Name: Bayle, Sheryhan T.

Clinical Experience: RLE

Clinical Area: Brent Hospital and Colleges Incorporated
Placement: Second Semester (Level III)
Rotation: Weeks 5-6
Day and Time: (Monday, Tuesday and Wednesday); 8:30 am - 11:30 am
Clinical Instructor: Mrs. Jana Lynn Rivera, RN

GENERAL OBJECTIVE:
Acquisition and application of knowledge, skills, and attitude through the
utilization of nursing process in the care of patients with infectious and
inflammatory diseases with emphasis on health promotion, prevention, and
maintenance of health.

LEARNING OBJECTIVES:
At the end of 3 hours of Related Learning Experience, I will be able to:
1. Become familiar with the hospital setup, etiquette, regulations, and policies of
the
related learning experience accordingly.
2. Establish rapport with the Clinical Instructor, fellow duty mates, and hospital
staff
professionally.
3. Understand the pathophysiology, signs, and symptoms of visual and auditory
disturbances meticulously.
4. Acquire skills and abilities in nursing practice to provide health care in the
actual
field efficiently.
5. Provide safe, secure, and high-quality medical care responsibly.
6. Assess patient using bait’s assessment tool and conduct nursing health history
comprehensively.
7. Perform diagnostic procedures with emphasis on nursing responsibilities and
rationale skillfully.
8. Document charts and record data accurately.
9. Submit all my requirements to my Clinical Instructor punctually.
Plan of Activities:

DAY 1 THURSDAY
6:30 am - 6:45 am – arrival at the hospital
6:45 am - 7:20 am - endorsement
7:20 am - 7:30 am – checking of attendance and uniforms
7:30 am - 7:45 am – courtesy call to the Head Nurse, Staff Nurses, and other
healthcare personnel
7:45 am - 8:05 am – orientation regarding hospital setting and medical officers of
the institution by the Clinical instructor
8:05 am – 8:20 am – distribution of tasks and assignments for student nurses
8:20 am – 9:00 am – introduction, assessment, and vital signs of patient
9:00 am - 9:20 am – BREAK TIME
9:20 am – 11:30 am – physical assessment and Gordon’s assessment pattern done
to the patient
11:30 am -12:00 pm – questions and clarifications from the patient
12:00 am -12:45 pm - LUNCH
12:45 pm - 1:00 pm – Checking of Attendance
1:00 pm - 1:15 pm – check patient’s vital signs and document
1:15 pm -1:45 pm – Assist nurse on duty in administering medication to patient
1:45 pm - 2:30 pm – complete charts and endorse patient to the incoming nurse
2:30 pm - 3:00 pm – discuss activities throughout the day
3:00pm - dismissal
 Ateneo de Zamboanga University
College of Nursing

BATES ASSESSMENT TOOL

MENTAL STATUS
APPEARANCE

Grooming: Neat                             Attire: Casual

Personal Hygiene: Clean
Gait: Normal/straight walking pattern  Posture: Normal General Body Built: Normal

BEHAVIOR
Level of Consciousness:
( ) Awake ( ) Alert () Lethargic
(  ) Drowsy (  ) Stupurous or unresponsive
( / ) Aware and responsive of internal and external stimuli
Facial Expression:     asleep Speech: n/a
Mood:       sleeping Affect: N/A

COGNITION

Oriented:     (  )Person (  ) Place       (  ) Time         (  ) Confused    (  ) Sedated

      ( ) Alert (  ) Restless    ( / ) Lethargic  (  ) Comatose
Recent Memory: N/A
Remote Memory: N/A

THOUGHT PROCESS

Thought Content:     (  ) Logical (  ) Consistent

Client’s Perceptions: (  ) Reality-base (  ) Congruent with others
                                  (  ) Others: N/A
Suicidal Thoughts/Ideation: (   ) Present (   ) Absent

INTEGUMENTARY SYSTEM
SKIN
INSPECTION
Color: ( / ) Normal (  ) Flushed (  ) Pale (  ) Dusky
             (  ) Cyanotic (  ) Jaundiced    (  ) Others: _________________________
Texture:Smooth                        Tone:                    
Lesions: ( ) Yes, site: _______ ( / ) No
PALPATION
Moisture: Slightly Dry Temperature: 37C
Turgor: _______________________
Edema: ( / ) Absent (  ) Present, site: _______________________
                                        (  ) Mild (  ) Moderate (  ) Severe
Pruritus: (  ) Yes, site: _________________ ( / ) No
Wound incision/pressure sore site: N/A  Dressing type: N/A
Odor: ( / ) None (  ) Mild (  ) Foul
Drainage/Exudates: (  ) Serous (  ) Sanguinous       (  ) Serosanguinous
Color:    (  ) Yellow (  ) Creamy (  ) Green       (  ) Beige/tan

NAILS
INSPECTION
Color: Pinkish Texture: Smooth  Configuration: Rounded  Symmetry: Symmetrical
Cleanliness: Well-trimmed

HEAD AND NECK

HEAD
INSPECTION
Head Structure and symmetry: Symmetrical
Hair Color: N/A     Thinning: (  ) Yes    (/ ) No

PALPATION
Temporal Artery: Normal
Cranium: Normal Scalp: Oily
Hair Texture: Smooth
Maxillary & Frontal Sinuses: Normal

EYES
INSPECTION
Conjunctiva:  R: Red L: Normal Sclera: R: Red L: Normal
Cornea:          R: Edematous L: Normal Iris:      R: Normal L: Normal
Ptosis:             R: Present L: None
Visual Fields:  R: Dysphotopsia L: Normal
Extraocular movements: : R: Normal L: Normal
Pupil: Color:  R: Black   L: Black         Size:  R: Large L: Equal
Response to Light & Accommodation: R: __sensitive___   L: __Normal___

NOSE
INSPECTION
External Nose: Normal
Nostrils: R: N/A    L: N/A

MOUTH
INSPECTION
Mouth & Throat Mucosa: Normal Tongue: Pinkish
Teeth and Gums: Complete teeth, symmetrical Floor of Mouth: Normal Palate: ______
Uvula: ______
Lesions and Ulcers: (  ) Yes, site: ____________ ( / ) No
Salivary Glands: ______

FACE
INSPECTION
Spasms: (  ) Yes, site: __________   ( /) No            
Tics:        (  ) Yes, site: __________ ( /) No
Lesions:  (  ) Yes: (  ) Mild   (  ) Moderate    (  ) Severe ( /) No              
Facial Paralysis: (  ) Yes R: _________    L: _________ (/ ) No

EARS
INSPECTION
Tympanic membrane: R: Intact ( /) Yes    (  ) No    L: Intact ( /) Yes    (  ) No    
Tragus of Ear: R: ______  L: ______
Canal:             R: ______  L: ______
Lesions: (  ) Yes, site: ___________    ( / ) No
Discharges: (  ) Yes, amount: ________  (  ) Left    (  ) Right   (  ) Both     ( / ) No

NECK
PALPATION
Thyroid gland size: Normal Shape: Normal
Tenderness: None Nodules: None
Position of Trachea: ______
Cervical Lymph Nodes: None

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: 18bpm
Pattern:     (  ) Shallow (  ) Dyspnea ( / ) Tachypnea (  ) Shortness of Breath
Chest Symmetry:    ( / ) Even (  ) Uneven
Chest Deformities:  (  ) Scoliosis (  ) Kyphosis (  ) Kyposcoliosis
PALPATION
Chest:     (  ) Masses, site: ____________
               (  ) Bulges, site: ____________

               (  ) Muscle Tone, site: ______________

               (  ) Crepitus, site: ______________
               (  ) Areas of Tenderness, site:  ______________
               (  ) Subcutaneous Emphysema, site: ______________
Excursion:   (  ) Respiratory:       R: ______cms.      L: ______cms.      
PERCUSSION
Notes elicited: ______________ Site: __________________
AUSCULTATION
Excursion:   (  ) Diaphragmatic: R: ______cms.      L: ______cms.
Breath Sounds: 
Normal:         ( / ) Bronchial   (  ) Bronchovesicular         (  ) Vesicular
Adventitious: ( / ) Crackles-Coarse, site: Upper Lobe 
                       (  ) Crackles-Fine, site: ____________      
                       (  ) Stridor, site: ____________
                       (  ) Rhonchi/Gurgles, site: ____________
                       (  ) Wheezes, site: ____________
                       (  ) Pleural Friction Rub, site: ____________
Other Abnormal Findings: Voice Resonance:
(  ) Bronchophony (  ) Egophony (  ) Whispered
(  ) Pecteriloquy (  ) Pleural Friction Rub
Chest Abnormality Location (state):
Cough:   ( / ) Yes: Type:   ( / ) Productive: 
                                              Color of Sputum: Red   Amount: __________   
 (  ) Non-productive      (  ) No

CARDIOVASCULAR SYSTEM
NECK VESSELS
PALPATION
Carotid Artery: R: Normal L: Normal
AUSCULTATION 
Carotid Arteries:  Bruits: ( / ) Absent (  ) Present 
Jugular Vein Distention: (  ) Yes: _______cms.      ( / ) No

HEART
INSPECTION
Point of Maximal Impulse (PMI): ______
Thrills: (  ) Present ( / ) Absent
PALPATION – Perfusion: Capillary Refill:_seconds
Murmurs: ____

PULSES
 ( ) Regular    ( / ) Strong           (  ) Irregular        (  ) Weak         (  ) Absent
 (  ) Doppler     (  ) Pacemaker
Radial: R: _______ L: _______
Pedal:  R: ____________ L: ____________
Apical: R: 101 bpm L: 101 bpm
BP:   120/70mmHg    R: ___________ L: ___________

GASTROINTESTINAL SYSTEM
Mouth: ______
Throat: ______

ABDOMEN
INSPECTION
Contour: Flat
Symmetry: Symmetrical
Gastrostomy (specify): N/A
AUSCULTATION
Bowel sounds:(  ) High-pitched & Gurgling (  ) Hyperactive
(  ) Low-pitched (  ) Hypoactive
                          (  ) Tympany
Rate: _  per minute
PERCUSSION
Notes: ____________________________   Site:__________________________________
PALPATION
Abdomen:  (  ) Tender( / ) Soft/Non-Tender (  ) Firm (  ) Rigid
Mass:           ( / ) No (  ) Yes
Ascites:        ( / ) No (  ) Yes
Girth: ________________                      Inguinal Area: Normal

MUSCULO-SKELETAL SYSTEM
INSPECTION
Symmetry: Normal
Deformities: N/A
Others: _________________
Peripheral pulses:
Upper Extremities:  Radial:             R: ______ L: ______
                                Ulnar:               R: ______ L: ______
                                Brachial           R: ______ L: ______
Lower Extremities: Popliteal:          R: ______ L: ______
Dorsalis Pedis:  R:_____ L: ______
                                Posterior Tibia:R: ______ L: ______
Edema:  (  ) Yes (  )Pitting (Grade) _________            ( / ) No
Temperature: _______________________  Site: __________________________
RANGE OF MOTION: ( / ) Yes (  ) No, area:  _________________
Deformity: ______________________________________________________________
Discrepancy in Extremity (Leg) Length (  )Yes ______________ ( / ) No
PALPATION
(  ) Musculature ________________ (  ) Body articulation_____________________
(  ) Crepitations ________________ (  ) Heat_____________________________(  ) Swelling
____________________ (  ) Tenderness_______________________
Normal ROM of extremities: ( / ) Yes (  ) No
(  ) Weakness ( Paresis) (  ) Paralysis
(  ) Contractures (  ) Joint Swelling
(  ) Pain: (  ) Bone Pain (  ) Muscle Pain (  ) Joint Pain
(  ) Others: __________________________________________
Hand Grasps: ( / ) Equal (  ) Unequal (  )Weakness (  ) R & L
Leg muscles:  ( / ) Equal (  ) Unequal (  ) Weakness (  ) R & L

NEUROLOGIC SYSTEM
 
CRANIAL NERVES
Olfactory Nerve (CN I)
Identifying different mild aromas, such as coffee, vanilla, peanut butter, and orange.
Optic Nerve (CN II)
 Normal
Oculomotor (CN III)
 Normal
Trochlear (CN IV)
 Normal
Trigeminal Nerves (CN V)
Abducens Nerve (CN VI)
 Normal
Facial Nerve (CN VII)
 Normal
Acoustic Vestibulocochlear Nerve (CN VIII)
 Normal
Glossopharyngeal Nerve (CN IX)
 Normal
Vagus Nerve (CN X)
 Normal
Spinal Accessory Nerve (CN XI)
 Normal
Hypoglossal Nerve (CN XII)
 Normal

CEREBELLAR FUNCTION
SENSORY SYSTEM
Discriminate Light Pain: (  ) Yes (  ) No
Detect Vibration: (  ) Yes (  ) No
Discriminate Light Touch: (  ) Yes (  ) No
Detect Temperature: (  ) Yes (  ) No
Detect Stereognosis: (  ) Yes (  ) No
Detect Graphesthesia: (  ) Yes (  ) No
Two-Point Discrimination: ( ) Yes (  ) No

DEEP TENDON REFLEXES

Insertion Tendon of Biceps (C5 to C6)
______________________________________________________________
Insertion Tendon of Triceps (C7 to C8)
______________________________________________________________
Insertion Tendon of Brachioradialis (C5 to C6)
_____________________________________________________________
Insertion Tendon of Quadriceps/Knee Jerk (L2 to L4)
_____________________________________________________________
Insertion Tendon of Achilles/Ankle Jerk (S1 to S2)
______________________________________________________________________
 SUPERFICIAL REFLEXES

Abdominal (upper T8 to T10, lower T10 to T12)

______________________________________________________________
Cremasteric Reflex (L1 to L2)
______________________________________________________________
Plantar Reflex
______________________________________________________________

GENITOURINARY
PERIANAL REGION
INSPECTION

(  ) Hemorrhoids: (  ) Bleeding ( / ) Not

(  ) Fissures (  ) Scars (  ) Lesions (  ) Rectal Prolapse
(  ) Fistula (  ) Discharge (  ) Blood in stool

PALPATION
(  ) Rectal Masses

MALE GENITALIA
INSPECTION
Hair Distribution: Even
Penis: Dorsal Vein: (  ) Yes   (  ) No
Urethral Meatus Appearance: _________________________________________
Bumps:   (  ) Yes, site: ___________  ( / ) No
             Blisters:    (  ) Yes, site: ___________  ( / ) No
Lesions:    (  ) Yes, site: ___________  ( / ) No
             Redness:  (  ) Yes, site: ___________  ( / ) No
Scrotum: R: ____________ L: ____________
Urine:   Color: Yellowish         Character: N/A
  Frequency per day: N/A Amount: N/A
(  ) Anuria (  ) Hematuria   (  ) Dysuria (  ) Incontinence
(  ) Catheter (Type): ______________________                
Others (specify): _________________________

FEMALE GENITALIA
INSPECTION
Mons Pubis: _____ Labia Majora: ____
Labia Minora:_____ Clitoris:_____
Vagina:_____ Urinary Meatus: _____
Skene’s and Bartholin’s Glands: ______
Urine: Color: ____________        Character: ______
Frequency per day: ___________       Amount: ___________________
(  ) Anuria (  ) Hematuria   (  ) Dysuria (  ) Incontinence
(  ) Catheter (Type): _________________                Other:____________________
LMP: ______    ( ) Vaginal Discharges: __________________________________
Menstrual Problems:
(  ) Amenorrhea (  ) Dysmenorrhea (  ) Menorrhagia
(  ) Metrorrhagia (  ) Pre Menstrual Syndrome
Others (specify) ______________________________________
Age of Menarche:_ Length of Cycle: ________
Menopause: ___________________Last Pap Smear: ____________________
Monthly Breast Self Examination ( ) Yes(  ) No
Method of Birth Control: _____________________________
Obstetrical History: _________ AOG ________
POP:  ______ Weight:  ________ FT _______ FHT_______
Leopold’s Maneuver: ________________ Presentation: ___________________
Urine Test Result: ___________________ Pregnancy Test: 
(  ) Albumin _______ (  ) Sugar ________
(  ) Protein   _______ (  ) RBC    ________                (  ) Pus ________
Bleeding:     (  ) Yes, amount: ___________ (  ) No    
Uterine Discharges:
Rubra:  Color ________  Amount________         Odor________         
                Serosa:  Color_______ Amount________ Odor_________
                Alba:     Color_______ Amount________ Odor_________

PSYCHOSOCIAL
Recent Stress: Present health condition
Coping Mechanism: N/A
Support System: Family
Calm:            (  ) Yes____________________  ( / ) No______________________
Anxious:        ( / ) Yes____________________  (  ) No______________________
Angry:           (  ) Yes____________________  ( / ) No______________________
Withdrawn:   (  ) Yes____________________  ( / ) No______________________
Irritable:        (  ) Yes____________________  ( / ) No______________________
Fearful:         ( / ) Yes____________________  (  ) No______________________
Religion: Roman Catholic                                       Restrictions:_________________
Feeling of Helplessness:      (  ) Yes        ( / ) No
Feeling of Hopelessness:     (  ) Yes        ( / ) No
Feeling of Powerlessness:   (  ) Yes        ( / ) No
Tobacco Use: (  ) Yes____________________  ( / ) No______________________
Alcohol Use:   (  ) Yes____________________  ( / ) No______________________
Drug Use:       (  ) Yes____________________  ( / ) No______________________

NUTRITION
General Appearance:     ( ) Well Nourished       (  ) Malnourished
                                        (  ) Emaciated            (  ) Other
Body Built: Normal   Weight: 52 kg      Height: N/A
Diet: N/A        Meal Pattern: N/A
                      ( / ) Feeds Self          (  ) Assist           (  ) Total Feed

Mastication/Swallowing Problem       (  ) Yes_________ ( ) No_________

Dentures:   (  ) Yes                ( / ) No
Appetite:   (  ) Increased      ( / ) Decreased    (  ) Unusual 
Decreased Taste Sensation: (  ) Yes             ( / ) No
Nausea:     (  ) Yes                ( / ) No   
Stool frequency: N/A               Characteristics: N/A
Last Bowel Movement: N/A
NGT/ Gastrostomy: N/A

VENOUS ACCESS RECORD

Date
# Site Date Inserted Fluid Gauge (color)/ Number of Drops Reason
Removed

PAIN ASSESSMENT
Location of pain: N/A Frequency: N/A
Intensity Pain Scale(0-10): N/A Quality: N/A
Onset: (When did your pain started?) N/A
Duration: 2 weeks Body Reaction: Elevated temperature, Sweating and lethargic
Alleviating Factors: N/A
Precipitating factors N/A
Special Assessment Devices
(  ) Wheelchair (  ) Contacts (  ) Venous Access device
(  ) Braces (  ) Hearing aid (  ) Epidural catheter
(  ) Cane/ Crutches (  ) Prosthesis (  ) Walker
(  ) Glasses
Others:____________________________________________________________

SELF-CARE
Need Assist With:
(  ) Ambulating (  ) Elimination
(  ) Bed Mobility (  ) Meals
(  ) Hygiene (  ) Dressing

PATIENT EDUCATION
( ) Safety / Restraint Use     (  ) Signs & Symptoms to Report
(  ) Ordered Therapies     (  ) Lifestyle Change
(  ) Diagnosis / Disease     (  ) Rehabilitation Measures
 (  ) Pain Management     (  ) Hygiene / Self care
(  ) Hospital Referrals     (  ) Diet or Nutrition
(  ) Community Referral        (  ) Mobility / Ambulation
(  ) Medication

Specify Plan of Care Intended:

Example medications (List Down all medications to be taken at home with special nursing care
instruction to be given to the client like, dosage, time, frequency.
____________________________________________________________________________
____________________________________________________________________________
______________________________________________