NURSING CARE REPORT FORMAT
EMERGENCY NURSING CARE
A. ASSESSMENT
1. Identity
a. Identity of the Client
Name
Age
Gender
Education
Occupation
Religion
Address
Date/Time entry to Hospital
Date/Time Assessment
Diagnosa medis
b. Responsible Identity
Name
Age
Gender
Religion
Address
Relationships with Client
: (initial)
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2. The Main Complain
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3. Reason for Hospital Admission
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4. History of the Disease
a. History of the Disease at This time
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b. Past Medical History
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c. Family Disease History
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5. Primary Survey
a. Airway
Open and inspect talking? tongue occluding airway? loose teeth/foreign
objects? secretions? edema? voice (stridor, snoring)? breath sound?
b. Breathing
Spontaneous? chest rise? Respiratory rate? accessory muscle use? abnormal
skin color? soft tissue or bone deformity? tracheal deviation? JVD? Chest wall
movement? Chest percussion? Lung auscultation?
c. Circulation
Palpate pulse rate? blood pressure?, external bleeding?, normal skin temp and
moisture? Capillary refill time? ECG?
d. Disability
Whats LOC using AVPU? GCS? Papillary light reflexes? GDS?
e. Exposure
Expose skin? whats body temp?
6. Secondary Survey
a. SAMPLE
1) Sign & Symptom : .
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2) Alergy : .............. .
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3) Medication : ....... .
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4) Past Illness : ...... .
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5) Last Meal : ......... .
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6) Enviroment/ Event : .
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b. Head To Hoe Assessment
Inspect for wounds, ecchymosis, deformities, from nose &
ears, check pupils
Palpate for tenderness, note bony cuepitus, deformity
Neck
Remove anterior portion of cervical collar to inspect &
palpate the neck
Inspect for wounds, ecchymosis, deformities & distended
neck veins
Palpate for tenderness, note bony crepitus, subcutaneous
emphysema & tracheal position
Chest
Inspect for breathing role & depth, wounds, deformities,
ecchymosis, use of accessory muscles, paradoxical
movement
Palpate for tenderness, note bony crepitus, subcutaneous
emphysema & deformity
Auscultate breath & head sounds
Abdomen and Inspect for wounds, distention, ecchymosis and scars
Flanks
Auscultate bowel sounds
Palpate all four quadrants for tenderness, rigidity, guarding,
masses and femoral pulses
Pelvis
and Inspect far wounds, deformities, ecchymosis, priapism,
Perineum
blood at the urinary meatus or in the perineal area
Palpate the pelvis and anal sphincter tone
Extremities
Inspect for erachymosis movement wounds and deformities
Palpate for pulses, skin temperature, sensation,
Head and Face
tenderness, deformities and note bony crepitus
7. Examination Support
(Laboratory test, X-Ray, BGA etc)
8. Therapy
(Drug, Diet etc)
B. Data Analysis
No
Day/ Date/
Time
Data
Etiology
Problem
Simple Pathway
C. Nursing Diagnoses
Ineffective airway ..
D. Intervention
No Dx
Day/ Date/
Time
Nursing Outcomes
Classification (NOC)
Nursing Interventions
Classification (NIC)
Implementation
Response
Signature/ Name
E. Implementation
No Dx
Day/ Date/
Time
Signature/ Name
S:
O:
F. Evaluation
No Dx
Day/ Date/
Time
Evaluation
S.
Reason for seeking care or other information the
patient or family members tell you
O. Factual, measurable data, such as observable
signs and symptoms, vital signs or test value
A.
Conclusion based on subjective and objective
data and formulated as patient problems or
nursing diagnoses
P.
Strategy for relieving the patients problems,
including short-term and long-term actions
G. Discharge Summary
Signature/ Name
