Head Nursing Tool
Head Nursing Tool
Head Nursing Tool
Definition:
A head nurse is the one who assumes responsibility for managing the Human and
material resources of a nursing unit and takes lead in developing to provide quality
patient care and an environment conductive to staff growth and satisfaction.
General Objectives:
Student nurse will be able to develop their potentials of being efficient and
productive Leaders by nurturing and enhancing their leadership skills by providing
training in management in team handling. And be able to familiarize with the different
nurse responsibility.
Specific Objective:
• Apply principles on head nursing and provide nursing standards and policies, and
procedures regarding patients care to guide the subordinates.
• Promotes and utilize quality assurance of the program standards.
• Motivate the nursing staff to provide quality nursing care and improvement in
nursing care.
• Manage the flow of activities by implementation of the nursing plan based on the
nursing care.
• Develop a skill in decision-making and other qualities of an efficient head nurse.
• Coordinate and communicate with the other members of the health team in
providing patient care.
• Document accurately the observation of the services rendered to the patient.
• Supervises and evaluate the quality of patient care provided by the staff by
observing them through frequent rounds guided by the evaluation check list.
Subordinates:
Assumes the responsibility for the delivery of quality patient care to patients
within the unit.
1. Provide nursing standards and policies regarding patient care to guide the staff
nurses.
2. They have the responsibility of orienting and updating the staff of the systems and
standard of patient care.
3. Responsible for the implementation of the health care programs, and standards of
patient care.
4. Assumes the role of patient advocate.
5. Assumes the role of staff members advocate.
6. Acts as liaison with the medical staff to coordinate medical and nursing
management of patient care.
7. Serves as resource person to nursing personnel under him in assessing, planning,
implementation and evaluating nursing care provided.
8. Coordinates the patient care with the other members of the health care team.
9. Keeps superior informed regarding problems or issues in patient care.
10. Evaluates the quality of patient care through frequent rounds.
11. Evaluates the nursing standard cyclically to provide development of the new
standards of patient care.
STAFF NURSE
Definition
The staff nurse is to the one responsible for rendering holistic nursing care to
patient in assigned areas, the specific function and responsibilities of which depend upon
the organizational structure of the Nursing service.
General objective:
Student nurses will be able to develop their knowledge, attitudes and skills
through working on this training, and be able to appreciate the importance of team work
and working under a directory.
Specific Objective:
• Follow the nursing standards and policies imposed by the nursing administration.
• Develop a sense of responsibilities and accountabilities on their action they make.
• Provide a quality nursing care and services.
• Develop a good attitude towards the work.
• Be able to work harmoniously with the fellow students and members of the health
care team.
• Develop good nursing skills, attitude and gain knowledge for the future use.
The staff nurse initiate and perform nursing care and services to meet the needs patient in
assigned areas utilizing the nursing process.
1. Assesses the individual needs for nursing care based on patient’s history, results
of physical, diagnostic, and laboratory examinations.
2. Infers correct nursing diagnosis.
3. Plans and prioritizes nursing care activities considering overall health needs of the
patient.
4. Institute nursing intervention consistent with the overall plan of care with special
consideration of the patient’s safety and comfort.
5. Provides health teaching to patient, his family and significant others so that they
may understand this illness and participate actively in his care.
6. Coordinates patient care services with members of the health team.
7. Evaluates or modifies of nursing care by means of:
• Effectiveness and efficiency of nursing measures rendered.
• Feedback from patient/family and significant others.
8. Documents accurately the observation and services rendered to the patient.
Plan of Activities
Areas:
Shift: 6-2
Time Activities
5:30-6:00 Call time
Preconference
• Orientation
• Distribution of area of assignment
6:00-6:30 Endorsement
6:30-6:45 Rounds with the staff nurse
• Check the patient’s condition
• Check for the IVF level from the
time received
6:45-7:00 Chart reading
• Patient’s profile/data
• Diagnosis
• Past/Present history
• Doctor’s Order
7:00-7:30 • Medication and time of medication
7:30-8:30 Reporting
Preparation of medications/Drug
8:30-9:00 study/Vital signs
9:00-10:00 V/S Plotting
10:00-10:30 Case discussion
10:30-11:00 Break of the first half of the group
11:00-11:15 Break of the second half of the group
11:15-11:45 Drug Preparation
11:45-12:00 Drug study
12:00-12:30 Vital Signs and Giving medication
12:30-1:00 Quiz
1:30-2:00 Prepare for SOPIE
Vital Signs / Endorsement
Shift: 2-10
Time Activities
1:30-2:00 Call time
Preconference
• Orientation
• Distribution of area of assignment
2:00-2:30 Endorsement
2:30-2:45 Rounds with the staff nurse
• Check the patient’s condition
• Check for the IVF level from the
time received
2:45-3:00 Chart reading
• Patient’s profile/data
• Diagnosis
• Past/Present history
• Doctor’s Order
3:00-3:30 • Medication and time of medication
3:30-4:00 Reporting
Preparation of medications/Drug study
4:00-4:15 V/S Plotting
4:15-5:00 Vital signs
5:00-5:30 Case discussion
5:30-6:00 Break of the first half of the group
6:00-7:15 Break of the second half of the group
7:15-7:45 Drug Preparation
7:45-8:00 Drug study
8:00-8:30 Vital Signs and Giving medication
8:30-9:00 Lecture
9:00-9:30 Prepare for SOPIE
9:30-10:00 Quiz
Endorsement
Shift: 10-6
Time Activities
9:30-10:00 Call time
Preconference
• Orientation
• Distribution of area of assignment
10:00-10:30 Endorsement
10:30-10:45 Rounds with the staff nurse
• Check the patient’s condition
• Check for the IVF level from the
time received
10:45-11:00 Chart reading
• Patient’s profile/data
• Diagnosis
• Past/Present history
• Doctor’s Order
11:00-11:30 • Medication and time of medication
11:30-12:00 Reporting
Preparation of medications/Drug study
12:00-12:15 V/S Plotting
12:15-1:00 Vital signs / Giving medications
1:00-1:30 Case discussion
1:30-2:00 Break of the first half of the group
2:00-2:15 Break of the second half of the group
2:15-2:45 Drug Preparation
2:45-3:00 Drug study
3:00-3:30 Vital Signs and Giving medication
3:30-4:00 Lecture
4:00-4:30 Prepare for SOPIE
4:30-5:00 Quiz
Endorsement
University of Perpetual Help System-Binan Campus
Dr. Jose G. Tamayo Medical University
Sto.Nino, Binan Laguna
COLLEGE OF NURSING
Name: ________________________
Date:________________
Year___ Section___ Group Number___
Rating:_______________
Direction: Put a check on the skills observed / performed, of not please include
remarks on the space provided.
Legend:
COLLEGE OF NURSING
Name: ____________________________
Date:_________________
Year___ Section___ Group Number___
Rating:_______________
Direction: Put a check on the skills observed / performed, of not please include
remarks on the space provided.
Legend:
COLLEGE OF NURSING
Name: ____________________________
Date:_________________
Year___ Section___ Group Number___
Rating:_______________
Direction: Put a check on the skills observed / performed, of not please include
remarks on the space provided.
Legend:
A. KNOWLEDGE 3 2 1 REMARKS
Subtotal:
B. SKILLS 3 2 1 Remarks
1. Checks, records and interprets accurately the
vital signs of assigned patients.
2. Ability to manipulate and care for the
equipment.
3. Ability to collect specimens for the
laboratory examination.
4. Demonstrate skill in providing
comprehensive nursing care.
5. Performs nursing procedures with maximum
result with minimum time, effort and materials
at her/his level.
6. Implements nursing care according to
priorities.
7. Provides health teaching for patient and his
family as manifested by good communication
skill.
8. Coordinates with other members of the
health team with regards to patient’s condition.
9. Ability to transcribe doctor’s order.
10. Records accurately patient’s condition’s
and nursing intervention.
Subtotal:
_____________________
________________________
Name:
____________________________________Date:___________________
Yr/Sec:______________Group:___________
Rating:__________________
Area:____________________Clinical Instructor:__________________________
P E R F O R M A N C E E V A L U A T I O N T O O L
NUMERICAL
QUANTITATIVE DESCRIPTION
RATING
Outstanding Carries out expected tasks in a very consistent manner with
5
minimal guidance and supervision
Very Carries out expected tasks in a consistent manner with
4
Satisfactory minimal guidance and supervision
Satisfactory Carries out expected tasks in a moderately consistent
3
manner with frequent guidance and supervision
Needs Carries out expected tasks in a rarely consistent manner
2
Improvement with close guidance and supervision
Unsatisfactory Does not carry out expected tasks even with close guidance
1
and supervision
PERFORMANCE RATING
I. ASSESSMENT / PLANNING
1.1 Establishes rapport with subordinates
1.2 Able to involve patients in plan of care
1.3 Punctual and prompt in all activities
1.4 Able to maintain stability under pressure
1.5 Gathers data using interview, observation, records review
and reports
1.6 Formulates appropriate nursing care plan
1.7 Wears complete prescribed RLE uniform
II. IMPLEMENTATION
a. Carries out assigned tasks based on the criteria of distribution
of assignments
b. Follows principles of time management
c. Equipped with required paraphernalia for RLE
d. Observes proper channels of communication
e. Carries out plan of care, including:
A. Bedside Care
B. Administration of medications
C. Administration of treatments (nebulization, IVF)
f. Shows initiative in performing tasks
g. Accomplishes delegated tasks within prescribed time frame
h. Provides psychological and spiritual support to patients
i. Accepts supervision and criticisms
j. Conducts appropriate health teachings
III. EVALUATION
1. Notifies immediate superior about untoward situations or
conditions related to patient care in the area
2. Make revisions in the plan of care as necessary
3. Evaluates Nursing Care rendered
V. ETHICOLEGAL CONSIDERATIONS
1. Demonstrates honesty at all times
2. Conducts self in a tactful manner
3. Keeps confidential patient information
4. Observes the PNA Code of Ethics
5. Guided by RA 9173
6. Observes the 11 Core Competency Guidelines
REMARKS :
CONFORME BY :
NOTED BY:
CLINICAL INSTRUCTOR
UPH- Dr JOSE G. TAMAYO MEDICAL UNIVERSITY
Sto. Niño Biñan, Laguna
College of Nursing
HEADNURSE
1. Supervises and evaluates the quality of patient care through frequent rounds
2. Oversees the action of assigned staff nurse, medication nurse and chart nurse.
3. Familiarized and take care of the emergency cart.
4. Takes note of the special procedures for the patients within the unit.
5. Keep superiors informed regarding the problems and issues in patient care with
the nursing unit.
6. Participates in the selection of nursing staff for the unit.
7. Presents changes or innovations to staff in a positive manner.
8. Provides conducive climate for work and maintains effective communication
within the unit department.
9. Makes the 24 hrs. Nursing report of the unit.
10. Checks daily time record of the staff.
STAFF NURSE
MEDICATION NURSE
CHART NURSE
1. Record all the vital signs taken on the TPR sheet on the patients chart.
2. Must know the normal values of BP, PR, RR and Temperature.
3. Reports intake and output
4. Makes a narrative report of the vital signs recording system for the shift then
submit to the assigned student head nurse.
UPH- Dr JOSE G. TAMAYO MEDICAL UNIVERSITY
Sto. Niño Biñan, Laguna
College of Nursing
E N D O R S E M E N T S H E E T
Name: ______________________________Date:______________
Yr/Sec: ______________Group:__________ Area: _____________
Clinical Instructor: _____________________
BED # :______________________________
PATIENT’S NAME: ______________________________
AGE : ______________________________
DIAGNOSIS : ______________________________
VITAL SIGNS:
____
TEMP = ____
CR = ____
PR = ____
RR = ____
BP = ____
____
TEMP = ____
CR = ____
PR = ____
RR = ____
BP = ____
DIET : ______________________________
INTAKE : ______________________________
OUTPUT : ______________________________
IV INFUSED : ______________________________
ORAL ____
VOM ____
NGT ____
TOTAL____
A. Knowledge 5 4 3 2 1
1. Applies as appropriate theory as a basis for
decision making in nursing practice.
2. Assesses staffs presenting symptoms to
determine a nursing diagnosis and plan of
action based on a medical expertise and
knowledge.
3. Knowledge in communication, clarification and
interpretation of existing problems with staff
and nursing responsibilities.
4. Inform the staff of the likely causes of errors
defects and waste.
5. Suggest in which risk, errors, quality of
problems maybe reduce.
B. Attitude
1. Neat and well groomed. Adheres to dress
code.
2. Punctual in reporting for duty
3. Complies with the code of ethics of the nursing
profession and upholds and implements school
rules.
4. Assist in training staff in particular by setting a
good example.
5. Promotion of professional responsibility,
accountability and behavior.
C. Skills
1. Provide leadership in the assessment,
planning, implementation, and evaluation of
comprehensive school health program.
2. Respond to the student/ staff medical
emergencies.
3. Instruct subordinates in appropriate method
and procedure in providing care.
4. Initiate and facilitate any steps necessary to
improve methods, equipments, materials and
condition in the work area for which they are
responsible.
Equivalent: ______________ Rating: _______________
Scaling Interpretation
_____________
Total 100%
Prepared By:
CABANISAS, AGNES LIBERTY M.
BSNIV-(F) 6 Group 18
PERFORMANCE CHECKLIST
KNOWLEDGE 5 4 3 2 1
1. Gathers data appropriately and
completely, then validating it focusing
function needing assistance support
2. Analyze and interpret collected data
3. Knows the correct way of doing physical
assessment.
4. Gives attention and synthesize the
significant laboratory findings
5. Knowledge in identifying nursing
problems and categorizing it according to
the patients need.
6. Knows the rationale behind every
intervention given for the care of the
patient.
7. Have knowledge in giving proper
instruction for medicine
a. classification
b. nursing responsibility
c. drugs and solution
8. Explain or discuss the report clearly and
able to answer question correctly.
9. Knowledge in preparation of patient for
any diagnostic procedure
10. Knows how to formulate an accurate
nursing care plan for particular cases.
SKILLS 5 4 3 2 1
1. Ability to give and respond to the care
needed by the patient
2. Perform procedure properly such as
doing physical assessment, taking VS,
and giving medication as ordered.
3. Able to provide or assist patient in
performance of activities of daily living
whenever needed.
4. Always guided in precautionary and
preventive measure in providing care to
the patient.
5. Able to give health teachings clearly to
the patient.
6. Communicate effectively in identifying the
needs of the patient.
7. Properly handling an instance of
emergency situation.
8. Implement Nursing care plan
appropriately
9. Reassesses patient to determine whether
a remodification of care plan is
necessary.
10. Able to conduct discharged planning
with the patient, his family and significant
others.
Legend:
5 – Outstanding (85)
4 – Very Satisfactory (83-84)
3 - Moderately satisfactory (81-82)
2 – Minimally satisfactory (75-80)
1 – Unsatisfactory (74 and below)
PLAN OF ACTIVITIES
2-10 shift
10-6 shift
General Objective:
As a student nurse, she will be able to acquire knowledge and at
the same time practice her own leadership and management skills, and
understand thoroughly the importance of being systemically in rendering nursing
care the patients.
Specific Objectives:
Subordinates
General Objective:
As a nursing student, he/she will show a better knowledge, skills
and attitude in rendering their task while working with their fellow students and
able to acknowledge the value of having a director.
Specific Objectives: