GUIDELINE TO NURSING CARE REPORT NURSING CLINICAL PRACTICE NURSING DIPLOMA PROGRAM BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE

By Zaqyyah Huzaifah

Students 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
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RESPONSIBLE PERSONS IDENTITY Name : Sex : Age : Occupation : Address : Relationship with the client:

HEALTH HISTORY
Main Complaint Filled with the clients complaint, when the nurse done 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.

Cont
Health History of Previous Disease Filled with the clients 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 familys 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 patients disease now. Is there any member of the family that has contaminated disease or descendant disease?

Cont
Child Growth History Filled with mothers prenatal history, childs birth process and childs growth, immunization status, childhoods 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 assessments result of skins integument system, skins condition in general, cleanliness, skins integrity, texture, moisture, the availability of wound or ulkus, turgor, skins color and other skins disorder.

Head and Neck Filled with assessment result data of heads area, hair distribution, heads 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 noses 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 ears 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, 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.

Abdomen Inspection result : 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

Genital and Reproduction Assessments result about genital in general and reproduction system function, disorder in anatomy and function. Complain and disorder in reproduction system.

Upper and Lower Extremity Assessments 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 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 or her disease.

FOCUS DATA
Subjective 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 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 DS : Data which come straight from client or his or her family PROBLEM Problems that occur in accordance with collected data ETIOLOGY 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)

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 DAY / DATE NURSING DIAGNOSIS PLANNING GOAL Time target to overcome the problem and The result criteria INTERVENTION Use active verb or imperative sentence RATIONAL Rationalizat ion from intervention that decided by the nurse

IMPLEMENTATION
NO DAY/ DATE TIME NO. DX IMPLEMENTATION ACTIONS EVALUATION Evaluation on every action that done by the nurse INITIALS

Using passive verb , in accordance with intervenes that already decided and clients condition

EVALUATION
NO. DAY / DATE TIME NO. DX EVALUATION 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. INITIALS

Thanks