Ateneo de Zamboanga University

COLLEGE OF NURSING

Name: Sheryhan Tahir Bayle

Clinical Experience: Nursing Care Management
Clinical Area: Hospital
Placement: First Semester (level 3)
Rotation: Week 5-6
Day and Time: 8:00 am- 3:00 pm (Thursday, Friday, Saturday)
Clinical Instructor: Mrs: Jana Rivera, RN
Case Scenario: Post- Cataract Surgery
Marcella is a 60 year old single woman who presented herself to the emergency department,
with a chief complaint of progressive diminished vision and increased difficulty with night
driving, R eye. Vital signs was taken and as follows: T- 37.0˚C, PR – 72bpm, RR – 18bpm and BP –
120/70mmHg. Her physician suspects that Marcella has a cataract and does a complete eye
examination and history.
Upon routine eye check-up and laboratory, it was confirmed that Marcella has cataract R eye
and was scheduled for surgery.
After the surgery, the physician ordered the following:
- Flat on bed until fully awake.
- Vital signs monitoring every 15 mins for the 1st hour, then 30 mins until stable.
- Diet as tolerated when fully awake
- Don’t rub affected eye
- Stay away from dusty areas
- Medications:
o Chloramphenicol 1 drop 4x a day to affected eye for 2 weeks
o Dexamethasone eye drop 1 drop 4x a day for 2 weeks

General Objectives:

Acquisition and application of knowledge, skills, and attitude through the utilization of nursing process in
the care of patients with infectious and inflammatory diseases with emphasis on health promotion,
prevention, and maintenance of health.

Learning Objectives:

At the end of the 24 hours of Related Learning Experience, I will be able to:

1) Acquire knowledge about Pneumonia properly.

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COLLEGE OF NURSING

2) To be oriented with the policies and protocols of current hospital

3) Acquire knowledge about the process of activities required in this hospital
4) Utilize/demonstrate the skills needed for Physical Assessment of patients properly
5) Assess the given patient’s health condition with Gordon’s Assessment
6) Determine the possible complication on a patient with Pneumonia
7) Identify the signs and symptoms of the presented medical condition
8) Determine the medical equipment/ nursing kit needed for physical assessment
9) Assess the heath condition of the 50-year old male carefully

Plan of Activity

Time Activities
Day 1
6:45 am – 7:00 am - Arrival at the waiting area

7:00 am – 7:15 am - Arrival at hospital and Checking of uniform and

attendance

7:15 am – 7:30 am - Sub-grouping the members and delegation of

areas of responsibilities

7:30 am – 7:45 am - Courtesy call to the Head Nurse, Staff Nurses,

and other health personnel

7:45 am – 8:00 am - Orientation regarding hospital setting

8:00 am – 8:15 am - Nurses go for rounds

8:15am – 8:30 am - Introduction with patient, inform about

physical assessment and Gordon’s assessment
and get vital signs of patient

8:30 am – 9:00 am - Ask questions with patient regarding

medications taken and current state and
provide morning care

9:00 am – 9:15am - Break time. Remind the group to stay inside

hospital premises.

9:15 am – 11:00 am - Assemble equipment for physical assessment

and start assessment with patient

11:00 am – 12:00 pm - Ask questions with patient while utilizing

Gordon’s assessment pattern

12:00 pm – 12:30 pm - Lunch

12:30 pm – 1:15 pm - Checking of attendance

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1:15 pm – 1:30 pm - Check and document patient’s vital signs

1:30 pm – 2:00 pm - Assist nurse on duty in administering

medication to patient

2:00 pm – 2:30 pm - Complete charting

2:30pm – 2: 59 pm - Discuss activities throughout the day

3:00 pm - Dismissal

BATES ASSESSMENT TOOL

MENTAL STATUS
APPEARANCE

Grooming: Neat                             Attire: Casual

Personal Hygiene: Clean
Gait: Normal/straight walking pattern  Posture: Normal General Body Built: Normal

BEHAVIOR
Level of Consciousness:
( / ) Awake ( / ) Alert (  ) Lethargic
(  ) Drowsy (  ) Stupurous or unresponsive
( ) Aware and responsive of internal and external stimuli
Facial Expression:     Sad                         Speech: Normal   
Mood:       Restless                                           Affect: N/A

COGNITION

Oriented:     ( / )Person ( / ) Place       ( / ) Time         (  ) Confused    (  ) Sedated

      ( / ) Alert (  ) Restless    ( ) Lethargic  (  ) Comatose
Recent Memory: N/A
Remote Memory: N/A

THOUGHT PROCESS

Thought Content:     (  ) Logical (  ) Consistent

Client’s Perceptions: (  ) Reality-base (  ) Congruent with others
                                  (  ) Others: N/A
Suicidal Thoughts/Ideation: (   ) Present (   ) Absent

INTEGUMENTARY SYSTEM
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SKIN
INSPECTION
Color: ( / ) Normal (  ) Flushed (  ) Pale (  ) Dusky
             (  ) Cyanotic (  ) Jaundiced    (  ) Others: _________________________
Texture:Smooth                        Tone:                    
Lesions: ( ) Yes, site: _______ ( / ) No
PALPATION
Moisture: Temperature: 38°C
Turgor: _______________________
Edema: ( / ) Absent (  ) Present, site: _______________________
                                        (  ) Mild (  ) Moderate (  ) Severe
Pruritus: (  ) Yes, site: _________________ ( / ) No
Wound incision/pressure sore site: N/A  Dressing type: N/A
Odor: ( / ) None (  ) Mild (  ) Foul
Drainage/Exudates: (  ) Serous (  ) Sanguinous       (  ) Serosanguinous
Color:    (  ) Yellow (  ) Creamy (  ) Green       (  ) Beige/tan

NAILS
INSPECTION
Color: Pinkish Texture: Smooth  Configuration: Rounded  Symmetry: Symmetrical
Cleanliness: Well-trimmed

HEAD AND NECK

HEAD
INSPECTION
Head Structure and symmetry: Symmetrical
Hair Color: N/A     Thinning: (  ) Yes    (/ ) No

PALPATION
Temporal Artery: Normal
Cranium: Normal Scalp: Normal
Hair Texture: Smooth
Maxillary & Frontal Sinuses: Normal

EYES
INSPECTION
Conjunctiva:  R: Normal    L: Normal Sclera: R: Normal L: Normal
Cornea:          R: Normal L: Normal Iris:      R: Normal L: Normal
Ptosis:             R: None L: None
Visual Fields:  R: Normal L: Normal
Extraocular movements: : R: Normal L: Normal
Pupil: Color:  R: Black   L: Black         Size:  R: Equal   L: Equal
Response to Light & Accommodation: R: ______   L: ______

NOSE
INSPECTION
External Nose: Normal
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Nostrils: R: N/A    L: N/A

MOUTH
INSPECTION
Mouth & Throat Mucosa: Normal Tongue: Pinkish
Teeth and Gums: Complete teeth, symmetrical Floor of Mouth: Normal Palate: ______
Uvula: ______
Lesions and Ulcers: (  ) Yes, site: ____________ ( / ) No
Salivary Glands: ______

FACE
INSPECTION
Spasms: (  ) Yes, site: __________   ( /) No            
Tics:        (  ) Yes, site: __________ ( /) No
Lesions:  (  ) Yes: (  ) Mild   (  ) Moderate    (  ) Severe ( /) No              
Facial Paralysis: (  ) Yes R: _________    L: _________ (/ ) No

EARS
INSPECTION
Tympanic membrane: R: Intact ( /) Yes    (  ) No    L: Intact ( /) Yes    (  ) No    
Tragus of Ear: R: ______  L: ______
Canal:             R: ______  L: ______
Lesions: (  ) Yes, site: ___________    ( / ) No
Discharges: (  ) Yes, amount: ________  (  ) Left    (  ) Right   (  ) Both     ( / ) No

NECK
PALPATION
Thyroid gland size: Normal Shape: Normal
Tenderness: None Nodules: None
Position of Trachea: ______
Cervical Lymph Nodes: None

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: 32bpm
Pattern:     (  ) Shallow (  / ) Dyspnea (  ) Tachypnea (  ) Shortness of Breath
Chest Symmetry:    ( / ) Even (  ) Uneven
Chest Deformities:  (  ) Scoliosis (  ) Kyphosis (  ) Kyposcoliosis
PALPATION
Chest:     (  ) Masses, site: ____________
               (  ) Bulges, site: ____________

               (  ) Muscle Tone, site: ______________

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               (  ) Crepitus, site: ______________

               (  ) Areas of Tenderness, site:  ______________
               (  ) Subcutaneous Emphysema, site: ______________
Excursion:   (  ) Respiratory:       R: ______cms.      L: ______cms.      
PERCUSSION
Notes elicited: ______________ Site: __________________
AUSCULTATION
Excursion:   (  ) Diaphragmatic: R: ______cms.      L: ______cms.
Breath Sounds: 
Normal:         ( / ) Bronchial   (  ) Bronchovesicular         (  ) Vesicular
Adventitious: ( / ) Crackles-Coarse, site: bilateral lung fields
                       (  ) Crackles-Fine, site: ____________      
                       (  ) Stridor, site: ____________
                       (  ) Rhonchi/Gurgles, site: ____________
                       (  ) Wheezes, site: ____________
                       (  ) Pleural Friction Rub, site: ____________
Other Abnormal Findings: Voice Resonance:
(  ) Bronchophony (  ) Egophony (  ) Whispered
(  ) Pecteriloquy (  ) Pleural Friction Rub
Chest Abnormality Location (state):
Cough:   ( / ) Yes: Type:   ( / ) Productive: 
                                              Color of Sputum: Red   Amount: __________   
 (  ) Non-productive      (  ) No

CARDIOVASCULAR SYSTEM
NECK VESSELS
PALPATION
Carotid Artery: R: Normal L: Normal
AUSCULTATION 
Carotid Arteries:  Bruits: ( / ) Absent (  ) Present 
Jugular Vein Distention: (  ) Yes: _______cms.      ( / ) No

HEART
INSPECTION
Point of Maximal Impulse (PMI): ______
Thrills: (  ) Present ( / ) Absent
PALPATION – Perfusion: Capillary Refill:_seconds
Murmurs: ____

PULSES
 ( ) Regular    ( / ) Strong           (  ) Irregular        (  ) Weak         (  ) Absent
 (  ) Doppler     (  ) Pacemaker
Radial: R: _______ L: _______
Pedal:  R: ____________ L: ____________
Apical: R: ____________ L: ____________
BP:       R: 110/70 L: 110/70
GASTROINTESTINAL SYSTEM
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Mouth: ______
Throat: ______

ABDOMEN
INSPECTION
Contour: Flat
Symmetry: Symmetrical
Gastrostomy (specify): N/A
AUSCULTATION
Bowel sounds:(  ) High-pitched & Gurgling (  ) Hyperactive
(  ) Low-pitched (  ) Hypoactive
                          (  ) Tympany
Rate: _  per minute
PERCUSSION
Notes: ____________________________   Site:__________________________________
PALPATION
Abdomen:  (  ) Tender( / ) Soft/Non-Tender (  ) Firm (  ) Rigid
Mass:           ( / ) No (  ) Yes
Ascites:        ( / ) No (  ) Yes
Girth: ________________                      Inguinal Area: Normal

MUSCULO-SKELETAL SYSTEM
INSPECTION
Symmetry: Normal
Deformities: N/A
Others: _________________
Peripheral pulses:
Upper Extremities:  Radial:             R: ______ L: ______
                                Ulnar:               R: ______ L: ______
                                Brachial           R: ______ L: ______
Lower Extremities: Popliteal:          R: ______ L: ______
Dorsalis Pedis:  R:_____ L: ______
                                Posterior Tibia:R: ______ L: ______
Edema:  (  ) Yes (  )Pitting (Grade) _________            ( / ) No
Temperature: _______________________  Site: __________________________
RANGE OF MOTION: ( / ) Yes (  ) No, area:  _________________
Deformity: ______________________________________________________________
Discrepancy in Extremity (Leg) Length (  )Yes ______________ ( / ) No
PALPATION
(  ) Musculature ________________ (  ) Body articulation_____________________
(  ) Crepitations ________________ (  ) Heat_____________________________(  ) Swelling
____________________ (  ) Tenderness_______________________
Normal ROM of extremities: ( / ) Yes (  ) No
(  ) Weakness ( Paresis) (  ) Paralysis
(  ) Contractures (  ) Joint Swelling
(  ) Pain: (  ) Bone Pain (  ) Muscle Pain (  ) Joint Pain
(  ) Others: __________________________________________
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Hand Grasps: ( / ) Equal (  ) Unequal (  )Weakness (  ) R & L

Leg muscles:  ( / ) Equal (  ) Unequal (  ) Weakness (  ) R & L

NEUROLOGIC SYSTEM
 
CRANIAL NERVES
Olfactory Nerve (CN I)
 Normal
Optic Nerve (CN II)
 Normal
Oculomotor (CN III)
 Normal
Trochlear (CN IV)
 Normal
Trigeminal Nerves (CN V)
Abducens Nerve (CN VI)
 Normal
Facial Nerve (CN VII)
 Normal
Acoustic Vestibulocochlear Nerve (CN VIII)
 Normal
Glossopharyngeal Nerve (CN IX)
 Normal
Vagus Nerve (CN X)
 Normal
Spinal Accessory Nerve (CN XI)
 Normal
Hypoglossal Nerve (CN XII)
 Normal

CEREBELLAR FUNCTION
SENSORY SYSTEM
Discriminate Light Pain: (  ) Yes (  ) No
Detect Vibration: (  ) Yes (  ) No
Discriminate Light Touch: (  ) Yes (  ) No
Detect Temperature: (  ) Yes (  ) No
Detect Stereognosis: (  ) Yes (  ) No
Detect Graphesthesia: (  ) Yes (  ) No
Two-Point Discrimination: ( ) Yes (  ) No

DEEP TENDON REFLEXES

Insertion Tendon of Biceps (C5 to C6)
______________________________________________________________
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Insertion Tendon of Triceps (C7 to C8)

______________________________________________________________
Insertion Tendon of Brachioradialis (C5 to C6)
_____________________________________________________________
Insertion Tendon of Quadriceps/Knee Jerk (L2 to L4)
_____________________________________________________________
Insertion Tendon of Achilles/Ankle Jerk (S1 to S2)
______________________________________________________________________

SUPERFICIAL REFLEXES

Abdominal (upper T8 to T10, lower T10 to T12)

______________________________________________________________
Cremasteric Reflex (L1 to L2)
______________________________________________________________
Plantar Reflex
______________________________________________________________

GENITOURINARY
PERIANAL REGION
INSPECTION

(  ) Hemorrhoids: (  ) Bleeding ( / ) Not

(  ) Fissures (  ) Scars (  ) Lesions (  ) Rectal Prolapse
(  ) Fistula (  ) Discharge (  ) Blood in stool

PALPATION
(  ) Rectal Masses

MALE GENITALIA
INSPECTION
Hair Distribution: Even
Penis: Dorsal Vein: (  ) Yes   (  ) No
Urethral Meatus Appearance: _________________________________________
Bumps:   (  ) Yes, site: ___________  ( / ) No
             Blisters:    (  ) Yes, site: ___________  ( / ) No
Lesions:    (  ) Yes, site: ___________  ( / ) No
             Redness:  (  ) Yes, site: ___________  ( / ) No
Scrotum: R: ____________ L: ____________
Urine:   Color: Yellowish         Character: N/A
  Frequency per day: N/A Amount: N/A
(  ) Anuria (  ) Hematuria   (  ) Dysuria (  ) Incontinence
(  ) Catheter (Type): ______________________                
Others (specify): _________________________
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FEMALE GENITALIA
INSPECTION
Mons Pubis: _____ Labia Majora: ____
Labia Minora:_____ Clitoris:_____
Vagina:_____ Urinary Meatus: _____
Skene’s and Bartholin’s Glands: ______
Urine: Color: ____________        Character: ______
Frequency per day: ___________       Amount: ___________________
(  ) Anuria (  ) Hematuria   (  ) Dysuria (  ) Incontinence
(  ) Catheter (Type): _________________                Other:____________________
LMP: ______    ( ) Vaginal Discharges: __________________________________
Menstrual Problems:
(  ) Amenorrhea (  ) Dysmenorrhea (  ) Menorrhagia
(  ) Metrorrhagia (  ) Pre Menstrual Syndrome
Others (specify) ______________________________________
Age of Menarche:_ Length of Cycle: ________
Menopause: ___________________Last Pap Smear: ____________________
Monthly Breast Self Examination ( ) Yes(  ) No
Method of Birth Control: _____________________________
Obstetrical History: _________ AOG ________
POP:  ______ Weight:  ________ FT _______ FHT_______
Leopold’s Maneuver: ________________ Presentation: ___________________
Urine Test Result: ___________________ Pregnancy Test: 
(  ) Albumin _______ (  ) Sugar ________
(  ) Protein   _______ (  ) RBC    ________                (  ) Pus ________
Bleeding:     (  ) Yes, amount: ___________ (  ) No    
Uterine Discharges:
Rubra:  Color ________  Amount________         Odor________         
                Serosa:  Color_______ Amount________ Odor_________
                Alba:     Color_______ Amount________ Odor_________

PSYCHOSOCIAL
Recent Stress: Present health condition
Coping Mechanism: N/A
Support System: Family
Calm:            (  ) Yes____________________  ( / ) No______________________
Anxious:        ( / ) Yes____________________  (  ) No______________________
Angry:           (  ) Yes____________________  ( / ) No______________________
Withdrawn:   (  ) Yes____________________  ( / ) No______________________
Irritable:        (  ) Yes____________________  ( / ) No______________________
Fearful:         ( / ) Yes____________________  (  ) No______________________
Religion: Muslim Restrictions:_________________
Feeling of Helplessness:      (  ) Yes        ( / ) No
Feeling of Hopelessness:     (  ) Yes        ( / ) No
Feeling of Powerlessness:   (  ) Yes        ( / ) No
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Tobacco Use: (  ) Yes____________________  ( / ) No______________________

Alcohol Use:   (  ) Yes____________________  ( / ) No______________________
Drug Use:       (  ) Yes____________________  ( / ) No______________________

NUTRITION
General Appearance:     ( ) Well Nourished       (  ) Malnourished
                                        (  ) Emaciated            (  ) Other
Body Built: Normal   Weight: 55 kg      Height: N/A
Diet: N/A        Meal Pattern: N/A
                      ( / ) Feeds Self          (  ) Assist           (  ) Total Feed

Mastication/Swallowing Problem       (  ) Yes_________ ( ) No_________

Dentures:   (  ) Yes                ( / ) No
Appetite:   (  ) Increased      ( / ) Decreased    (  ) Unusual 
Decreased Taste Sensation: (  ) Yes             ( / ) No
Nausea:     (  ) Yes                ( / ) No   
Stool frequency: N/A               Characteristics: N/A
Last Bowel Movement: N/A
NGT/ Gastrostomy: N/A

VENOUS ACCESS RECORD

Date
# Site Date Inserted Fluid Gauge (color)/ Number of Drops Reason
Removed

PAIN ASSESSMENT
Location of pain: N/A Frequency: N/A
Intensity Pain Scale(0-10): N/A Quality: N/A
Onset: (When did your pain started?) 1 week
Duration: N/A Body Reaction: Fever associated with loss of appetite, dry cough
and colds
Alleviating Factors: N/A
Precipitating factors N/A
Special Assessment Devices
(  ) Wheelchair (  ) Contacts (  ) Venous Access device
(  ) Braces (  ) Hearing aid (  ) Epidural catheter
(  ) Cane/ Crutches (  ) Prosthesis (  ) Walker
(  ) Glasses
Others:____________________________________________________________

SELF-CARE
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Need Assist With:

(  ) Ambulating (  ) Elimination
(  ) Bed Mobility (  ) Meals
(  ) Hygiene (  ) Dressing

PATIENT EDUCATION
( ) Safety / Restraint Use     ( / ) Signs & Symptoms to Report
( / ) Ordered Therapies     ( / ) Lifestyle Change
( / ) Diagnosis / Disease     (  ) Rehabilitation Measures
(  ) Pain Management     (  ) Hygiene / Self care
(  ) Hospital Referrals     ( / ) Diet or Nutrition
(  ) Community Referral        (  ) Mobility / Ambulation
( / ) Medication

Specify Plan of Care Intended:

Example medications (List Down all medications to be taken at home with special nursing care
instruction to be given to the client like, dosage, time, frequency.

MEDICATION:
 Cefixime 400mg/tab (1 tab OD for 3 days)
 Montelukast 10mg/tab (1 tab OD HS for 14 days)
 Cetirizine 10 mg/tab (1 tab OD for 30 days)
 Sodium Ascorbate + Zinc tab (1 tab OD for 30 days)
 NAC sachet (1 sachet + ½ glass of water OD for 7 days)

DIET:
 Eat Nutritious Food

HEALTH TEACHINGS:
 Always wear mask and face shield
 TCB after 3 days for follow up
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