NURSING CONCEPT

A. ASSESSMENT
Room: Interna
Nurse Reviewing:
Room:
Anamnese obtained from :
Entry Date :
Anamnese Date / Hour:
Hospital Entry Time : 15.00
1. Identitiy
a. Patient Identity
Name :
Age :
Gender :
Religion :
Marital Status :
Education :
Job :
Address :
b. Identity of the Person in Charge
Name:
Relationship with Patients :
Age :
Education : Middle School
Job :
2. General Complaints :

3. Health History Now :

4. Past Health History :

5. General Conditions :
a. How to Enter :
b. Illness :
c. Vital sign :
- Awareness :
- Temperature :
- Nadi :
- TD :
- Respiration :
6. Health Pattern Assessment
 A. Nutrition
a. At Home :
b. At the Hospital :
B. Drink
a. At Home :
b. At the hospital :
C. Elimination
a. BAK
At Home :
At RS :
b. BAB
At Home :
At the Hospital :
D. Sleep Rest
a. At Home :
b. At the hospital :
E. Activity
a. At Home :
b. At the Hospital :
F. Personal hygiene
a. At Home :
b. At the hospital :
G. Recreation
a. At Home :
b. At the hospital :
7. PHYSICAL EXAMINATION (Head to toe)
a. Head
Mesosepalus form, there is no dirt or dandruff, the movement is not rigid can be moved
left to right, there is no injury to the scalp and the scalp is clean enough.
b. Hair
Client's hair is short straight, black and client's hair looks clean.
c. Eyes
Symmetrical eye shape, good vision function, conjunctiva is not anemic, pupil and reflex
light are good, clients do not use visual aids.
d. Nose
The shape and position of the nose are simestrical, the olfactory function is good, there
is no secret or foreign material that is attached, there are no epithaxis and no
inflammation.
e. Ears
Symmetrical shape and position, good hearing acuity, no cerumen and fluid in the ear
canal, no bleeding and no saliva using hearing aids.
f. Mouth and teeth
 Symmetrical lip shape, lip color blackish, mycosae look dry, good taste function, no
bleeding and hearing, the mouth is clean enough and the spleen does not use dentures.
g. Neck
There is no enlarged lymph nodes and thyroid gland, there is no inflammation and the
neck can be moved anatomically.
h. Thorax (respiratory function)
Symmetrical shape, no wheezing sound and no decrease in left and right lung
expansion.
i. Abdomen
Symmetrical shape, the abdomen looks clean there is no wound. Abdomen clients
bloated during percussion, when auscultation bowel sounds 15x / minute (Normal: 8-
12x / minute).
j. Reproduction
The sex of the client is male, has a wife and two children.
k. Extremities
- Upper limb : can be moved properly and the upper extremity of the right is
infused.
- Lower extremity : both can be moved well but the client's weak condition is
forced by the client to rest completely in bed.
l. Integument
Brown skin color of the brown client, there were no lesions and bruises.
8. TREATMENT
- RL : 28 tpm
- Vicilin : 1 gram / 8 hours
- PCT : 3x1
- Albumin VIP : 3x1
- Ceftriaxon : 2 grams / day
- Baquanor : 2x1
- Plasmodin : 1x3
- Divavit : 1x1
- Nurodex : 2x1
- Dexamethason : 1 amp / 8 hours
- Megazing : 1x1