NURSING CARE ANALYSIS RECORD

Name :________________________________________

Level/ Section :________________________________________

RLE Instructor :________________________________________

Date Submitted :________________________________________

Grade:________________
___

I. Content:__________________________________ 90% ________________

Assessment___________________________ 30%

Anatomy and physiology/ _________________ 10%

Pathophysiology

Laboratory and Diagnostic Examination _______ 10%

Drug Study ______________________________10%

Nursing care Plan__________________________30%

II. Presentation:____________________________ 5% _________

Neatness , Organization & Format 5% _________
III. Punctuality: ____________________________ 5%_____________

REMARKS: ________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
___________________________________________________________________________

Name and signature of clinical instructor: _______________________________________

CASE ABSTRACT

CLIENT E.R EXPERIENCES BILATERAL LEG PAIN

LEARNING OBJECTIVES:
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

ADMISSION DATA:

Name: E.R Date & Time of Admission: 9/24/22

Arrived Via: Wheelchair Stretcher Ambulatory

Weight:60KG Height:___________ Blood Pressure: R 110/70 L _____________

Temperature 36.1 Pulse 46 Respiration: 20

Source providing Information: Patient / Others ______________________

Reason for consultation: ABDOMINAL PAIN/ LBM

Diagnosis:HEMOROID

BIOGRAPHICAL DATA:

Age:30 YEARS OLD Sex:FEMALE Marital Status:SINGLE Religion: ROMAN CATHOLIC

Address:30 MEICO STREET BETTER LIVING SUBDIVISION DON BOSCO PARANAQUE

CITY Tel# ---------- Date of Birth: NOVERMBER 30 1991 Place of Birth: MANILA

Educational Attainment:COLLEGE GRAD Occupation:NURSING

Dialect/language Spoken: ENGLISH, TAGALOG

Name of the father of the baby:__________________________His Age: _________________

Emergency Contact: M.F.A.E Phone number:_________________

NURSING HISTORY

Chief complaints: ABDOMINAL PAIN AND LBM (LOOSE BOWEL MOVEMENT)

History of present illness ( onset of labor): FOCAL DYSTONIA INTO THE RIGHT HAND
WHICH AFFECT HER WRITING CAPABILITY, POST APPENDECTOMY (2011), DENGUE,
AMOEBIASIS

Past medical history :

Childhood illnesses: ASTHMA

Childhood immunization status: COMPLETE IMMUNIZATION

Allergies: ARCOXIA MEDICINE

Accident and injuries: __________________________________________________________

Hospitalization:________________________________________________________________

Family History:

Health state and ages of: (cause of death if deceased)

Parents: BOTH PARETS HAVE A DIABETIS

Siblings: BOTH 2 BROTHERS HAVE AN ASTHMA

Spouse: ____________________________________________________________________

Children: ____________________________________________________________________
Illness in the family similar to the client: ____________________________________________

Genogram

CURRENT HEALTH STATUS:

A. Activity and Rest Pattern:

Frequency & Duration of Exercise:____________________________________________

Limitations in Activity:______________________________________________________

Complaint of Fatigue:______________________________________________________

Usual Number of Hours of Sleep at Night:___________________;at daytime:__________

Number of Hours of sleep needed to fell rested__________________________________

Any change in sleep pattern? SLEEPING DISTURBANCE DUE TO PAIN

Any routine preparation before going to sleep?__________________________________

B. Oxygenation and Circulation pattern:

Presence of Cough:___________________________Duration:______________________

Presence of Chest Pain:_____________(Location, Frequency, Duration and Type of pain)___

__________________________________________________________________________

History of Heart disease?:______________________HPN?___________________________

History of Asthma, PTB in the family? HISTORY OF ASTHMA, (CLIENT AND 2 BROTHER)

Do you smoke?:________________________ Number of cigarettes per day?:_____________

Shortness of breath?:___________________Coldness of extremities?:___________________

Usual or Known BP:_______________________

C. Nutritional-Metabolic patterns:

Food preference:_______________________ Food restrictions:DIARY PRODUCTS OR OILY

FOODS

Any change in diet?:________________________________________________________

Any change in appetite?:____________________________________________________

Medication used related to diet:_______________________________________________

Volume & Type of fluid taken per day:___________________________________________

Source of water supply for drinking:_____________________________________________

Nausea and vomiting: _______________________________________________________

Management: ______________________________________________________________

D. Elimination Pattern:

a. Bladder

Frequency & amount of urination per day:_______________________________

Color & Odor of Urine: _______________________________________________

Any discomfort in urination:___________________________________________

Intervention done:__________________________________________________

Changes: _________________________________________________________

Intervention done: __________________________________________________

b. Bowel:

Frequency of bowel elimination per day:15X A DAY

Consistency & color of stool: WATERY,YELLOWISH

Any discomfort in bowel elimination:______________________________________

Intervention done:_____________________________________________________

c. Senses:

Any difficulty in:

Seeing: GOOD

Hearing: GOOD

Feeling (touch): GOOD

Tasting:GOOD

Smelling:GOOD

How long have you had the difficulty?__________________________________________

 How did you manage it?_____________________________________________________

How did this affect your lifestyle?______________________________________________

MEDICAL HISTORY:

No major problem

Cardiac________________________ Gastro_____________________________

Hyper/Hypotension_______________ Arthritis_____________________________

Diabetes_______________________ Stroke______________________________

Cancer________________________ Seizure_____________________________

Respiratory_____________________ Glaucoma___________________________

Allergies & reactions: ARCOXIA MEDICINE others FOCAL DYSTONIA INTO THE
RIGHT HAND WHICH AFFECT HER WRITING CAPABILITY, POST APPENDECTOMY
(2011), DENGUE, AMOEBIASIS

Drug: _______________________

Food: _______________________

Signs & Symptoms:___________________________________________________

Surgery Date

COLONOSCOPHY SEPTEMBER 27, 2022

_____________________________ ___________________________

PSYCHOSOCIAL HISTORY:

Recent Stress: _____________________________________

Coping Mechanism:__________________________________

Support System:_____________________________________

Tobacco Use:_____________Alcohol Use:_________________

 Drug use:___________________________________________

PHYSICAL EXAMINATION

Date Performed______________________ Hospital day # (Patient) 59141

I. GENERAL SURVEY: (Appearance & Mental Status)

Body build, height & weight proportional to age ……. / Yes No

Relaxed, erect posture, coordinated movement…….

In standing, sitting & walking………………../ Yes No

Clean, Neat……………………………………………../Yes No

Body Odor……………………………………………….Yes /No

Distress noted…………………………………………...Yes /No

Obvious signs of illness…………………………………./Yes No

Cooperative………………………………………………./Yes No

Responses appropriate to the situation………………../Yes No

Understandable speech…………………………………/Yes No

Relevant and Organized thoughts……………………../Yes No

II. VITAL SIGNS, HEIGHT & WEIGHT:

Temperature:36.1 Pulse:46 Respiration: 20

Blood Pressure: L: 110/70 R____________Height:_________Weight:_________

III. INTEGUMENT :

Skin: / Light brown Deep brown

Pallor Cyanosis jaundice

No edema Edema present:_______________

Lesion present:__________________ Abrasion present: _____________

Excessive moisture Excessive dryness

IV. HEAD:

Hair:/ Evenly distributed Patches of loss hair

 /Thick Thin Silky, resilient Brittle, dry

/ No infestation Lice, nits

Skull: / Rounded, symmetrical, smooth Lack of symmetry

Absence of nodules or masses & depression

Local deformities from trauma

Face:/ Symmetrical facial features

Exophthalmos

Periorbital Moon face

Chloasma Sunken eyes

Eyes & Vision:

Color of conjunctiva________________________________________________

Clarity of cornea___________________________________________________

Color, shape & symmetry of size of pupils_______________________________

Pupil’s reaction to accommodation_____________________________________

Ocular movement__________________________________________________

Visual Activity_____________________________________________________

Ears:

Color & shape of auricle: ______________________________________________

Position: ___________________________________________________________

Discharges/growth: ___________________________________________________

Response to normal voice tones: _________________________________________

Nose:

Shape & color: _______________________________________________________

Discharges/growth: ____________________________________________________

Mouth & Pharynx:

Teeth: ____________complete__________dentures __________ carries__________

Color of lips & buccal mucosa: ____________________________________________

Color, position & texture of tongue: _________________________________________

Tongue movement: _____________________________________________________

Color of gums: _________________________________________________________

V. NECK

Muscle size/ symmetry: __________________________________________________

Head movement: _______________________________________________________

Lymph nodes: ____________________________Thyroid glands:__________________

Melasma: ______________________________________________________________

VI. UPPER EXTREMITIES

Skin & Nail: _____________________________________

Muscle strength & tone: _________________________________________________

Joint range of motion: ___________________________________________________

Brachial pulses:____________________Radial pulses: ________________________

Palmar erythema: ______________________________________________________

VII. CHEST & BACK:

Symmetry: ___________________________Size & shape:_______________________

Spine alignment: _________________________________________________________

Breathing pattern: _____________________ Breath sounds: _____________________

Respiratory muscle movement: _____________________________________________

Heart sounds:__________________Pitch:_______________Intensity:_______________

Extra sounds/beats:_____________________Murmurs: __________________________

Breast symmetry:_______________________Contour: ___________________________

Discharge:___________________Lymph nodes:__________Growth:________________

VIII. ABDOMEN:

Symmetry:_____________________Size:____________Shape:__________________

Abdominal sounds:______________________Growth: __________________________

Striae Gravidarum: ______________________Linea Nigra: _______________________

Fundic height: ______________Fetal heart tone: __________/ min. Location:_________

IX. GENITALS

Growth: _______________________Discharge: ________________________________

X. ANUS & RECTUM:

Growth: _______________________Discharge: ________________________________

XI. LOWER EXTREMITIES:

Skin & toenails: DARK BROWN / GRAY TOENAILS

Gait & balance:

Joint range of motion: _____________________________________________________

Femoral pulses:_________________________Popliteal pulses:____________________

Posterior tibial pulses:____________________Pedal pulses:_______________________

Bi-pedal Edema: ________________________Grade: ____________________________

Tendon & Plantar reflexes:_________________Spider angiomata : __________________

ANATOMY
 PATHOPHYSIOLOGY /PHYSIOLOGY

_______________________________________

According to book As experienced by the patient

TREATMENT
 STANDARD ACTUAL

(According to the book) (Done to patient)

ON-Going APPRAISAL
(Daily Condition of Patient)

Note: Start on the next day after assessment.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

DISCHARGED PLAN

M____________________________________________
______________________________________________
E_____________________________________________
______________________________________________
T_____________________________________________
______________________________________________
H_____________________________________________
______________________________________________
O_____________________________________________
______________________________________________
D_____________________________________________
______________________________________________
 HEALTH TEACHING

EVALUATION OF LEARNING OBJECTIVES