CHAPTER I

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

1.2 Problem Formulation

1. What is the meaning of nursing documentation?
2. What are the processes of nursing documentation?
3. What are the processes of nursing documentation in children?
4. What are the benefits of nursing documentation?
1.3 Purpose
1. To find out what is meant by nursing documentation.
2. To know the process of nursing documentation.
3. To know the process of nursing documentation in children.
4. To know the benefits of nursing documentation.
 CHAPTER II
CONTENTS

2.1 Definition of Nursing Documentation

Nursing documentation is a system of recording and reporting information
about the client's health status as well as all nursing care activities undertaken by the
nurse (Potter and Perry, 1997). Documentation is a provable record and is legally
proof. (Tung palan, 1983). Nursing Documentation is a document that contains
complete, tangible and recorded data not only about the patient's level of illness, but
also the type and quality of services provided (fisbach, 1991 ).

2.2 Process of Nursing Documentation

1. Assessment
Assessment is the basic thought of a nursing process that aims to collect
information or data about a patient. Assessments were conducted to identify, identify
problems, health needs, and nursing.
2. Nursing Diagnosis
A nursing diagnosis is a statement of a real or potential patient problem based
on the data already obtained, whose solution may be within the limits of the nurse's
authority to do so.
3. Intervention
The intervention is to develop a nursing action plan that the nurse will
undertake to tackle the patient's problem in accordance with a predetermined nursing
diagnosis with the aim of fulfilling the patient's health. The components of the
nursing plan consist of the objectives, the outcome criteria, and the action plan of
nursing.
4. Implementation
Implementation is the implementation of the action that has been determined,
with the intention that the patient's needs are met optimally. Implementation of
nursing actions is the implementation of nursing patients in order of priority issues
that have been made in the action plan of nursing care, including the serial number
and time of enforcement of the implementation of nursing care.
5. Evaluation
Evaluation is the process of goal achievement assessment and nursing plan
review. Evaluation assesses patient response which includes subject, object,
assessment, plan of action.

3.1 Nursing Documentation In Children

1. Assessment
 Developmental assessment
Developmental assessments identify the specific characteristics of the child so
that the nurse can make individual nursing plans and make the coping skills better.
 Observation of response to hospitalization
Anxiety due to separation, loss of control, fear of the body being hurt, and
pain are the main causes of behavioral reactions of children who experience
hospitalization.
 Previous history of disease, hospitalization, and separation
The nurse collects data on how the child is against the previous
hospitalization. The nurse also determines the influence of the hospitalization on
subsequent behavior.
 Perception of disease
Determining what children know and being able to understand about their
illness is the first step in helping them understand the reasons for hospitalization.
 Available support people
Based on information provided by parents, nurses help families plan their support for
children during hospitalization.
2. Nursing Diagnosis
The diagnostic process for the child that is being promoted reveals how the
data analysis of the assessment action. The diagnostic sentence identifies the problem
and its possible causes. This identification allows the nurse to devise specific
interventions for healing.
3. Intervention
After identifying the nursing diagnoses, the nurse develops a treatment plan.
The goal setting and expected outcome of care for each nursing diagnosis is the first
stage, as the children's and parent's response to illness and hospitalization help the
nurse determine priority goals.
4. Implementation
Implementation of actions performed by nurses, children, or family. At the
time the child is hospitalized the nurse tries to ensure that the experience is a positive
thing for the child and family.
5. Evaluation
It is important to evaluate the child and family's response to nursing actions to
determine whether the goal of the nurse has been achieved. Client as result of
evaluation.

4.1 Examples of Nursing Care In Children

FORMAT ASSESSMENT
CHILD NURSING SCIENCE CHILDREN

I. Biodata
1. Client Identity
1. Name / Nickname :

2. Place of birth date / Age :

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 :

10. Therapeutic plan :

2. Identity of Parents

1. Father :

a. Name :

b. Age :

c. Education :

d. Employment / Source of income:

e. Religion :

f. Address :

2. Mother

a. Name :

b. Age :

c. Education :

d. Employment / Source of income:

 e. Religion :

f. Address :

3. Identity of Siblings

NO NAME OLD RELATION INFORMATION

II. Main Complaint / Reason for RS.

III. Current History

A. Current Health History

B. Past Health History

Especially for children aged 0 - 5 years)

1. Pre Christmas Care

a. Pregnancy check ......

b. Complaints during pregnancy: bleeding ... .., PHS ... .., infection ..., cravings ....,
Vomiting ......., Fever ......., Care during pregnancy

c. History: exposed to light ........., drug therapy .......

d. Weight gain during pregnancy ......... Kg

e. TT immunization ......... .. time

f. Blood type mother ...... .., Blood type Dad .......

2. Christmas
a. Place of birth: RS ......., Clinic ...... .., home .......

b. Length and type of labor: spontaneous ...... .., Forceps ... .., Operation ......, others
.......

c. Birth Aid: Doctor ... .., Midwife ......, Shaman .......

d. Ways to facilitate labor: drip ...... .., stimulants ....

e. Complications at birth: tear perineum ........., puerperal infections .......

3. Post Christmas

a. Baby condition: BB born ......... ..gram, PB ......... .cm

b. Does the child have: jaundice ......, bluish ......, redness ......., Breastfeeding problem
... .BB unstable .........

(For all ages)

a. Diseases that have been experienced: cough ...... .., fever .........., Diarrhea ..........,
Seizures ...... .., others ... ..

b. Accident suffered: falling ...... .., drowning ........., traffic ...... .., poisoning ... ..

c. Ever: surgery ......, hospitalized .........

d. Allergy: food ...... .., drugs ...... ..zat / chemical substance ......., Textiles ......

e. Free drug consumption ...

f. Development of children compared to their brothers: slow ........., same .........., Fast
......

Family Health Historya.

Diseases of family members: Allergies ......, asthma ..., tuberculosis ..., hypertension
..., heart disease ..., stroke .., anemia ..., hemopilia ......, arthritis ... .., DM ..., cancer ...
.. soul .. ..

b. Genogram

IV. Immunization history

No Jenis Imunisasi Waktu pemberaian Reaksi setelah pemberian

1. BCG
2. DPT
3. Polio
4 Campak
5. Hepatitis
Lain – lain

V. History of Growth Flower.

A. Physical Growth

1. Weight Loss: BB birth: Kg enter RS: kg.

2. Height: PB: cm, PB enter RS: Cm

3. Teething time:B. Development Each stageChild Age at: (month)

1. Roll over:

2. Sitting:

3. Crawling:

4. Standing up:

5. Walking:

6. Smile to others:

7. Talk first:

8. Dress without help:

VI. History of Nutrition

A. Breastfeeding

1. First breastfeeding .......

2. How to give: every time cry ........., scheduled ... ..

3. The length of giving ......... year

B. Provision of additional Milk

1. Reason for giving:

2. Grant amount:

3. How to administer: with dot ... .., spoon ... ..

C. Supplementary feeding

1. First given age ...... .., month ... ..

2. Type: milk porridge ......, banana ......, others ......

D. Pattern of Nutritional change each stage of age to current nutrition

Age Type of Nutrition Length of administration

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 ...... ..

VIII. Spiritual History

• Support system in the family

• Religious activity :

IX. Reaction Hospitalization

A. Family understanding of illness and hospitalization

• Why did the mother take her child to the hospital:

• 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 ... ..

B. Child's understanding of illness and hospitalization

• Why did the family / parents take you to the hospital?

• What do you think your cause hurts

• 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 :

Kondisi Sebelum sakit saat sakit

1. Selera makan
2. Menu makan
3. Frekuensi makan
4. Makanan yang disukai
5. Makanan pantangan
6. Pembatasan pola makan
7. Cara makan.
8. Ritual saat makan

B. FLUIDS

Kondisi Sebelum sakit saat sakit

1. Jenis minuman
2. Frekuensi minum
3. Kebutuhan cairan
4. Cara pemenuhan

C. Elimination (tub / chapter):

Kondisi Sebelum sakit saat sakit

1. Tempat pembuangan
2. Frekuensi (waktu)
3. Konsistensi
4. Kesulitan
5. Obat pencahar

D. Sleep rest

Kondisi Sebelum sakit saat sakit

1. Jam tidur
- siang
- malam
2. Pola tidur
3. Kebiasaan sebelum tidur
4. Kesulitan tidur

E. Exercise:

Kondisi Sebelum sakit saat sakit

 1. Program olah raga
2. Jenis dan frekuensi
3. Kondisi setelah olah raga

F. Personal Hygine:

Kondisi Sebelum sakit saat sakit

1. Cara mandi
a. Cara
b. Frekuensi
c. Alat mandi
2. Cuci rambut
a. Frekuensi
b. Cara
3. Gunting kuku
a. Frekuensi
b. Cara
4. Gosok gigi
a. Cara
b. Frekuensi

G. Physical activity / mobility:

Kondisi Sebelum sakit saat sakit

1.Kegiatan sehari-hari
2.Pengaturan jadwal harian
3. Penggunaan alat Bantu
aktivitas
4. Kesulitan pergerakan
tubuh

H. Recreation

Kondisi Sebelum sakit saat sakit

1.Perasaan saat sekolah
2.Waktu luang
3. Perasaan setelah rekreasi/
bermain.
4. Waktu senggang keluarga
5. Kegiatan hari libur
XI. Physical examination

A. General Client Condition:

Good ...... .., weak ........., seriously ill .......

B. Vital signs:

• Temperature:

• Pulse:

• Respiration :

• Blood pressure :

C. Anthropometry:

• Body length:

• Weight :

• Upper arm circumference :

• Head circumference:

• Chest size :

• Abdominal circumference:

• Skin fold:

D. Respiratory System

• Nose: Symmetry ......, breathing nostrils ..., secret ... ..., polyp ...... .., epistaksis ......

• Neck: Enlarged gland ....... Tumor ...... ..

• D a d a:

o Chest shape: Normal ......, barrel ...... .., pingion chest .......

o Comparison of anterior-posterior size with tranversal: ..........

o Chest movement: Symmetrical ...., there is a retraction ..... the muscles of the
breathing aids .......

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 Size: Normal ......, enlarged ......., Ictus cordis / apex

• Heart Sound: S1 ......., S2 ......, Aortic Noisy ... .., murmur .. ...., Gallop .......

• Capillary refilling time: ......... .detik

F. Digestive System

• Skelera: jaundice / no, lips: moist ......., Dry, cracked ..., labio skizis ... ..

• Mouth: Stomatitis ...... .., palatoskizis ... .., number of teeth ......., Swallowing
ability: good ...... / difficult ......

• Gaster: bloated ........., pain ........., peristaltic movement ... ..

• Abdomen: heart: palpable .........., Lien ......... .., kidney ...... ..Faeses .......

• Anus: Blisters ......, hemorrhoid ......... ..

G. System of the senses

1. Eye:

Eyelids ...... eyelashes ......... .., eyebrows ......

Visus (use snellen chard) ............

Field of view ............

2. Nose:

• Smell ....... ... .., Ravaged nose ............, trauma ........., nosebleeds
• Secret that blocks olfaction ............... ..

3. Ear:

• The state of the earlobe ............, the audiotor channel: clean ......... .., serumen .......

• Hearing function ............... ..

H. The nervous system

1. Cerebral function:

a. mental status: orientation ............, memory ............, attention and calculation .......,
language .........

b. Awareness: (eyes ............, motor ........., verbal .........) with GCS: .........

c. Expressive talk ..............., respectively

2. cranial function:

Nervus 1:

Nervus II: Visus .................., viewing field ............ ..

Nerve III, IV, VI: eye movements ............ .., pupil isokor ............, anisokor .......

Nerve V: Sensoric .............................. .., motor ........................ ..

Nerve VII: sensory .................. .., autonomous ..................... motoric ..................

Nervus VIII: listener .........................., balance ............................

Nerve IX: .................................... ..

Nerve X: Ovula movement .................., excitatory vomiting / swallowing .........

Nerve XI: Sternocleidomastoideus ........................, trapesius ......................

Nerve XII: tongue movement ......................................................

3. Motor function: muscle mass ............ .., muscle tone ........., muscle strength
4. Sensory function temperature ........., pain ......... .. vibration ......, position ...... ..,
discrimination .........

I. Skeletal Musculo System

1) Head: head shape .................., movement .............

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 ......

6) Hand: swelling ........., movement ......... .., ROM ............ ..

A. Integumentary System

• Hair: color .................., easily revoked ............... ..

• Skin: color ......, temperature ..., moisture .........., Skin feathers ..., eruption ......,
moles ..............., rashes ..............., texture .............

• Nails: color ......., Surface nails ............, easily broken ......., Cleanliness .........

K. Endokrine System:

• Thyroid gland:

• Excessive urine excretion ........., polypheny ............... .., poliphagi ............... ..

• Unbalanced body temperature .................., excessive sweating .....................

• History of urine excrement surrounded by ants ........................

L. Urinal system

• Odema palpebra ............... .., moon face ............ .. anasarka model .............

• Bladder state

• Nocturia ............ .., dysuria ..................., Pee stones ...............

M. Immune system:

• allergies (weather ...... .., dust ......., Animal fur ......... .., chemicals ............)

• Diseases related to climate change: flu ... .., urticaria ......, others ......

XI. Developmental leveling

A. 0-6 years

By using DDST

1. Rough motor

2. Fine motor

3. Language

4. Personal social

B. 6 years and over

1. Cognitive development

2. Psychosexual development

3. Psychosocial development