NURSING DOCUMENTATION

ASSESSING EYES

Assessor : Lista Guspani

Patient     : Ria Masela

Report     :

Left and right eyes simetris, sclera white, conjunctiva normal, cornea brown, both eyeballs move together in one direction. Normal visual, no tenderness on both eyeballs. No oedema, snellen 20/20 OD and 20/20 OS. Able to read newspaper at distance of 12 inch.

ASSESSING EARS

Assessor : Lista Guspani

Patient     : Ria Masela

Report     :

Left and right ears simetris, color matching with other members part of the body, whisper test response positive bilaterally, voice perceived from 15 feet. Pinna smooth with no tenderness over mastoid. Ear canals clear with no drainage, np bulging noted.

BATHING REPORT

Assessor : Lista Guspani

Patient     : Ria Masela

Report     :

07.30 WIB. Complete bath given. Patient cooperate and able to assist. Skin on both legs dry flaking, complains have a painful in shoulder . Bath oil added to bath water. Bathing with warm water and  her own soap.  After bath, emollient lotion applied in her legs and eucalyptus oil applied in her shoulder. States painful is less now.