Guideline to Nursing Care Report

7/28/2019 Guideline to Nursing Care Report

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GUIDELINE TO NURSING CARE REPORT

NURSING CLINICAL PRACTICENURSING DIPLOMA PROGRAM

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE

By

Zaqyyah Huzaifah


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Students Name :

SRN :

Day / Date :

Ward :


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ASSESSMENTINDENTITYCLIENT IDENTITYName :Sex :Age :Address :Education :Occupation :Marital Status :Religion :Nationality :Date of entry :Date of Assessment :Medical Diagnose :


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RESPONSIBLE PERSONS IDENTITY

Name :Sex :

Age :

Occupation :Address :

Relationship with the client:


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HEALTH HISTORYMain Complaint

Filled with the clients complaint, when the nursedone the assessment in the first contact with

the client.

Health History of Current Disease

Filled with the clients 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.


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ContHealth History of Previous Disease

Filled with the clients health history beforesick, pervious diseases diagnose, if he or she

ever felt the same complaint, or ever

experience the same disease or the same

diagnose before.


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ContHealth History of Families Disease

Filled with familys health history, is there anymember 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 thepatients disease now. Is there any member of

the family that has contaminated disease or

descendant disease?


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ContChild Growth History

Filled with mothers prenatal history, childsbirth process and childs growth,

immunization status, childhoods disease

history, nutrition status (if the patient is

children).


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PHYSICAL ASSESSMENTGeneral Condition

Filled with vitals sign data, conscious rate, andanthropometry data.

Skin

Filled with the assessments result of skinsintegument system, skins condition in general,

cleanliness, skins integrity, texture, moisture,

the availability of wound or ulkus, turgor, skins

color and other skins disorder.


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Head and Neck

Filled with assessment result data ofheads area, hair distribution, heads

condition in general, the symmetries of

head, disorder in head in general.

Neck assessments are the availability ofvena jugularis widening, enlargement of

thyroid gland, enlargement of lymph

gland, inadequacy of neck movement,

other disorder.


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Sight and Eyes

Filled with the assessments result data ofeyes 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


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Smelling and Nose

Filled with the assessments result data ofnoses 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.


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Hearing and Ears

Filled with the assessments result data ofears area and hearing system function,

ears condition in general, hearing

disorder, the usage of hearing aid, shape

disorder or other disorder.


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Mouth and Teeth

Filled with the assessments result data ofmouth 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.


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Chest, Respiratory and Circulation

Filled with the assessments result data of chest,

from the inspection result (the expansion ofchest, chests symmetric), palpation (chests

symmetric, taktil premitus), percussion (lungs

resonant, piling of secret, fluid or blood),

auscultation (respiratory : breaths sound,heart : hearts sound). Circulation : bloods

percussion to prefier, the color of the fingers,

lips, skins moisture, urine output, dizzies

complain, blurred sight if changing position,CRT. Other complains such as beating heart,

chests pain, suffocates.


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Abdomen

Inspectionresult : abdomen condition in general,breath movement, swollen part existence,

skins color.

Palpation : the existence of mass in the abdomen,

skins tugor, and asites.

Percussion : timpani sound, hyper timpani for

inflated abdomen

Auscultation : intestine peristaltic per minute


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Genital and Reproduction

Assessments result about genital ingeneral and reproduction system

function, disorder in anatomy and

function. Complain and disorder in

reproduction system.


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Upper and Lower Extremity

Assessments result of up and downextremists, 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


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PHYSICAL, PSYCOLOGICAL,

SOCIAL AND SPIRITUAL NEEDSActivities and Rest (At Home / Before Sick and

At the Hospital / During Sickness)

At Home : habit, activity, rest pattern,

activity disorderAt the Hospital : activity ability, activity

disorder


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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


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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


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Psychosocial

Clients relationship with other people, clients

relationship with his or her family or relatives,clients relationship with health employee,

clients psychology condition, the clients

acceptance and hope about his or her disease,

clients knowledge about his or her disease.

Spiritual

Clients believe in God, clients faith about his orher disease.

FOCUS DATA


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FOCUS DATASubjective data : in the form of clients

complain

Objective data

1. Inspection :2. Palpation :

3. Percussion :

4. Auscultation :


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SUPPORTED EXAMINATION

Filled with supported examination such asroentgen, biopsy, laboratory et cetera

PHARMOCOLOGY THERAPYFilled 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 shouldbe recorded as per day and date.

DATA ANALYSIS


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DATA ANALYSISNO. DATA PROBLEM ETIOLOGY

1. DS :

Data which come straight

from client or his or her

family

Problems that

occur in

accordance with

collected data

Etiology from

the collected

problems from

the diseases

patophysiology

analysis result

DO: Collected data from the

result of nursing assessment

and other data (examination

by other health employee,

supported examination)


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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


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PLANNINGNO DAY / DATE

NURSINGDIAGNOSIS

PLANNINGGOAL INTERVENTION RATIONAL

Time target to

overcome the

problem and

The resultcriteria

Use active verb

or imperative

sentence

Rationalizat

ion from

intervention

thatdecided by

the nurse

IMPLEMENTATION


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IMPLEMENTATIONNO DAY/ DATE TIME NO. DX IMPLEMENTATION ACTIONSEVALUATION INITIALS

Using passive

verb , in

accordance with

intervenes that

already decided

and clientscondition

Evaluation on

every action

that done by

the nurse

EVALUATION


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EVALUATIONNO. DAY / DATE TIME NO. DX EVALUATION INITIALS

S : make evaluation to

every action, entiresubjective data in

accordance with decided

diagnose

O : make evaluation to

every action, entire

objective data in

accordance with decideddiagnose

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.


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Guideline to Nursing Care Report

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