FORMAT ASSESSMENT OF NURSING CARE

ASSESSMENT
Held on December 19, 2018
1. Biodata
Name : Mr. A
Age : 40 years old
Sex : male
Religion : Islam
Address : Jln nirwana Green, no. 5
Education : High School
Job : Not working
Marital status : Married
Date MRS : December 19, 2018
Medical diagnosis : DHF
A family that is easy to contact
Name : Mrs. A
Job : Teacher
Address : Jl Nirwana Green, no. 5
Family Relationship : Husband
Complaint
1. Reasons for admission to hospital:
Fever, throbbing dizziness nausea vomiting decreased appetite from 7 days
ago
2. Complaints during assessment:
Patients say fever, throbbing dizziness, nausea and vomiting and decreased
appetite from 7 days ago.
3. Current medical history:
Patients said throbbing dizziness fever nausea vomiting and appetite decreased
since 7 days ago, before the patient had treatment to the nearest pukesmas and
did not go away then the patient came to the ULIN Banjarmasin Hospital.
4. History of past diseases:
Patients say they have not had MRS before and only have a past illness such
as a common cold cough.
 5. Family health history
Patients say they do not have declining diseases such as hypertension,
diabetes, heart disease, etc. And do not have infectious diseases such as
tuberculosis, HIV / AIDS, SCABIES, etc.
6. Psychosocial Spiritual History:
1) Psychology
Self-image: The patient looks nervous, and anxious.
Ideal self: patients feel unable to gather with their friends.
2) Social
Relationship between patients and cooperative nurses.
Relationship of patients with good families.
3) Spiritual
patients worship during illness.
4) Daily Activity Pattern (at home & in hospital):

No HABITS DIRUMAH DIRUMAH SAKIT

At home patients eat 3 In the hospital the patient said

times a day with the eating 3x / day with chicken
1. Eat
composition of rice and porridge composition was only 2
side dishes eaten. mouthfuls per meal.

At home the patient

At the hospital patients say
2. Drink says drinking 9 glasses
drinking water ± 1.5 liters / day.
of water per day.

At home the patient

says CHAPTER 1x /
Elimination day, with soft In the hospital the patient said he
3.
(defecate) consistency, a could not defecate
distinctive yellow stool
odor

At home the patient In the hospital the patient says

Eliminatin
4. says urinate 4-5x / day urinating 4-5x / day with a yellow
(Urinate)
with consistency, a distinctive urine
 the consistency of odor.
yellow, the distinctive
smell of Urine.

At home the patient In the hospital the patient said he

says the night's rest is could not sleep because of pain in
5. Sleep/Relaxation
enough the stump and stiffness of the
8:00 to 4:00 p.m. neck

At home patients
diligently exercise In the hospital patients only lie in
6. Training/sports,etc
aerobic exercise every bed.
Sunday.

7. Physical examination
Awareness : Samnolen
a. Vital signs: ° c
- Respiration: 20x / minute
- Pulse: 94x / minute TB / BB: 55 kg
- Blood pressure: 130/90 mmhg
- Temperature: 39
b. Head and Neck Examination:
- Head: Pain in stiffness, tenderness, no lesions with no lesions.
- Hair: Normal, straight hair, black and clean.
- Face: face looks grimace
- Eyes: right symmetrical, and left, not anemic.
- Nose: Right and left symmetrical, nose appears clean and no secret,
no lesions and tenderness.
- Ears: both right and left symmetrical ears appear clean with no
lesions and tenderness.
- Mouth & throat: Mukosa lips appear dry, no lesions, no cyanosis
there is no interference with swallowing and talking
- Neck: Tenderness in the neck, normal neck shape, no lumps, no
lesions, and no visible swelling of the thiroid gland.
c. examination of Integumen / skin and nails:
- Normal elastic skin tugor 1 second, nails appear clean.
d. Breast and Armpit Examination
- Right and left hemorrhoid symmetry, no lesions and tenderness. Nails
look clean elastic skin tugor.
e. Chest / Chest Check:
- Thorax: (Inspection) symmetrical chest shape right and left, no
additional breath movements.
- Lung: (Inspection, Percussion, Palpation, Auscultation)
There is no tenderness for no lesions, versatile breath sounds.
- Heart: (Inspection, Percussion, Palpation, Auscultation)
- Normal chest shape, no tenderness, no lesions, heartbeat.
f. Abdomen Examination (Inspection, Percussion, Palpation,
Auscultation)
- Flat abdominal shape / flat, there is heartburn, no lesions, 24x /
minute bowel sounds, hypertensive stomach sounds.
g. Examination of genitals and surrounding area (if needed)
- Genetalia
- Anus
h. Muskulo (Extremity) Examination:
- Upper extremity: normal right, left 4 terp inf.
- Lower extremity: normal right, normal left
i. Neurology Examination:
- GCS: 4/5/6
j. Medical Support Check:
December 19, 2018
- Management / therapy
DATA ANALYSIS

1. Subjective Data: The

patient's family said the
patient had a fever for 7
days
Objective Data:
Skin feels warm

Hipertermia
Troubled dizziness
Infection process
TTV
TD: 130/90 mmhg
N: 94 x / minute
.
RR: 23 x / minute
S: 39 ° C
\