 WEEK 2
Item Points
GOSO
Clinical Teaching Plan
Patient’s Health Profile
Head to Toe Physical Assessment
Humpty Dumpty Fall Prevention Assessment
Developmental Stages or Milestones
Diagnostic, Laboratory Procedures and Nursing
Responsibilities
Medical Management and Nursing Responsibilities
iii. Intravenous Fluid Therapy & NR
iv. Pharmacotherapy & NR
Vital Signs Monitoring
TPR Sheet
Nursing Process Record
Evidence – Based Nursing Research (Reflection Paper)
Total

Clinical Instructor

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 24 | P a g e

 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

Name : Date: _
Hospital _______________________________ Shift:
Clinical Instructor: Area: _

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECIFIC OBJECTIVES
ST
1 DAY 2ND DAY
Knowledge
3. 1.

4. 2.

Skills
3. 1.

4. 2.

Attitude
3. 1.

4. 2.

Activities
Time 1ST Day 2ND Day
 PATIENT’S HEALTH PROFILE

Instructions: Kindly fill out the information below through interview of the patient
or his/her significant others. Be sure to write it legibly and accurately.

I. Biographical Data

Name : Age:
Birth Date : Sex:
Civil Status : Religion:
Address : Height:
Educational Attainment : Weight:
Ethnic Group : Vital Signs
Date & Time of Admission : BP:
Attending Physician : RR:
Medical Diagnosis : PR:
Temp:

II. Client’s History

A. General Health Status:

B. Chief Complaints:

C. History of Present Illness

D. Family Health History (Narrative):

Paternal History
Maternal History

E. Personal History:

c. Prenatal and Birth History

Mother’s Age: _ _ G: P: (T: , P: , A: , L: )
Birth Weight:
Type of delivery:
( ) NSVD ( ) CS due to: _
Age of Gestation: _
( ) Term ( ) Preterm
Place of Delivery:
( ) Hospital ( ) LHC ( ) Others: _
Complication/s at Birth: Yes ( ); No ( )
If yes, please specify: _ _

d. Feeding History
( ) Breastfeeding ( ) Milk formula Duration:
Age solid foods introduced _______________
Vitamin supplement: _ _

F. Hospitalization History:

G. Childhood Illness: (Past illnesses)

[ ] Allergies [ ] Childhood Disease [ ] Asthma [ ] Chicken pox
[ ] Measles [ ] Mumps [ ] Tonsillitis
[ ] Operations: _ _ [ ] Others:

H. Immunizations:

BCG Hepa B DPT OPV/PV

Hib Measles MMR PCV
Typhoid Hepa A Varicella
Others
 HEAD TO TOE PHYSICAL ASSESSMENT

Instructions: Kindly accomplish this matrix. Be sure to include the normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. (Only for body parts/systems that are applicable)

Areas to be 1ST DAY 2ND DAY

Assessed

General
Survey/Mental
Status

Integumentary

Head & Face

Neck

Eyes

Ears
 Ears

Nose & Sinuses

Mouth & Throat

Lungs & Thorax

Breasts &
Axillae

Heart

Abdomen
Gastrointestinal/
Nutrition
(BMI: Ideal Body
Weight, Height,
Waist to Hip
Ratio)

Musculoskeletal

Genitourinary

Neurologic
Date: _
Patient’s Name:
Age/Sex:

Instruction: Encircle the appropriate score that corresponds to the parameter

being assessed.
PARAMETER CRITERIA SCORE
Less than 3 years old 4
AGE 3 to less than 7 years old 3
7 to less than 13 years old 2
13 years old and above 1
GENDER Male 2
Female 1
Neurological Diagnosis 4
Alterations in Oxygenation (Respiratory
Diagnosis, Dehydration, Anemia, 3
DIAGNOSIS Anorexia, Syncope/Dizziness, etc.)
Psych/Behavioral Disorders 2
Other Diagnosis 1
Not aware of limitations 3
COGNITIVE Forgets limitation 2
IMPAIRMENTS Oriented to own ability 1
History of falls or infant-toddler placed in 4
bed
Patient uses assistive device or
ENVIRONMENTAL infant-toddler in crib or 3
FACTORS furniture/lighting (tripled room)
Patient placed in bed 2
Outpatient area 1
Within 24 hours 3
RESPONSE TO Within 48 hours 2
SURGERY/SEDATI More than 48 hours/none 1
ON/ANESTHESIA
Multiple usage of:
Sedatives (including ICU patients sedated &
paralyzed)
Hypnotics
MEDICATION Barbiturates 3
USAGE Phenothiazines
Anti-depressants
Laxatives/diuretics
Narcotics
One of the meds listed above 2
Other medications/None 1
TOTAL
Interpretation:
Score Interpretation Note
12 and above High Risk for Fall The highest score to be garnered is 23 points.
7 – 11 Medium Risk for Fall
6 and below Low Risk for Fall
 DEVELOPMENTAL STAGES/MILESTONE
Developmental Theories
Instruction: Provide brief descriptions of the various developmental tasks of your patient in accordance to the different developmental theories.
(Pertains only to the child’s age)
Stages FREUD ERIKSON PIAGET KOHLBERG HAVIGHURST
(Psychosexual) (Psychosocial) (Cognitive) (Moral Reasoning) (Developmental Tasks)

Stage
Description

Developmental
Tasks
Performed and
Observed
Behaviors

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 32 | P a g e

 DIAGNOSTICS, LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC /LABORATORY INDICATIONS & PURPOSES RESULTS/ NORMAL VALUES NURSING RESPONSIBILITIES
PROCEDURES INTERPRETATION
DIAGNOSTIC /LABORATORY INDICATIONS & PURPOSES RESULTS/ NORMAL VALUES NURSING RESPONSIBILITIES
PROCEDURES INTERPRETATION
 MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose Nursing Responsibilities
II. Pharmacotherapy & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 DIET & ACTIVITY MANAGEMENT & NURSING RESPONSIBILITIES

Type of Diet/Activity General Description Indication or Purposes Restricted Nursing Responsibilities

Foods/Activities
 MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and intake
and output sheet accordingly.

C. Vital Signs Monitoring

Shift: _

Date & Temp HR/PR RR BP O2 Sat

Time

D. Intake & Output Monitoring

Shift: _

Date & Intake Output

Time
IVF IVTT PO Others Total Urine Stool Others Total

TOTAL INTAKE TOTAL OUTPUT

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 40 | P a g e

 TPR SHEET
(Please attach here)
 Instructions: Fill – out the table below with the appropriate nursing diagnosis and make your nursing care plan utilizing the nursing process.
NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 42 | P a g e

 NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _
 NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _
 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a Research Article relates to the case of your patient
and give your own reflection/insights.

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 45 | P a g e

 __

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 45 | P a g e

 LEARNING FEEDBACK DIARY

Learnings Problems Encountered Actions Taken Realization

Self

Peers

Patient’s
Area

Clinical
Instructor

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 46 | P a g e

 WEEK 3
Item Points
GOSO
Clinical Teaching Plan
Patient’s Health Profile
Head to Toe Physical Assessment
Humpty Dumpty Fall Prevention Assessment
Developmental Stages or Milestones
Diagnostic, Laboratory Procedures and Nursing
Responsibilities
Medical Management and Nursing Responsibilities
v. Intravenous Fluid Therapy & NR
vi. Pharmacotherapy & NR
Vital Signs Monitoring
TPR Sheet
Nursing Process Record
Evidence – Based Nursing Research (Reflection Paper)
Total

Clinical Instructor

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 47 | P a g e

 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

Name : Date: _
Hospital _______________________________ Shift:
Clinical Instructor: Area: _

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECIFIC OBJECTIVES
ST
1 DAY 2ND DAY
Knowledge
5. 1.

6. 2.

Skills
5. 1.

6. 2.

Attitude
5. 1.

6. 2.

CLINICAL TEACHING PLAN

Activities
Time 1ST Day 2ND Day
 PATIENT’S HEALTH PROFILE

Instructions: Kindly fill out the information below through interview of the patient
or his/her significant others. Be sure to write it legibly and accurately.

I. Biographical Data

Name : Age:
Birth Date : Sex:
Civil Status : Religion:
Address : Height:
Educational Attainment : Weight:
Ethnic Group : Vital Signs
Date & Time of Admission : BP:
Attending Physician : RR:
Medical Diagnosis : PR:
Temp:

II. Client’s History

A. General Health Status:

B. Chief Complaints:

C. History of Present Illness

D. Family Health History (Narrative):

Paternal History
Maternal History

E. Personal History:

e. Prenatal and Birth History

Mother’s Age: _ _ G: P: (T: , P: , A: , L: )
Birth Weight:
Type of delivery:
( ) NSVD ( ) CS due to: _
Age of Gestation: _
( ) Term ( ) Preterm
Place of Delivery:
( ) Hospital ( ) LHC ( ) Others: _
Complication/s at Birth: Yes ( ); No ( )
If yes, please specify: _ __ _

f. Feeding History
( ) Breastfeeding ( ) Milk formula Duration:
Age solid foods introduced: __
Vitamin supplement: _ _

F. Hospitalization History:

G. Childhood Illness: (Past illnesses)

[ ] Allergies [ ] Childhood Disease [ ] Asthma [ ] Chicken pox
[ ] Measles [ ] Mumps [ ] Tonsillitis
[ ] Operations: _ _ [ ] Others:

H. Immunizations:

BCG Hepa B DPT OPV/PV

Hib Measles MMR PCV
Typhoid Hepa A Varicella
Others
 HEAD TO TOE PHYSICAL ASSESSMENT

Instructions: Kindly accomplish this matrix. Be sure to include the normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. (Only for body parts/systems that are applicable)

Areas to be 1ST DAY 2ND DAY

Assessed

General
Survey/Mental
Status

Integumentary

Head & Face

Neck

Eyes

Ears
 Ears

Nose & Sinuses

Mouth & Throat

Lungs & Thorax

Breasts &
Axillae

Heart

Abdomen
Gastrointestinal/
Nutrition
(BMI: Ideal Body
Weight, Height,
Waist to Hip
Ratio)

Musculoskeletal

Genitourinary

Neurologic
Date: _
Patient’s Name:
Age/Sex:

Instruction: Encircle the appropriate score that corresponds to the parameter

being assessed.
PARAMETER CRITERIA SCORE
Less than 3 years old 4
AGE 3 to less than 7 years old 3
7 to less than 13 years old 2
13 years old and above 1
GENDER Male 2
Female 1
Neurological Diagnosis 4
Alterations in Oxygenation (Respiratory
Diagnosis, Dehydration, Anemia, 3
DIAGNOSIS Anorexia, Syncope/Dizziness, etc.)
Psych/Behavioral Disorders 2
Other Diagnosis 1
Not aware of limitations 3
COGNITIVE Forgets limitation 2
IMPAIRMENTS Oriented to own ability 1
History of falls or infant-toddler placed in 4
bed
Patient uses assistive device or
ENVIRONMENTAL infant-toddler in crib or 3
FACTORS furniture/lighting (tripled room)
Patient placed in bed 2
Outpatient area 1
Within 24 hours 3
RESPONSE TO Within 48 hours 2
SURGERY/SEDATION More than 48 hours/none 1
/ ANESTHESIA
Multiple usage of:
Sedatives (including ICU patients sedated &
paralyzed)
Hypnotics
MEDICATION Barbiturates 3
USAGE Phenothiazines
Anti-depressants
Laxatives/diuretics
Narcotics
One of the meds listed above 2
Other medications/None 1
TOTAL
Interpretation:
Score Interpretation Note
12 and above High Risk for Fall The highest score to be garnered is 23 points.
7 – 11 Medium Risk for Fall
6 and below Low Risk for Fall
 DEVELOPMENTAL STAGES/MILESTONE
Developmental Theories
Instruction: Provide brief descriptions of the various developmental tasks of your patient in accordance to the different developmental theories.
(Pertains only to the child’s age)
Stages FREUD ERIKSON PIAGET KOHLBERG HAVIGHURST
(Psychosexual) (Psychosocial) (Cognitive) (Moral Reasoning) (Developmental Tasks)

Stage
Description

Developmental
Tasks
Performed and
Observed
Behaviors

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 55 | P a g e

 DIAGNOSTICS, LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC /LABORATORY INDICATIONS & PURPOSES RESULTS/ NORMAL VALUES NURSING RESPONSIBILITIES
PROCEDURES INTERPRETATION
DIAGNOSTIC /LABORATORY INDICATIONS & PURPOSES RESULTS/ NORMAL VALUES NURSING RESPONSIBILITIES
PROCEDURES INTERPRETATION
 MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose Nursing Responsibilities
II. Pharmacotherapy & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 DIET & ACTIVITY MANAGEMENT & NURSING RESPONSIBILITIES

Type of Diet/Activity General Description Indication or Purposes Restricted Nursing Responsibilities

Foods/Activities
 MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and intake
and output sheet accordingly.

E. Vital Signs Monitoring

Shift: _

Date & Temp HR/PR RR BP O2 Sat

Time

F. Intake & Output Monitoring

Shift: _

Date & Intake Output

Time
IVF IVTT PO Others Total Urine Stool Others Total

TOTAL INTAKE TOTAL OUTPUT

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 63 | P a g e

 TPR SHEET
(Please attach here)
 Instructions: Fill – out the table below with the appropriate nursing diagnosis and make your nursing care plan utilizing the nursing process.
NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis : __
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _

CMU – CON: Clinical Workbook (Pediatric Nursing 2 nd Edition) 65 | P a g e

 NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)
 NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _

CMU – CON: Clinical Workbook (Pediatric Nursing 2 nd Edition) 67 | P a g e

 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a Research Article related to the case of your patient
and give your own reflection/insights.

CMU – CON: Clinical Workbook (Pediatric Nursing 2 nd Edition) 68 | P a g e

CMU – CON: Clinical Workbook (Pediatric Nursing 2 nd Edition) 68 | P a g e
 LEARNING FEEDBACK DIARY

PROBLEMS ENCOUNTERED ACTIONS TAKEN REALIZATION

LEARNINGS

SELF

PEERS

PATIENT’S
AREA

CLINICAL
INSTRUCTOR

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 69 | P a g e

 WEEK 4
Item Points
GOSO
Clinical Teaching Plan
Patient’s Health Profile
Head to Toe Physical Assessment
Humpty Dumpty Fall Prevention Assessment
Developmental Stages or Milestones
Diagnostic, Laboratory Procedures and Nursing
Responsibilities
Medical Management and Nursing Responsibilities
vii. Intravenous Fluid Therapy & NR
viii. Pharmacotherapy & NR
Vital Signs Monitoring
TPR Sheet
Nursing Process Record
Evidence – Based Nursing Research (Reflection Paper)
Total

Clinical Instructor

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 70 | P a g e

 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

Name : Date: _
Hospital _______________________________ Shift:
Clinical Instructor: Area: _

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECIFIC OBJECTIVES
ST
1 DAY 2ND DAY
Knowledge
7. 1.

8. 2.

Skills
7. 1.

8. 2.

Attitude
7. 1.

8. 2.

CLINICAL TEACHING PLAN

Activities
Time 1ST Day 2ND Day
 PATIENT’S HEALTH PROFILE

Instructions: Kindly fill out the information below through interview of the patient
or his/her significant others. Be sure to write it legibly and accurately.

I. Biographical Data

Name : Age:
Birth Date : Sex:
Civil Status : Religion:
Address : Height:
Educational Attainment : Weight:
Ethnic Group : Vital Signs
Date & Time of Admission : BP:
Attending Physician : RR:
Medical Diagnosis : PR:
Temp:

II. Client’s History

A. General Health Status:

B. Chief Complaints:

C. History of Present Illness

D. Family Health History (Narrative):

Paternal History
Maternal History

E. Personal History:

g. Prenatal and Birth History

Mother’s Age: _ _ G: P: (T: , P: , A: , L: )
Birth Weight:
Type of delivery:
( ) NSVD ( ) CS due to: _
Age of Gestation: _
( ) Term ( ) Preterm
Place of Delivery:
( ) Hospital ( ) LHC ( ) Others: _
Complication/s at Birth: Yes ( ); No ( )
If yes, please specify: _ _

h. Feeding History
( ) Breastfeeding ( ) Milk formula Duration:
Age solid foods introduced _______________
Vitamin supplement: _ _

F. Hospitalization History:

G. Childhood Illness: (Past illnesses)

[ ] Allergies [ ] Childhood Disease [ ] Asthma [ ] Chicken pox
[ ] Measles [ ] Mumps [ ] Tonsillitis
[ ] Operations: _ _ [ ] Others:

H. Immunizations:

BCG Hepa B DPT OPV/PV

Hib Measles MMR PCV
Typhoid Hepa A Varicella
Others
 HEAD TO TOE PHYSICAL ASSESSMENT

Instructions: Kindly accomplish this matrix. Be sure to include the normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. (Only for body parts/systems that are applicable)

Areas to be 1ST DAY 2ND DAY

Assessed

General
Survey/Mental
Status

Integumentary

Head & Face

Neck

Eyes

Ears
 Ears

Nose & Sinuses

Mouth & Throat

Lungs & Thorax

Breasts &
Axillae

Heart

Abdomen
Gastrointestinal/
Nutrition
(BMI: Ideal Body
Weight, Height,
Waist to Hip
Ratio)

Musculoskeletal

Genitourinary

Neurologic
Date: _
Patient’s Name:
Age/Sex:

Instruction: Encircle the appropriate score that corresponds to the parameter

being assessed.
PARAMETER CRITERIA SCORE
Less than 3 years old 4
AGE 3 to less than 7 years old 3
7 to less than 13 years old 2
13 years old and above 1
GENDER Male 2
Female 1
Neurological Diagnosis 4
Alterations in Oxygenation (Respiratory
Diagnosis, Dehydration, Anemia, 3
DIAGNOSIS Anorexia, Syncope/Dizziness, etc.)
Psych/Behavioral Disorders 2
Other Diagnosis 1
Not aware of limitations 3
COGNITIVE Forgets limitation 2
IMPAIRMENTS Oriented to own ability 1
History of falls or infant-toddler placed in 4
bed
Patient uses assistive device or
ENVIRONMENTAL infant-toddler in crib or 3
FACTORS furniture/lighting (tripled room)
Patient placed in bed 2
Outpatient area 1
Within 24 hours 3
RESPONSE TO Within 48 hours 2
SURGERY/SEDATI More than 48 hours/none 1
ON/ANESTHESIA
Multiple usage of:
Sedatives (including ICU patients sedated &
paralyzed)
Hypnotics
MEDICATION Barbiturates 3
USAGE Phenothiazines
Anti-depressants
Laxatives/diuretics
Narcotics
One of the meds listed above 2
Other medications/None 1
TOTAL
Interpretation:
Score Interpretation Note
12 and above High Risk for Fall The highest score to be garnered is 23 points.
7 – 11 Medium Risk for Fall
6 and below Low Risk for Fall
 DEVELOPMENTAL STAGES/MILESTONE
Developmental Theories
Instruction: Provide brief descriptions of the various developmental tasks of your patient in accordance to the different developmental theories.
(Pertains only to the child’s age)
Stages FREUD ERIKSON PIAGET KOHLBERG HAVIGHURST
(Psychosexual) (Psychosocial) (Cognitive) (Moral Reasoning) (Developmental Tasks)

Stage
Description

Developmental
Tasks
Performed and
Observed
Behaviors

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 78 | P a g e

 DIAGNOSTICS, LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC /LABORATORY INDICATIONS & PURPOSES RESULTS/ NORMAL VALUES NURSING RESPONSIBILITIES
PROCEDURES INTERPRETATION
DIAGNOSTIC /LABORATORY INDICATIONS & PURPOSES RESULTS/ NORMAL VALUES NURSING RESPONSIBILITIES
PROCEDURES INTERPRETATION
 MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose Nursing Responsibilities
II. Pharmacotherapy & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name:

Brand Name:

Classification:

Dose, Route &

Timing:
 DIET & ACTIVITY MANAGEMENT & NURSING RESPONSIBILITIES

Type of Diet/Activity General Description Indication or Purposes Restricted Nursing Responsibilities

Foods/Activities
 MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and intake
and output sheet accordingly.

G. Vital Signs Monitoring

Shift: _

Date & Temp HR/PR RR BP O2 Sat

Time

H. Intake & Output Monitoring

Shift: _

Date & Intake Output

Time
IVF IVTT PO Others Total Urine Stool Others Total

TOTAL INTAKE TOTAL OUTPUT

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 86 | P a g e

 TPR SHEET
(Please attach here)
 Instructions: Fill – out the table below with the appropriate nursing diagnosis and make your nursing care plan utilizing the nursing process.
NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 88 | P a g e

 NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _
 NURSING PROCESS RECORD
Patient’s Name :
Medical Diagnosis :
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION INTERVENTIONS RATIONALE EVALUATION
(NOC) CLASSIFICATION (NIC)

Reference/s: _
 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a Research Article related to the case of your patient
and give your own reflection/insights.

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 91 | P a g e

 __

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 91 | P a g e

 LEARNING FEEDBACK DIARY

Learnings Problems Encountered Actions Taken Realization

Self

Peers

Patient’s
Area

Clinical
Instructor

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 92 | P a g e

 APPENDICES

CMU – CON: Clinical Workbook (Pediatric Nursing 2nd Edition) 93 | P a g e

Appendix A

RUBRIC FOR REFLECTIVE JOURNAL

POINTS DESCRIPTION
Content
Excellent to very good: knowledgeable, substantive, thorough;
(10 pts) include appropriate examples; quotations are well-chosen to
support the argument, well integrated and presented correctly,
good analysis and synthesis of the topic. Good use of
comparison and contrast, critical inquiry and interpretation,
interpretation is imaginative and valued.
Good to average: some knowledge of the subject; adequate
(8 pts) range of analysis and synthesis; limited use of examples;
mostly relevant to the topic but lacks detail in critical
interpretation; readings/ articles adequately support the
argument or topic but
may be too long or too short. Articles or readings shows some
originality.
(6 pts) Fair to poor: limited knowledge of the subject, minimal
substance, analysis and synthesis, inadequate use of
quotations, articles or readings. Interpretation is predictable
and or unfocused.
(4 pts) Very poor: shows little or no knowledge of the subject; lacking
analysis or synthesis of the materials and lacking good
examples; inadequate quantity; not relevant, or not enough to
rate. Interpretation is copied.
Organization and Format
Excellent to very good: clear statement of ideas, clear
organization of thoughts (beginning, middle, and end) and
(10 pts) smooth transitions; introduction leads reader into topic;
conclusion effectively summarizes main points; bibliographical
material length, spacing, fonts, margin, numbered pages all
carefully adhered to.
Good to average: main ideas clear but loosely organized or
(8 pts) connected; little pertinent to the topic. Sequencing logical and
incomplete, bibliographical material and formatting adequate.
Fair to poor: ideas not well connected; little too general; poor
(6 pts) organization of thoughts, logical sequencing and development
lacking; formatting inadequate.
Very poor: ideas not communicated; no title; organization,
(4 pts) sequencing and transitions lacking, or not enough to rate,
formatting lacking.
Grammar, Vocabulary and Fluency
Excellent to very good: fluent expression; accurate use of
(10 pts) grammar. Complex range of vocabulary; accurate word or
idiom choice; mastery of construction of sentences.
Good to average: adequate fluency; significant mistakes in the
(8 pts) usage of grammar, some problems in the construction of
sentences; some spelling errors.
Fair to poor: low fluency; significant mistakes in the construction
(6pts) of sentences, frequent grammar and spelling errors; lack of
accuracy interferes with meaning.
Very poor: lacks fluency, no mastery of simple sentence
(4 pts) constructions, text dominated by errors, does not communicate
meaning, not enough to rate.
Appendix B.

PEDIATRIC VITAL SIGNS REFERENCE CHART

Developed by Dr. Chris Novak and Dr. Peter Gill for PedsCases.com.
July 10, 2018.
Appendix C.

COMMONLY USED ABBREVIATIONS IN NURSING

SYMBOL MEANING
a: Before
@: at
A&P: anterior and posterior
aa: of each
abd: abdomen
ABGs: arterial blood gases
ac: before meals
American Diabetes Association or American Dietetic
ADA: Association
ad lib: as desired or as freely as desired
ADH: antidiuretic hormone
ADL: activities of daily living
AF: atrial fibrillation
AFB: acid-fast bacillus
Ag: silver or antigen
American Hospital Association or American Heart
AHA: Association
AHCD: advanced health care directive
AIDS: acquired immune deficiency syndrome
AKA: above the knee amputation
acute lymphocytic leukemia or acute lymphoblastic
ALL: leukemia
ALOC: altered level of consciousness
ALS: amyotrophic lateral sclerosis
a.m.a.: against medical advice
A.M.A.: American Medical Association
AMB or amb: ambulatory
acute myocardial infarction or anterior myocardial
AMI: infarction
amp: ampule
ANA: antinuclear antibody test or American Nurses Association
AP: apical pulse or anterior and posterior
acute respiratory distress syndrome or adult respiratory
ARDS: distress syndrome
AS: aortic stenosis
ASA: aspirin or acetyl salicylic acid
ASD: atrial septal defect
ASHD: arteriosclerotic heart disease
AST: aspartate aminotransferase
AV: atrio-ventricular or arterio-venous
ax: axillary
Ba: barium
BE: barium enema
bid: two times a day
BKA: below the knee amputation
BM: bowel movement
BMR: basal metabolic rate
BP: blood pressure
BPH: benign prostatic hypertrophy
BR: bedrest
BRP: bathroom privileges
BSA: body surface area
 BSC: bedside commode
BSE: breast self-examination
BSI: body substance isolation
BSO: bilateral salpingo-oophorectomy
BUN: blood urea nitrogen
bx: biopsy
c: with
C: Centigrade
C&S: culture and sensitivity
++ calcium
Ca :
CA: cancer or carcinoma
CABG: coronary artery bypass graft
CAD: coronary artery disease
cap: capsule
CAPD: continuous ambulatory peritoneal dialysis
CAT: computed axial tomography
cath: catheter or catheterize
CBC: complete blood count
CBI: continuous bladder irrigation
CBR: complete bedrest
cc: cubic centimeter
CCU: Coronary Care Unit or Critical Care Unit
CC: chief complaint
CDC: Centers for Disease Control
CDE: Certified Diabetes Educator
CEA: carcinoembryonic antigen
cg: centigram
CHF: congestive heart failure
CHO: carbohydrate
CKD chronic kidney disease
- chloride or chlorine
Cl :
cm: centimeter
CMS: circulation, movement, sensation or color, movement,
sensation
CN: cranial nerve
CNS: central nervous system
c/o: complains of or complaint of
CO: cardiac output or carbon monoxide
CO2: carbon dioxide
COPD: chronic obstructive pulmonary disease
CPK: creatinine phosphokinase
CPM: continuous passive motion
CPR: cardiopulmonary resuscitation
CRT: capillary refill time
CSF: cerebrospinal fluid
CT: computed tomography or chest tube
CVA: cerebrovascular accident or costovertebral angle
CVP: central venous pressure
CXR: chest x-ray
dc; D/C: discontinue
D&C: dilation and curettage
DIC: disseminated intravascular coagulation
diff: differential or differential blood count
dil: dilute or diluent
DKA: diabetic ketoacidosis
dl: deciliter
 DM: diabetes mellitus or diastolic murmur
DNR: do not resuscitate
DOE: dyspnea on exertion
DSD: dry sterile dressing
DTR: deep tendon reflex or deep tendon reflexes
DVT: deep vein thrombosis
DW: daily weight
D5W: 5% dextrose in water
dx; DX: diagnosis
EC: enteric-coated
ECF: extracellular fluid
ECG; EKG: electrocardiogram
ECT: electroconvulsive therapy
EDB: estimated date of birth
EDD: estimated date of delivery
EEG: electroencephalogram
EGD: esophagogastroduodenoscopy
elix: elixir
EMG: electromyogram
ENT: ear, nose and throat
EOM: extra-ocular movements
ER: extended release or Emergency Room
ESR: erythrocyte sedimentation rate
ESRD: end-stage renal disease
ESRF: end-stage renal failure
ET: enterostomal therapist
ETOH: ethyl alcohol or ethanol
F: Fahrenheit
Fe: iron
FeSO4: iron sulfate
FHR: fetal heart rate
FSBS: fingerstick blood sugar
f/u: follow up
FUO: fever of unknown origin
fx; Fx: fracture or fractional urine test
g; gm; Gm: gram
GERD: gastroesophageal reflux disease
GI: gastrointestinal
gr: grain
grav I, II, III, etc: gravida (pregnancy) 1, 2, 3, etc.
GSW: gunshot wound
gtt: drop or drops
GTT: glucose tolerance test
GU: genitourinary
GYN; Gyn: gynecological
h: hour
+ hydrogen ion
H :
H/A: headache
H/H: hemoglobin and hematocrit
H&P: history and physical examination
HAV: hepatitis A virus
Hb; Hgb: hemoglobin
HBAg: hepatitis B antigen
HBV: hepatitis B virus
- bicarbonate
HCO3 :
Hct; HCT: hematocrit
 HCV: hepatitis C virus
HEENT head, eyes, ears, nose and throat
HD: hemodialysis
Hg: mercury
HHNS: hyperglycemic hyperosmolar nonketotic syndrome
HIPAA: Health Insurance Portability and Accountability Act
HIV: human immunodeficiency virus
h/o: history of
H2O: water
HOB: head of bed
HOH: hard of hearing
HR: heart rate
hs: at bedtime
HTN: hypertension
I&D: incision and drainage
I&O: intake and output
ICD: implantable cardiac defibrillator
ICF: intracellular fluid
ICP: intracranial pressure
ICU: intensive care unit
ID: intradermal
Ig: immunoglobulin
IHI: Institute for healthcare improvement
IM: intramuscular
INR: International Normalized Ratio
IOM: Institute of Medicine
IOP: intraocular pressure
IPPB: intermittent positive pressure breathing
IS: incentive spirometry
IV: intravenous
IVDA: intravenous drug abuse
IVP: intravenous push or intravenous pyelogram
JVD: jugular vein distention or jugular venous distention
+
K : potassium
Kg: kilogram
KUB: kidney, ureters, bladder
KVO; kvo: keep vein open
L; l: liter
LA: left atrium or left atrial
LBBB: left bundle branch block
LDH: lactic dehydrogenase
LLL: left lower lobe
LLQ: left lower quadrant
LMP: last menstrual period
LOC: level of consciousness
LP: lumbar puncture
LUL: left upper lobe
LUQ: left upper quadrant
LV: left ventricle or left ventricular
LVH: left ventricular hypertrophy
lytes: electrolytes
m: meter
m; min: minim
MAP: mean arterial pressure
M.A.R.: Medication Administration Record
mcg: microgram
MCV: mean corpuscular volume or mean cell volume
MDI: metered dose inhaler
meq: milliequivalent
met(s): metastasis or metastases
mg: milligram
Mg: magnesium
MI: myocardial infarction
Mobile Intensive Care Unit or Medical Intensive Care
MICU: Unit
ml: milliliter
mm: millimeter
MR: mitral regurgitation
MRI: magnetic resonance imaging
MRSA: methicillin resistant staph aureus
MS: multiple sclerosis or mitral stenosis
MVA: motor vehicle accident
MVC: motor vehicle crash
MW: molecular weight
N: nitrogen
Na: sodium
NaCl: sodium chloride
neg: negative
NG: nasogastric
NICU: Neonatal Intensive Care Unit
NIH: National Institutes of Health
NKA: no known allergies
NKDA: no known drug allergies
NMR: nuclear magnetic resonance
noc: night
NPO: nothing by mouth
NPSG National Patient Safety Goals
NS: normal saline
NSAIDS: nonsteroidal anti-inflammatory drugs
NSR: normal sinus rhythm
NWB: non weight bearing or no weight bearing
O&P: ova and parasites
O2: oxygen
OOB: out of bed
OR: Operating Room
ORIF: open reduction and internal fixation
O.T.: Occupational Therapy or Occupational Therapist
OTC: over the counter
p: after
P: pulse
PA: pulmonary artery
PACU: Postanesthesia Care Unit
pc: after meals
PCA: patient-controlled analgesia
PCN: penicillin
PE: pulmonary embolus or physical examination
PEEP: positive end expiratory pressure
PEG: percutaneous endoscopic gastrostomy
per: through or by way of
PERRLA: pupils equal, round, reactive to light and accommodation
PHI Protected Health Information
PICC: peripherally inserted central catheter
PID: pelvic inflammatory disease
 PMH: past medical history
PMI: point of maximum impulse or point of maximal impulse
PNA: pneumonia
PND: paroxysmal nocturnal dyspnea
po: by mouth
P.O.D.: post-operative day
pos: positive
postop: postoperative or after surgery
PPD: purified protein derivative
ppd: packs per day
PPN: partial parenteral nutrition
preop: preoperative or before surgery
PRN: as needed
PSA: prostate specific antigen
pt; Pt: patient
Physical Therapy or Physical Therapist or prothrombin
PT: time
PTCA: percutaneous transluminal coronary angioplasty
PTT: partial thromboplastin time
PUD: peptic ulcer disease
PVC: premature ventricular contraction
PVD: peripheral vascular disease
q: every or each
qid: four times a day
qs: quantity sufficient
QSEN: Quality and Safety Education for Nurses
R: respirations
RA: rheumatoid arthritis or right atrium
RBC: red blood cell
RLL: right lower lobe
RLQ: right lower quadrant
RML: right middle lobe
R/O: rule out
ROM: range of motion or rupture of membranes
ROS: review of systems
RRR: regular rate and rhythm
r/t: related to
RT: Respiratory Therapist or Respiratory Therapy
RUL: right upper lobe
RUQ: right upper quadrant
RV: right ventricle or right ventricular
Rx: treatment or take
s: without
SBO: small bowel obstruction
SCD: sequential compression device
SGOT: serum glutamic oxaloacetic transaminase
SICU Surgical Intensive Care Unit
SL; sl: Sublingual
SLE: systemic lupus erythematosus
SNF: Skilled Nursing Facility
S.O.A.P.: subjective, objective, assessment, plan
SOB: shortness of breath
sol: solution
s/p: status post
SR: sustained release
s/s: signs and symptoms
STAT: immediately
 STD: sexually transmitted disease
Subcut: subcutaneous
supp: suppository
susp: suspension
SVT: supraventricular tachycardia
sx: symptoms or signs
T: temperature
T&C: type and cross
TAH: total abdominal hysterectomy
TB: tuberculosis
TCDB: turn, cough, deep breathe
TEA: thromboendarterectomy
THR: total hip replacement
TIA: transient ischemic attack
TJC: The Joint Commission
tid: three times a day
TKO: to keep open
TKR: total knee replacement
TPN: total parenteral nutrition
TPR: temperature, pulse, respirations
TSH: thyroid stimulating hormone
TURP: transurethral resection of the prostate
UA: urinalysis
up ad lib: up as desired or up as freely as desired
URI: upper respiratory infection
US: ultrasound
UTI: urinary tract infection
V.A.C.: vacuum assisted closure
VS: vital signs
VTBI: volume to be infused
W/A: while awake
WBC: white blood count or white blood cell
WC: wheelchair
WNL: within normal limits
wt: weight
Appendix D.
MEDICAL PREFIXES

PREFIX MEANING EXAMPLE

a-, an-, in- Without, Amenorrhea- without a monthly flow
negative
ab- From, away Abnormal- away from normal
from
ad-, ac-, as-, at- To, toward Adduct- carry toward
aniso- Unequal Anisocytosis- abnormal condition of
unequal cells
ante-, pre- Before Anterior-front; prenatal- before birth
anti-, ant, ob- Against Antipyretic- agent used against fever
bi- to Bilateral- two sides
bio- life Biology- study of life
brachy short Brachydactylism- short fingers and
toes
brady slow Bradycardia- slow heart rate
cent- hundred Centimeter- 1/100 of a meter
circum- Around Circumcision- to cut around
co-, com, con- With, together Congenital- born with
contra- Against Contraindicated- against indication
de- Away from Dehydrated- loss of water
dextro- right Dextrocardia- heat displaced to right
dia- through Diarrhea- flow through
dis- apart Dissect- to cut apart
dys- bad, difficult Dyspnea- difficult breathing
e-, ex- out, out from Excise- to cut out
ect-, exo-, extra- outside Extracorporeal- outside the body
en- in, on Encapsulated- in a capsule
end- within Endoscopy- visualization within
epi- upon Epidermis- upon the skin
eu- good Euphonic- good sound
hemi-, semi- half Hemigastrectomy- surgical removal of
half of the stomach
hyper- over, above Hyperkinetic- overactive
hypo- under, below Hypoglossal- under the toungue
immune- free, exempt Immunity-exempt from the effects of
specific disease-causing agent
infra- beneath Inframammary- beneath the breast
inter- between Intercellular- between the cells
intra- within Intracranial- within the cranium
kilo thousand Kilogram- 1,000 grams
lyso- dissolution, Lysosome- organelle that degrades
disintegration worn cell parts
macro- large Macrocyte- large cells
mal- bad Malnutrition- bad nourishment
mes- middle Mesentery- middle of intestine
meta- after, beyond Metacarpals- beyond the carpals
(wrist)
micro- small Microcephalic- having a small head
milli- one-thousandth Milliliter- 1/1000 of a liter
multi- many Multipara- one who has many children
neo- new Neoplasm- new growth
olig- scanty, few Oliguria- scanty amount of urine
onc- tumor Oncology- study of tumors
per- through Percutaneous- through the skin
peri- around Peritonsillar- around the tonsil
pleur- rib, side Pleural membranes, serous
membranes that encloses the lungs
poly- much, many Polycystic- many cysts
post- after Postmortem- after death
pre- before Prenatal- before birth
presby- old Presbyopia- old vision
primi- first Primigravida- first pregnancy
pro- before Prognosis- foreknowledge, predict
outcome
re- back , again Regenerate- produce, develop again
retr- behind Retrosternal- behind the sternum
sub- under Sublingual- below the tounge
super-, supra- above Superior- above
syn-, sym- with, together Synergism- working together
tachy- fast Tachyphasia- fast speech
Appendix E.
MEDICAL SUFFIXES

SUFFIX MEANING EXAMPLE

-algia Pain Dentalgia- pain in the tooth
-atresia Without an Procatresia – rectum without and
opening opening
-cele Hernia Omphalocele- umbilical hernia
-centesis Puncture to Arthrocentesis- puncture to aspirate
aspirate fluid from a joint
-cept Take, receive Receptor- something that receives
again
-cide Kill Bactericidal- able to kill bacteria
-cis Cut Circumcision- cutting around
-cyte Ell Erythrocyte- red cell
-denia Pain Cephalodenia- pain in the head
-desis Fusion Arthrodesis- fusion of a joint
-ectasia Expansion Corectasis- expanding/ dilating pupil
-ectomy Cut out, excise Nephrectomy- surgically remove
kidney
-edema Swelling Cephaledema- swelling of head
-emesis Vomiting Hyperemesis- excessive vomiting
-emia Blood Hyperglycemia- elevated blood sugar
-ognosis Knowledge Diagnosis- knowledge through
examination (determining cause of
disease)
-gram Record Myelogram- Xray of the spinal cord
-graphy Making a record Angiography-making a record of the
vessels
-iasis Condition Cholelithiasis- condition of gallstones
-ist One who Optometrist- one who measures vision
-it is Inflammation Adenitis- inflammation of a gland
-lepsy Seizures Narcolepsy- seizures of numbness
-logist One who Ophthalmologist- one specializing in
specializes eyes
-logy Study of Biology- study of life
-lysis, -lytic, -lyze Break down, Tenolysis- distruction of tendons
dissolved
-lyt Dissolvable Electrolyte- substance
-malacia Abnormal Osteomalacia- abnormal softening of
softening bone
-mania Madness Pyromania- irresistible urge to set fire
-megaly Enlargement Splenomegaly- enlargement of the
spleen
-meter Measure Thermometer- instrument to measure
temperature
-oid Resembling Mucoid- resembling mucus
-oma Tumor Neurma- nerve tumor
-opia Vision Amblyopia- dim vision
-osis Abnormal Nephrosis- abnormal condition of
condition kidney
-osme Smell Anosmia- inability to smell
-ostomy Create an Colostomy- create an opening in the
opening colon
-otia Ear Macrotia- large ear
-pathy Disease Encephalopathy- disease of the brain
-penia Deficiency, poor Leukocytopenia- deficiency of white
cells
-pepsia Digestion Dyspepsia- bad digestion
-pexy Surgical fixation Nephropexy- surgical fixation of kidney
-phasia Speak, say Aphasia- inability to speak
-philia Love, attraction chromophillic
-phobia Abnormal fear Agoraphobia- abnormal fear of crowds
-plasia Formation Hyperplasia- excessive formation
-plasm Substance Protoplasm- original substance
-plasty Make, shape Rhinoplasty- to shape the nose
-plegia Paralysis Hemiplegia- paralysis of one half of
body
-pnea Breath Tachypnea- fast breathing
-ptosis Prolapse, Hysteroptosis- prolapse of uterus
dropping
-rrhagia Burst forth Metorrhagia- hemorrhage from uterus
-rrhaphy Suture, sew Herniorrhaphy- suture of hernia
-rrhea Flow, discharge Otorrhea- discharge from ear
-rrhexis Rupture Splenorrhexis- rupture of the spleen
-scope Instrument for Otoscope- instrument to look in ears
viewing
-scopy Visualization Laryngoscopy- visualization of larynx
-some, -soma Body Lysosome- body that lyses/ dissolves
-spasm Twitching Blepharospasm- twitching of eyelids
-stasis Stop, control Hemostasis- control bleeding
-therapy Treatment Hydeotherapy- treatment with water
-tome Instrument to Osteotome- instrument to cut bone
cut
-tomy To cut Laparotomy- to cut into the abdomen
-tripsy Crushing Nephrolithotripsy- crushing stone in
kidney
-trophy, -trophic, - development Hypertrophy- over deveolpment
trophin
-uria Urine Hematuria-blood in the urine
Appendix F.
MEDICAL ROOTS

ROOTS MEANING EXAMPLE

Acr- Extremity Acromegaly- enlarged extremities
Acrophobia- abnormal fear for heights
Aden- Gland Adenopathy- disease of a gland
Aer- Air Aerophagia- swallowing air
Angi- Vessel Angioma- tumor of a vessel
Arthr- Joint Arthralgia- pain in the joint
Blast- Bud, growing Neuroblast- growing nerve cell
thing
Blephar- Eyelid Blepharoptosis- drooping of eyelid
Brachi- Arm Brachial- pertaining to the arm
Bronch- Windpipe Bronchus- a branch of the trachea
(windpipe)
Carcin- Cancer Adenocarcinoma- cancerous tumor of a
gland
Cardi- Heart Myocarditis- inflammation of heart
muscle
Carp- Wrist Flexor carpi- muscle to bend wrist
Caud- Tail Caudal- pertaining to tail
Celio- Abdomen Celiotomy- incision of the stomach
Cephal- Head Cephalodynia- pain in the head
Cervic- Neck Cervicitis- inflammation of the neck of
the uterus
Cheil- Lip Cheiloplasty- shaping the lip
Cheir, Chir Hand Chiromegaly- large hands
Chol- Bite, gall Cholecystectomy- surgical removal of
the gallbladder
Chondr- Cartilage Chondro/ malacia- softening of the
cartilage
Chrom- Color Polychromatic- having many colors
Chron- Time Synchronous- occurring at the same
time
Col- Colon Megacolon- enlarged colon
Colp- Vagina Colporrhaphy- suture of vagina
Cost- Rib Intercostal- between ribs
Crani- Skull Craniotomy-incision into the skull
Cry- Cold Cryophilic- cold loving
Crypt- Hidden Cryptorchidism- hidden (undescended)
testicle
Cutan-, cut- Skin Subcutaneous- below the skin
Cyan- Blue Acrocyanosis- abnormal condition of
blueness of extremities
Cyst- Bladder Cystocele- bladder hernia
Cyt- Cell Thrombocyte- clotting cell (platelet)
Dacry- Tear Dacryorrhea- flow of tears
Dent-, odont- Tooth Periodontal- around the teeth
Dentalgia- toothache
Derm-, dermat- Skin Intradermal- within the skin
Dextr- Right Dextrocardia- heart displaced to the
right
Dips- Thirst Polydipsia- excessive thirst
Dors- Back Dorsal- pertaining to the back
Duct- Carry Oviduct- tube to carry ova (eggs)
Encephal- Brain Encephalocele- hernia of the brain
Enter- Intestine Gastroenteritis- inflammation of
stomach and intestines
Erg- Work Energy- working with
Erthyr- Red Erthyrocytopenia- deficiency of red
blood cells
Esthe- Sensation Anesthetic- agent to eliminate
sensation
Esthen- Weakness Myasthenia- muscle weakness
Febr- Fever Afebrile- without fever
Gastr- Stomach Gastroscopy- visualization of the
stomach
Gen- Produce Pathogenic- agent that produces
diseases
Ginggiv- Gums Gingivectomy- removal of gums
Gloss- Tongue Hypoglossal- under the tongue
Glyc-, gluc- Sugar Hypoglycemia- low blood sugar
Gnath- Saw Micrognathism- small jaw
Grav- Heavy Secundigravida- second pregnancy
Gynec- Female Gynecology- study of female conditions
Hem-, hemat- Blood Hematemesis-vomiting blood
Hepat- Liver Hepatomegaly- enlarged liver
Heter- Different Heterogeneous- different origins
Hidr- Perspiration Hidrorrhea- flow of perspiration
Troph- Turn Ectropion- turned out
Ur- Urine Uremia- urine constituents in the blood
Vas- Vessel Vasoconstriction- narrowing of a vessel
Vert- Turn Retroverted- turned backward
Vasic- Bladder Vasicocele- hernia of the bladder
Viscer- Internal organs Evisceration- process of viscera
protruding from abdominal wall
Vitra- Life Vital- necessary for life