Name: Sanaani, Nur-Fatima, M.

Clinical Experience: Nursing Care Management

Clinical Area: Brent hospital, in Pre-operative, intra-operative, and post-operative care
Placement: Second Semester (Level III)
Rotation: Weeks 5-6
Day and Time: February 17-19 (Thursday, Friday and Saturday); 8:30 am - 11:30
am
Clinical Instructor: Flor Palmillaran San Luis, RN

GENERAL OBJECTIVE:

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:
-Acquisition and application of knowledge, skills, and attitude through the utilization of nursing
process in the care of patient with respiratory, Fluid & Electrolytes with emphasis of health
promotion, prevention, maintenance of health, curative and rehabilitation aspect of health care
delivery system

Specific objectives:
At the end of the 72 hours of virtual Related Learning Experience( asynchronous and
synchronous ), I shall be able to:
- Establish a helping relationship with the patient’s family and significant others sincerely
- Familiarize with the physical set-up of the assigned clinical area thoroughly
- Identify patient for care correctly
- Gather pertinent information about the patient from primary and secondary source of data
- Assess the patient condition utilizing the Gordon’s 11 functional health patterns
- Assess the patient cephalocadually
- Identify health needs/problem of the patient
- Formulate nursing care plan based on the prioritized nursing problem
- Implement planned nursing intervention
- Monitor and record patient vital signs accurately, such as: temperature, pulse rate,
respiratory rate, blood pressure, and pain scale
- Administer prescribe medication per CI’s supervision
 - Performed other nursing management such as, sponge both, bed bath, bed making
- Conduct health teaching to the patient
- Evaluate effectiveness of nursing care rendered to patient properly

Ateneo de Zamboanga University

College of Nursing

BATES ASSESSMENT TOOL

MENTAL STATUS
APPEARANCE

Grooming: Neat                             Attire: Laboratory Gown

Personal Hygiene: Clean
Gait: Normal/straight walking pattern  Posture: Lying on bed 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:     Slepping                         Speech: Drowsy
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
SKIN
INSPECTION
Color: ( / ) Normal (  ) Flushed (  ) Pale (  ) Dusky
             (  ) Cyanotic (  ) Jaundiced    (  ) Others: _________________________
Texture:Smooth                        Tone:
Lesions: ( ) Yes, site: _______ ( / ) No
PALPATION
Moisture: Slightly Dry Temperature: 37C
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: Convex curvature 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: Oily
Hair Texture: Smooth
Maxillary & Frontal Sinuses: Normal

EYES
INSPECTION
Conjunctiva:  R: appears pink L: appears pink Sclera: R: white and surrounds the iris and
pupil. L: white and surrounds the iris and pupil
Cornea:          R: translucent, smooth and avascular L; translucent, smooth and avascular
Iris:      R: Dark brown L: Dark brown
Ptosis:             R: None L: None
Visual Fields:  R: 200/20L: 40/20
Extraocular movements: : unable to occur ocular movement; L: Normal

Pupil: Color:  R:Cloudy   L: Black         Size:  R: pupil be widely dilated 4mm   L: 2 to 4 mm

Response to Light & Accommodation: R: Unresponsive L: responsive
NOSE
INSPECTION
External Nose: Normal
Nostrils: R: N/A    L: N/A

MOUTH
INSPECTION
Mouth & Throat Mucosa: Normal Tongue: Pinkish
Teeth and Gums: Complete teeth, symmetrical, gums Pink, moist, and firm Floor of Mouth:
Normal Palate: ______ Uvula: Pink in color, Positioned in the midline

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: Contains hair follicles, glands, and cerumen L: Contains hair follicles, glands,
and cerumen
Lesions: (  ) Yes, site: ___________    ( / ) No
Discharges: (  ) Yes, amount: ________  (  ) Left    (  ) Right   (  ) Both     ( / ) No
 NECK
PALPATION
Thyroid gland size: 1.8 to 2.0 cm Shape: butterfly-shaped gland
Tenderness: None Nodules: None
Position of Trachea: straight up and down, running along the center of the front side of the
throat.
Cervical Lymph Nodes: None

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: 18bpm
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: ______________

               (  ) 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: Upper Lobe
                       (  ) 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:_3seconds
Murmurs: ____

PULSES
 ( ) Regular    ( / ) Strong           (  ) Irregular        (  ) Weak         (  ) Absent
 (  ) Doppler     (  ) Pacemaker
Radial: R: _______ L: _______
Pedal:  R: ____________ L: ____________
Apical: R: 72 bpm L: 72 bpm
BP:       R:120/70mmHg L: ___________

GASTROINTESTINAL SYSTEM
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: __________________________________________
Hand Grasps: ( / ) Equal (  ) Unequal (  )Weakness (  ) R & L
Leg muscles:  ( / ) Equal (  ) Unequal (  ) Weakness (  ) R & L

NEUROLOGIC SYSTEM
CRANIAL NERVES
Olfactory Nerve (CN I)
Able to smell.
Optic Nerve (CN II)
 Left eye vision is clear, the right eye vision is recovering
Oculomotor (CN III)
 Left eye functions normally, Right eye function is unaccommodating
Trochlear (CN IV)
 Able to move left eye in upward and downward movements, right is unable
Trigeminal Nerves (CN V)
Left eye can blink normally; Right eye still unable due to discomfort
____________________________________________________________________________

Abducens Nerve (CN VI)

 Left eye functions normally
Facial Nerve (CN VII)
 Normal
Acoustic Vestibulocochlear Nerve (CN VIII)
 Able to hear with both ears.
Glossopharyngeal Nerve (CN IX)
 Gag reflex is present
Vagus Nerve (CN X)
 No difficulty in swallowing
Spinal Accessory Nerve (CN XI)
 Able to move and turn head with ease.
Hypoglossal Nerve (CN XII)
Speech is quiet.
______________________________________________________________________________
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)
______________________________________________________________
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): _________________________

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: Roman Catholic                                       Restrictions:_________________
Feeling of Helplessness:      (  ) Yes        ( / ) No
Feeling of Hopelessness:     (  ) Yes        ( / ) No
Feeling of Powerlessness:   (  ) Yes        ( / ) No
Tobacco Use: (  ) Yes____________________  ( / ) No______________________
Alcohol Use:   (  ) Yes____________________  ( / ) No______________________
Drug Use:       (  ) Yes____________________  ( / ) No______________________

NUTRITION
General Appearance:     ( ) Well Nourished       (  ) Malnourished
                                        (  ) Emaciated            (  ) Other
Body Built: Normal   Weight: 52 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?) N/A
Duration: 2 weeks Body Reaction: Elevated temperature, Sweating and lethargic
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
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.
____________________________________________________________________________
____________________________________________________________________________
______________________________________________