Format Pola Sistem Translasi - Nursing Documentation In Systemic Pattern

DOCUMENTATION OF NURSING CARE PLAN IN SYSTEMIC PATTERN

FORMAT OF SYSTEMIC PATTERN ASSSESSMENT Day / Date Ward / class Registration Number

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Tribe / nationality : Education background : Occupation :

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Marital status Address

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DEMOGRAPHY DATA A. Client’s Identity Name Age Sex Religion

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B. Client’s Family’s Identity Name of p/w/h : .................................................................................... Age : .................................................................................... Sex : .................................................................................... Religion Tribe/ nationality Education background Occupation Address Source of cost

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HEALTH HISTORY A. Main Complaint Patient’s reason entering hospital........................................................................... : ....................................................................................

B. Current Health History Chronology of the complaint according to PQRST pattern................................... : .................................................................................... C. Current Illness History Illness which is ever be have  When : ....................................................................................  Accident/ trauma : ....................................................................................  Previous hospitalization...................................................................................:  Other illness : .................................................................................... D. Immunization History  Previous immunization :.................................................................................. E. Allergic History  Risks factors(medicine, Food etc) : ....................................................................................  Body reaction : ....................................................................................  Medication/care : .................................................................................... F. Life Pattern / Habits (which is influencing Client’s Health)  Smoking  Type (filtered etc) :..................................................................................  Frequency : ....................................................................................  Quantity : ....................................................................................  Since : ....................................................................................  Liquor  Type : ....................................................................................  Frequency : ....................................................................................  Quantity : ....................................................................................  Since : ....................................................................................  Reason : ....................................................................................  Drug Dependence  Type : ....................................................................................  Frequency : ....................................................................................  Type : ....................................................................................  Since : ....................................................................................  Reason : .................................................................................... G. Family Health History Have genetics illness/ disease Have contagious illness/ disease Care/ medication

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H. Psychological History Emotional mental status as be sick Used effective coping mechanism Believe / hope to undergo care/ treatment Acceptance / refusal of client Client’s ability to discuss his/her health problem

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I. Social History Communication pattern verbal/non verbal/ combination Client's close person/main supporter source Interaction with environment (person/place/time) Relationship with family Illness/ hospitalization threatening client’s occupation Adherence to the therapy : J. Spiritual Worship after sick, in order/ disturbed Other worship which made Belief which is be incompatible with medication / care

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DOCUMENTATION OF SYSTEMIC MODE

PHYSICAL ASSESSMENT 1.General Condition a. Vital signs  Blood Pressure :  Pulse :  Breathing :  Temperature : b. Height : Weight :

mm/Hg x / minute x / minute °C cm kg

2.Integument System a. Skin  Skin condition = injured ( ), bruising ( ), itch ( ), notes .....................  Turgor = good ( ), average ( ), bad ( ).  Color = cyanosis ( ), red ( ), pale ( ).  Texture = smooth/ flexible ( ), rugged/ thick ( ).  Humidity = dry ( ), sweaty ( ), oily ( ).  Touching sensitivity = good ( ), average ( ), bad ( ), hypersensitive ( ).  Usage of topical medicine/ concoction = Yes ( ), No ( ). Type.................. b. Nails  Base color ( N = transparent, smooth, and dome-shaped ) = ...........................  Nail corner and nail base (N = 160 ) = ...............................................  Nail condition ( after pressuring 2-3 seconds ) = .....................................  Any current trauma ?  Nail-biting habit = Yes ( ), No ( )  Nail condition ( long/ short, dirty/ clean ) = ................................. c. Hair and Head skin  Head skin condition = lesion ( ), itchy ( ), louse ( ), dandruff ( ), bruised ( ), pain ( ), inflamed ( )

 Hair condition = dry ( ), branched off ( ), oily ( ), fall off ( ), thick ( ), thin ( ), color change ( )  Used kind of shampoo?  Wearing wig? 3.Neurologic System a. Consciousness level : compos mentis ( ), apathies ( ), somnolence ( ), delirium ( ), stupor / semi coma ( ), coma ( ) b. GCS = ....................................... c. Trauma history? d. Face = symmetric ( ), asymmetric ( ). e. Neck = symmetric ( Yes / No ), pain ( Yes / No ), nape of neck stiff ( Yes / No ) 4.Vision System a. Usage of tools = glasses ( ), contact lens ( ) b. Eyes position = enteropian ( ), elektropian ( ), triakiasis ( ) c. Conjunctive = red ( ), infected or pus ( ), anemic ( ) d. Sclera = white ( ), ikterik ( ) e. Cornea = clear ( ), inflamed or keratitis ( ), edema ( ) f. Pupil = isochoric ( ), anisokor ( ), meiosis ( ), mydriasis ( ) reflex to light ( ), size = ............................. g. Eye muscle movement = nistagmus ( ), strabismus ( ), normal ( ) h. Vision field = N ( ), abnormal ( ), notes ............................... i. Eyebrow = symmetric ( ), asymmetric ( ) j. Previous eye illness = cataract ( ), glaucoma ( ), trauma ( ) 5.Hearing System a. Hearing tools = ............................................................................. b. Auricle = normal or not sick as moved ( ),sick as moved ( ),auricle condition = lesion ( ), reddish ( ), pain ( ), tinnitus ( ), inflamed ( ), itchy ( ), normal ( ) c. Cerumen = normal ( ), much ( ), (consistency, smell, etc ) =........................ d. Vertigo = Yes ( ), No ( ) e. Inspection of weber and Rinnes = normal ( ), abnormal ( ) f. Ear illness history? g. Respond to sound or voice and interlocutor? 6.Smelling System a. Nose condition = lesi ( ), epistaksis ( ), itchy ( ), reddish ( ), polyp ( ), pressure pain ( ), inflamed ( ), normal ( ). b. Nose shape and size = symmetric ( ), asymmetric ( ). c. Any allergic? And using nasal medicines? d. Any fluid which turns out of nose (amount, color, uni / bilateral) = ......... e. Respond to smells? Good? ( ), hyposensitive ( ), hypersensitive ( )

7.Speech System Difficulty or disturbance of speech = normal ( ), aphasia ( ), analrtria ( ), dysphasia ( ), disartria ( ). 8.Central Nerve System a. Anxiety = Yes ( ), No ( ) b. Consciousness loss history = .................................................................. c. Deportment change, orientation to person, place, and situation = ..... d. Ability to remember = short-term memory ( ), average ( ), long ( ) e. Psychomotor = ataxia ( ), paralysis ( ), tremor, spasm ( ) 9.Respiratory System a. Airway = clean ( ), uncrowded ( ), with activity ( ), without activity ( ) b. Use respiration muscles = ........................................................ c. Depth = deep ( ), shallow ( ) d. Rhythm = coordinated ( ), uncoordinated ( ) e. Cough = Yes ( ), No ( ), productive ( ), non productive ( ) f. Sputum = white ( ), yellow ( ), green ( ) g. Consistency = thick ( ), aqueous ( ), bloody ( ) h. Air sound = normal ( ), ronchi ( ), wheeze ( ),crackles ( ) 10.Cardiovascular System a. Peripheral circulation  Regular rhythm ( ), irregular ( )  Pulse = weak ( ), strong ( )  Jugular vein distention= Yes ( ), No ( ), notes .........................  Skin temperature = warm ( ), cold ( )  Edema = Yes ( ), No ( ), notes ................................................... b. Heart circulation  Heart sound disorder = murmur ( ), gallop ( ), normal ( )  Chest pain = Yes ( ), No ( ), with activity ( ), without activity ( ), characteristic ( ) 11.Gastrointestinal System a. Mouth and faring  Appetite = good ( ), nausea ( ), vomited ( )  Mouth Hygiene = ...........................  Swallowed reflex = ............................  Teeth / gums = caries ( ), inflamed ( ), bleeding ( )  Mouth mucus = color ............................ lesion ( ), inflamed ( )  Habit pattern = ................................... b. Abdomen  Size / contour = ..........................

 Shape or condition = symmetric ( ), asymmetric ( ), asites ( ), distension or regedity ( )  Noise of intestine = normal ( ), increase ( ), decrease ( ), notes ........  Pain and the location ........................................  Rectum = hemorrhoid ( ), lesi ( ), reddish ( ), abses ( ), pain ( ), etc ....  Intestine elimination - Habit pattern = ...................... diarrhea ( ), constipation ( ), platus ( ), melena ( ), use of laxative ( ), etc

12.Urogenital System a. Urinal pattern change = retention ( ), urgency ( ), hesitance ( ), frequency .................................. unreleased ( ), etc ............................................... b. Urinary bladder detention = Yes ( ), No ( ) c. Back pain complain = Yes ( ), No ( ) d. Enlargement of prostate gland= Yes ( ), No ( ) e. Genital condition = ........................................ 13.Musculoskeletal System a. difficulty in movement = Yes ( ), No ( ) b. painful on joint bones = Yes ( ), No ( ) c. Fracture = Yes ( ), No ( ) d. Disorder on joint shape = contracture ( ), scoliosis ( ), lordosis ( ), kiposis ( ) 14.Endocrine System a. Ketone smell breathing = Yes ( ), No ( ), much sweats ( ), much urine ( ), a little ( ), hyperkalemia ( ), polipagi ( ), poliuri ( ), polidipsi ( ) b. Gangrene = Yes ( ) No ( ) c. Color = ..................................... d. Smell = Yes ( ),No ( ) e. Exoptalmus = Yes ( ), No ( ) f. Enlargement of thyroid gland = Yes ( ), No ( ) 15.Body Immunity System a. Weight before sick ................................... b. Weight after sick .................................. c. Enlargement of lymph gland = Yes ( ), No ( ) SUPPORTING ASSESSMENT .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................

APPLICATION .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................

SOURCES: 1.Potter, Patricia .A.Pengkajian Kesehatan.Edisi 3. 2.Manning, Robert. T. Diagnosis Fisik.Edisi IX.