DOCUMENTATION OF NURSING CARE PLAN

IN SYSTEMIC PATTERN

FORMAT OF SYSTEMIC PATTERN ASSSESSMENT

Day / Date : ....................................................................................

Ward / class : ....................................................................................
Registration Number : ....................................................................................

DEMOGRAPHY DATA

A. Client’s Identity
Name : ....................................................................................
Age : ....................................................................................
Sex : ....................................................................................
Religion : ....................................................................................

Tribe / nationality : ....................................................................................

Education background : ....................................................................................
Occupation : ....................................................................................

Marital status : ....................................................................................

Address : ....................................................................................

B. Client’s Family’s Identity

Name of p/w/h : ....................................................................................
Age : ....................................................................................
Sex : ....................................................................................

Religion : ....................................................................................
Tribe/ nationality : ....................................................................................
Education background : ....................................................................................
Occupation : ....................................................................................
Address : ....................................................................................
Source of cost : ....................................................................................

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 : ................................................................
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 : ..................................

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 : ..................
 DOCUMENTATION OF SYSTEMIC MODE

PHYSICAL ASSESSMENT
1.General Condition
a. Vital signs
 Blood Pressure : mm/Hg
 Pulse : x / minute
 Breathing : x / minute
 Temperature : °C
b. Height : cm
Weight : 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
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APPLICATION
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SOURCES:
1.Potter, Patricia .A.Pengkajian Kesehatan.Edisi 3.
2.Manning, Robert. T. Diagnosis Fisik.Edisi IX.