Beruflich Dokumente
Kultur Dokumente
PRELIMINARY
1.1 Background
Nursing Documentation is a document that contains complete, tangible and
recorded data not only about the patient's morbidity level, but also the type and
quality of service provided (fisbach, 1991). Mental health nursing is an interpersonal
process that seeks to enhance and sustain behaviors that contribute to integrated
functions. Patients or client systems can be individuals, families, groups,
organizations or communities (Stuart Sundeen, 1995). Depression is a mental
disorder that everyone has a chance to experience. Many of us are confused to
distinguish between depression, stress and sadness. Not to mention different types of
depression, such as unipolar depression, biological depression, manic depression,
seasonal affective disorder, dysthymia, and others. There are so many terms used to
describe depression. Now is the time for us to know what is depression, in order to
facilitate a person or your self when depressed. In the documentation of depressed
clients taken can use the narrative documentation format. Narrative format is the
format used to record the progress of the patient from day to day in the form of
narration. Narrative formats are traditional, long-lasting, and flexible records
FORMAT ASSESSMENT
CHILD NURSING SCIENCE CHILDREN
I. Biodata
1. Client Identity
1. Name / Nickname :
3. Gender :
4. A g a m a :
5. Education :
6. A l a m a t :
7. Entry Date :
8. Date of review :
9. Medical Diagnosis :
2. Identity of Parents
1. Father :
a. Name :
b. Age :
c. Education :
e. Religion :
f. Address :
2. Mother
a. Name :
b. Age :
c. Education :
f. Address :
3. Identity of Siblings
b. Complaints during pregnancy: bleeding ... .., PHS ... .., infection ..., cravings ....,
Vomiting ......., Fever ......., Care during pregnancy
2. Christmas
a. Place of birth: RS ......., Clinic ...... .., home .......
b. Length and type of labor: spontaneous ...... .., Forceps ... .., Operation ......, others
.......
3. Post Christmas
b. Does the child have: jaundice ......, bluish ......, redness ......., Breastfeeding problem
... .BB unstable .........
a. Diseases that have been experienced: cough ...... .., fever .........., Diarrhea ..........,
Seizures ...... .., others ... ..
b. Accident suffered: falling ...... .., drowning ........., traffic ...... .., poisoning ... ..
d. Allergy: food ...... .., drugs ...... ..zat / chemical substance ......., Textiles ......
f. Development of children compared to their brothers: slow ........., same .........., Fast
......
Diseases of family members: Allergies ......, asthma ..., tuberculosis ..., hypertension
..., heart disease ..., stroke .., anemia ..., hemopilia ......, arthritis ... .., DM ..., cancer ...
.. soul .. ..
b. Genogram
A. Physical Growth
1. Roll over:
2. Sitting:
3. Crawling:
4. Standing up:
5. Walking:
6. Smile to others:
7. Talk first:
A. Breastfeeding
C. Supplementary feeding
1. 0 - 3 months
2. 4-12 months
3. Currently
VII.Phichosocial History
• Does the child live in: apartment ........., own house ...... ..., contract ...... ..
• The environment is in: city ......, half city ......., Village .......
• What is a house near: school ...... .., there is a playground ......, have their own
bedroom ......
• Is there a ladder that can be dangerous: .........., Does the child have a playroom
......... ..
• Relationship between family members: harmonious ......... .., far apart .........
• Nanny: parents ... .., baby sitter ... .., housekeeper ......., Grandma / grandpa ...... ..
• Religious activity :
• Did the doctor tell about the child's condition: yes ......, no ......
• How do parents feel now: anxious ......, fear ..., worry ... .., ordinary ... ..
• Will parents always visit: yes ......, sometimes ... .., no ... ..
• Who will stay with the child: father ......, mother ......, brother ......, others ... ..
• Did the doctor tell you your situation: yes ......, no ......
• How does it feel to be hospitalized: bored ...... .., afraid ... .., happy ... .. others ... ..
X. DAILY ACTIVITIES
A. Nutrition :
B. FLUIDS
D. Sleep rest
E. Exercise:
F. Personal Hygine:
H. Recreation
B. Vital signs:
• Temperature:
• Pulse:
• Respiration :
• Blood pressure :
C. Anthropometry:
• Body length:
• Weight :
• Head circumference:
• Chest size :
• Abdominal circumference:
• Skin fold:
D. Respiratory System
• Nose: Symmetry ......, breathing nostrils ..., secret ... ..., polyp ...... .., epistaksis ......
• D a d a:
o Chest shape: Normal ......, barrel ...... .., pingion chest .......
o Breath sound: Vocal premitus ...., ronchi ...., wheezing ... .., stridor ......, rales ......
E. Cardiovascular system:
• Conjunctiva: anemia / not, pale lips / cyanosis ...... .., carotid arteries: strong / weak,
jugular venous pressure: elevated / not
• Heart Sound: S1 ......., S2 ......, Aortic Noisy ... .., murmur .. ...., Gallop .......
F. Digestive System
• Skelera: jaundice / no, lips: moist ......., Dry, cracked ..., labio skizis ... ..
• Mouth: Stomatitis ...... .., palatoskizis ... .., number of teeth ......., Swallowing
ability: good ...... / difficult ......
• Abdomen: heart: palpable .........., Lien ......... .., kidney ...... ..Faeses .......
1. Eye:
2. Nose:
• Smell ....... ... .., Ravaged nose ............, trauma ........., nosebleeds
• Secret that blocks olfaction ............... ..
3. Ear:
• The state of the earlobe ............, the audiotor channel: clean ......... .., serumen .......
1. Cerebral function:
a. mental status: orientation ............, memory ............, attention and calculation .......,
language .........
b. Awareness: (eyes ............, motor ........., verbal .........) with GCS: .........
2. cranial function:
Nervus 1:
Nerve III, IV, VI: eye movements ............ .., pupil isokor ............, anisokor .......
3. Motor function: muscle mass ............ .., muscle tone ........., muscle strength
4. Sensory function temperature ........., pain ......... .. vibration ......, position ...... ..,
discrimination .........
2) Vertebrae: scoliosis ......, lordosis ......, kiposis ......, movement ......, ROM ...... ..,
motion function ......
3) Pelvis: road style ......., Movements ......., ROM ......., Trendelberg test .......,
Ortalani / bariow
4) Knee: Swelling ...... .., stiff ......, movement ...... Mc Murray test ...... .ballotement
test .........
5) Legs: swelling ......, movements .........., Ability of the road ......, the sign of
attraction ......
A. Integumentary System
• Skin: color ......, temperature ..., moisture .........., Skin feathers ..., eruption ......,
moles ..............., rashes ..............., texture .............
• Nails: color ......., Surface nails ............, easily broken ......., Cleanliness .........
K. Endokrine System:
• Thyroid gland:
L. Urinal system
• Odema palpebra ............... .., moon face ............ .. anasarka model .............
• Bladder state
M. Immune system:
• allergies (weather ...... .., dust ......., Animal fur ......... .., chemicals ............)
• Diseases related to climate change: flu ... .., urticaria ......, others ......
A. 0-6 years
By using DDST
1. Rough motor
2. Fine motor
3. Language
4. Personal social
1. Cognitive development
2. Psychosexual development
3. Psychosocial development