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the patient said the left eye is blurred and foggy to see, the eye is dazzled if exposed to bright

light, has
difficulty seeing at a distance or close distance the patient said the vision was blurred two weeks ago,
especially at night

3. history of disease now

the patient said the left eye was blurred and foggy since two weeks ago, the patient also felt anxious
about the current condition, then on 29 november 2018 the family decided to bring the patient to the
Kediri Baptist hospital through an outpatient installation (polyeye). and the patient also said he felt
uncomfortable with the illness he was experiencing at the moment. then the doctor diagnoses cataracts.

4 history of past illnesses

The patient said that he had never had cataract before and the patient had never experienced a serious
illness such as having to be operated on. The patient had only experienced dizziness, coughs and colds

5.family health history

the patient says no family has the same disease (cataract)

6. psychosocial and spiritual history

psychosocial: patients say they are anxious about current illnesses

social: patients have good relationships with family, patients are also cooperative with nurses and
doctors

spiritual: patients say they are Christian and worship diligently in church

7. daily activity patterns (eating, resting, sleeping, elimination, activity, cleanliness and sexual)

8 state / appearance / general impression of the patient

when it comes to outpatient installations the patient looks clean and neat, the patient looks restless and
anxious because of his illness, the patient also looks uncomfortable because the left eye is blurry and
foggy to see

9 Vital sign

body temperature

pulse

blood pressure

Respiratory

weight
10. physical examination

A. head and neck examination

head: white hair, no dandruff, no sores or bumps on the head

eyes: the left and right eyes are symmetrical, the conjunctiva is pink and the pupils appear foggy whit

nose: clean nose, no injuries, no secretions, no visible nasal bleeding

Ears: Right and left ears are symmetrical there are no injuries to the ears

mouth: no stomatitis.

neck: no enlargement of the thyroid gland

B. nail and skin integument examination

skin:

inspection: brown skin color, there are no sores or lesions on the skin

palpation: good skin turgor, no edema and no tenderness

nail:

inspection: short and clean nails

Palpation: CRT less than 2 seconds

C. Armpit and breast examination (if needed)

not reviewed

D. chest or thorax examination

Thoracic inspection: the chest looks symmetrical, there are no deformities of the chest, no lumps or
enlargements are seen, there are no injuries or lesions

Lungs:

palpation: right and left chest refraction are the same, no palpable enlargement or swelling, no
tenderness

percussion: Sonor's lung percussion sound.

auscultation: vesicular breath sounds, no additional sounds such as ronchi wheezing and others

E. heart examination:
inspection: no visible enlargement, no ictus cordis

palpation: not palpable enlargement or swelling, no tenderness.

percussion: deaf heart percussion sound

auscultation: S1 and S2 single heart sounds, lub: dub, no additional heart sounds

F. abdominal examination

Inspection: There were no visible injuries or surgery marks

Auscultation: bowel sounds 11 times / minute

palpasi: tidak teraba pembesaran / pembengkakan, tidak ada nyeri tekan

percussion: sounds tympanic

G. genital examination and the surrounding area (if needed)

genetalia: female patients, not using a catheter.

anal: no hemorrhoids.

H. musculoskeletal examination

information:

0: no contraction.

1: there is muscle contraction.

2: able to move without defying gravity.

3. able to move against gravity without resistance.

4. able to move widely.

5. able to move against gravity and fight maximum resistance

I. neurological examination

awareness: composmentis

GCS: 4-5-6

eye: 4: open eyes spontaneously.

verbal: 5: orientation, time, place and good people.


motor: 6: can follow intruction

J. mental status check

she patient's emotions are stable but the patient looks restless, anxious and uncomfortable. patients can
still respond well to what is asked by the nurse or family ,, orientation of the orientation of the time of
the person and place well

11. medical support examination

examination........ outcome.... normal value.... interpretation of results

no medical support

12. implementation / therapy

13. client / family expectations regarding the ailment

patients and families hope to get well soon and can see clearly as usual

Kediri city, on the 29th of November in 2018.... student signature

data analysis

Patient's name: Mrs. T

age: 63 years.

register no: 790570

objective data.

objective data

related factors / risks..... nursing problem