Documente Academic
Documente Profesional
Documente Cultură
IN KLUNGKUNG HOSPITAL
I. Identity of Client
Name : ND
Place, Date of birth: Karangasem, December, 30st 1950
Ages : 65 years old
Sex : Female
Education background : Elementary school
Job/Work : Farmer
Date of hospitalized : May, 10st 2015
Religions : Hindu
Status : Married
Nationality : Indonesia
Address : Padang Bay, Karangasem.
Resources : Pasient, patient's family and medical records
= Male = dead
= Pasient
V. Psychosocial Aspects:
1. Mindset and perception
a. Tools used:
The patient does not use assistive devices such as glasses and hearing
aids
b. Difficulties experienced:
Patients say there are no difficulties experienced by patients at this time
2. Self perception
a. What is currently estimated:
The patient said the thing he was thinking about right now was about the
current healing process.
b. Hope after undergoing treatment:
The patient said his hope after undergoing treatment was that the
tightness he experienced could heal and his blood sugar did not rise.
c. Mood :
The patient said his mood was nervous because he was thinking about
his current health condition.
1. Communication relations:
a. Talk
Patients can speak clearly using Balinese.
b. Residence
Have your own house that is occupied with the extended family.
c. Family life
• The customs adopted:
Patients say they usually take part in activities in their homes such as
traditional ceremonies or banjar activities.
• Decision making in the family:
Patients say decisions are taken more often by their sons as family in
charge.
• Communication patterns:
Patients are able to communicate with family, doctors and nurses.
• Finance;
The patient said that his financial problems were all sufficient and borne
by his son.
• Difficulties in the family:
Patients say relationships with children, son-in-law, grandchildren and
siblings have no obstacles / difficulties.
2. Sexual habits
a. Disorders of sexual relations are due to the following conditions:
The patient said her husband had died 7 years ago.
b. Understanding of sexual function:
Patients say they already understand sexual function.
3. Defense of coping
a. Decision-making
The patient says decision making is assisted by his son.
b. What you like about yourself:
The patient said that even though he was now sick but he was proud of
him who had been 75 years old and still able to live and gather with his
children and grandchildren.
c. What you want to change from life:
The patient said he wanted to reduce the consumption of sweets and
sweet foods.
d. What is done when under stress:
Patients say that if they are stressed the patient is usually angry and
nags the people around him.
1. System of trust value
a. Who or what is a source of strength:
Patients say the source of strength is family and God.
b. Is God, Religion, Trust important to you:
Yes. The patient says thanks to God's grace, He can still live
and be given time to gather with his family.
c. Religious activities or beliefs carried out (types and
frequencies) state:
Patients say they usually pray / mebanten every afternoon.
d. Religious activities or beliefs that you want to do while in
the hospital, state:
The patient said that during the hospital he wanted to do it only
to pray in the heart.
IV. Physical Study
A. Vital sign
Blood pressure: 140/80 mmHg
Temperature: 36.50C
Pulse: 96 x / minute
Breathing: 36 x / minute
B. Awareness: Compos Mentis GCS: 15
Eye: 4
Motor: 5
Verbal: 6
C. General conditions:
Pain / pain: -
Nutritional status: Normal
BB: 56 kg TB: 155 cm
Attitude: Calm down
Personal hygiene: Clean
Time / place / person orientation: Good
D. Physical Head To Toe Examination
1. Head
Form: Mesochepale
Lesions / wounds: There are no lesions / wounds on the head
2. Hair
Color: White gray
Abnormalities: not fall out or dandruff
3. Eyes
Vision: Normal
Sclera: No icteric
Conjunctiva: Not anemic
Pupil: Isokor
Efficacy: There are no abnormalities in the patient's vision
4. Nose
Irritation: Normal
Secret / blood / polyp: There is no secretions, blood, or
polyps in the patient's nose
Nasal lobe pull: There is no pull of the nostrils when the
patient breathes
3. Ears
Hearing: Normal
Scret / fluid / blood: There are no secretions, fluids, or
blood in the patient's ear
6. Mouth and Teeth
Lips: Moist
Mouth and throat: Normal
Tooth: Full / normal
7. Neck
Thyroid enlargement: No thyroid enlargement
Lesions: There are no lesions
Carotid pulse: Tinged with carotid pulse
Lymphoid enlargement: There is no lymphoid
enlargement
1. Thorax
Heart: 1. Pulse: 96x / minute, 2. Strength: Strong
3. Rhythm: Regular
Lungs: 1. Frequency of Breath: Fast
2. Quality: Normal
3. Breath Sound: Vesicular
4. Cough: No
5. Airway obstruction: There is no airway obstruction
Chest retraction: None
2. Abdomen
Peristaltic intestine: There are, 10 times / minute
Bloating: No
Press pain: No.
Ascites: No.
3. Genetalia
Pimosis: No.
Tools: No
Abnormalities: No.
4. Skin
Turgor: Elastic
Lacerations: No.
Skin color: Normal (brown)
12. Extremities
Muscle Strength: 4 4 4 4 4 4
444444
R O M: Limited
Hemiplegi / parase: No
Accrual: Warm
C R T: <3 seconds
Edema: None
An IV is inserted in the right hand
A. DATA ANALYSIS
COPD
B. DIAGNOSA KEPERAWATAN DAN PRIORITAS MASALAH
pressure, pulse,
breathing).