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GUIDELINE TO NURSING CARE REPORT NURSING CLINICAL PRACTICE

NURSING DIPLOMA PROGRAM

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE

By Zaqyyah Huzaifah

Student’s Name :

SRN

:

Day / Date

:

Ward

:

ASSESSMENT

INDENTITY

CLIENT IDENTITY

Name

:

Sex

:

Age

:

Address

:

Education

:

Occupation

:

Marital Status

:

Religion

:

Nationality

:

Date of entry

:

Date of Assessment

:

Medical Diagnose

:

RESPONSIBLE PERSON’S IDENTITY

Name

:

Sex

:

Age

:

Occupation

:

Address

:

Relationship with the client:

HEALTH HISTORY

Main Complaint

Filled with the client’s complaint, when the nurse done the assessment in the first contact with the client.

Health History of Current Disease

Filled with the client’s disease development, from

the first complaint at home, the effort to decrease the complaint (how to overcome it, taken to the health center or other health care),

until brought to the hospital and having

nursing care.

Cont…

Health History of Previous Disease

Filled with the client’s health history before

sick, pervious diseases diagnose, if he or she

ever felt the same complaint, or ever experience the same disease or the same diagnose before.

Cont…

Health History of Families Disease

Filled with family’s health history, is there any

member of the family has ever experience the

same disease that happen to the patient now. Is there any member of the family has ever experience the related disease with the

patient’s disease now. Is there any member of

the family that has contaminated disease or descendant disease?

Cont…

Child Growth History

Filled with mother’s prenatal history, child’s birth process and child’s growth, immunization status, childhood’s disease

history, nutrition status (if the patient is children).

PHYSICAL ASSESSMENT

General Condition

Filled with vitals’ sign data, conscious rate, and

anthropometry data.

Skin

Filled with the assessment’s result of skin’s integument system, skin’s condition in general, cleanliness, skin’s integrity, texture, moisture, the availability of wound or ulkus, turgor, skin’s color and other skin’s disorder.

Head and Neck

Filled with assessment result data of

head’s area, hair distribution, head’s

condition in general, the symmetries of

head, disorder in head in general.

Neck assessments are the availability of

vena jugularis widening, enlargement of

thyroid gland, enlargement of lymph gland, inadequacy of neck movement, other disorder.

Sight and Eyes

Filled with the assessments result data of

eyes’ area and sight system function,

eyes’ condition in general, conjunctiva (anemic, inflammation, trauma), abnormality in the eyes or eyelid, visus, eyes’ accommodation ability, the usage of

sight aid, disorder to see

Smelling and Nose

Filled with the assessments result data of

nose’s area and Smelling System

Function, nose condition in general, respiratory or plugging of nose, polyp, inflammation, secret or bleeding,

breathe disorder, shape disorder or

other disorder.

Hearing and Ears

Filled with the assessments result data of

ear’s area and hearing system function,

ears condition in general, hearing disorder, the usage of hearing aid, shape disorder or other disorder.

Mouth and Teeth

Filled with the assessments result data of mouth and the upper digestion function, the condition of mouth and teeth, swallow disorder, inflammation in the mouth (mouth mucosa, gums, pharynx),

shape and other disorder.

Chest, Respiratory and Circulation

Filled with the assessments result data of chest, from the inspection result (the expansion of

chest, chest’s symmetric), palpation (chest’s symmetric, taktil premitus), percussion (lung’s

resonant, piling of secret, fluid or blood),

auscultation (respiratory : breath’s sound,

heart : heart’s sound). Circulation : blood’s

percussion to prefier, the color of the fingers,

lips, skin’s moisture, urine output, dizzies

complain, blurred sight if changing position,

CRT. Other complains such as beating heart, chest’s pain, suffocates.

Abdomen

Inspection result : abdomen condition in general, breath movement, swollen part existence,

skin’s color.

Palpation : the existence of mass in the abdomen, skin’s tugor, and asites.

Percussion : timpani sound, hyper timpani for inflated abdomen

Auscultation : intestine peristaltic per minute

Genital and Reproduction

Assessment’s result about genital in

general and reproduction system function, disorder in anatomy and function. Complain and disorder in reproduction system.

Upper and Lower Extremity

Assessment’s result of up and down

extremists, movement stretching, muscle

strength, the ability to do mobility, movement insufficiency, trauma or disorder of hand and leg, infuse insersi,

other complain or disorder.

PHYSICAL, PSYCOLOGICAL,

SOCIAL AND SPIRITUAL NEEDS

Activities and Rest (At Home / Before Sick and

At the Hospital / During Sickness)

At Home

: habit, activity, rest pattern,

activity disorder

At the Hospital : activity ability, activity disorder

Personnel Hygiene

At Home

: bath habit, hair washing, teeth

brushing (personnel hygiene)

At the Hospital : general description about client cleanliness, the ability to self cleanliness

Nutrition At Home

: eating habit, forbidden foods

that can make allergy

At the Hospital : food pattern, eating disorder, diet that given

Elimination (Bowel and Urinary)

At Home

: bowel and urinary habit,

complain or disorder during elimination

At the Hospital : bowel and urinary pattern, alteration in elimination pattern.

Sexuality

Sexuality pattern, sexuality complain

Psychosocial

Client’s relationship with other people, client’s

relationship with his or her family or relatives,

client’s relationship with health employee, client’s psychology condition, the client’s

acceptance and hope about his or her disease,

client’s knowledge about his or her disease.

Spiritual

Client’s believe in God, client’s faith about his or

her disease.

FOCUS DATA

Subjective data : in the form of client’s complain

Objective data 1. Inspection

:

  • 2. Palpation

:

  • 3. Percussion

:

  • 4. Auscultation :

SUPPORTED EXAMINATION

Filled with supported examination such as roentgen, biopsy, laboratory et cetera

PHARMOCOLOGY THERAPY

Filled with medicine list that given to the client (kind of medicine, how to give it, how many times a day, the dose). Each change in pharmacology therapy should be recorded as per day and date.

DATA ANALYSIS

NO.

1.

DATA

PROBLEM

DS :

Problems that

Data which come straight

occur in

from client or his or her

accordance with

family

collected data

DO: Collected data from the result of nursing assessment and other data (examination by other health employee, supported examination)

ETIOLOGY

Etiology from

the collected

problems from

the disease’s

patophysiology analysis result

Problem Priority:

Filled with problems from data analysis, written in the form of complete nursing diagnose (problem + etiology), ordered in accordance with which problem need main handling.

1.

2.

3.

PLANNING

NO

 

NURSING

 

PLANNING

DAY / DATE

DIAGNOSIS

 

GOAL

INTERVENTION

   

Time target to overcome the problem and

Use active verb or imperative sentence

The result

criteria

RATIONAL

Rationalizat ion from intervention

that

decided by the nurse

IMPLEMENTATION

NO

DAY/ DATE

TIME

NO. DX

IMPLEMENTATION

ACTION’S

INITIALS

EVALUATION

     

Using passive verb , in accordance with intervenes that already decided

Evaluation on every action that done by the nurse

 

and client’s

condition

           

EVALUATION

NO.

DAY / DATE

TIME

NO. DX

EVALUATION

INITIALS

 

S : make evaluation to every action, entire subjective data in accordance with decided diagnose O : make evaluation to

every action, entire objective data in accordance with decided diagnose A : Nurse assessment for all

action that taken to

overcome one nursing problem, does the problem solve entirely or only half way. P : Filled with intervention

that must be taken in the

next shift

1.

2.

3.

Thanks…

Thanks…