MEDICAL SURGICAL NURSING Mrs.

H
IN THE LAVENDER ROOM

Prepared by :

Eka Rahayu (16012)

AKADEMI KEPERAWATAN PELNI

JAKARTA
Jl. Aipda KS Tubun 92-94 Jakarta Barat
Telp. 021.5484809 Fax. 5485709

TAHUN AJARAN 2018/2019

 Patient Assessment Form

A. NURSING ASSESSMENT

1. Client Identity
My client’s name is Mrs.H and She is 29 years old. She is Moslem and married. Her
last education is senior high school. Her address is Kebon Jeruk RT 09/03. She speaks
Indonesian.
She entered Pelni Hospital Jakarta on 16th April 2018 in Lavender Room. Her
register number is 342165 and her medical diagnose is Bronchial Ashtma. Her financial
source is BPJS and the information source is from family.

2. Resume
Mrs.H was come to hospital 16th April 2018. The client came to hospital with
complaints of shortness of breath and cough accompanied by phlegm that has been felt
during the last 1 week. This complaint occured when the client was congested and
coughing when waking up in the morning and increasing when the move.
The results of the client's assessment found the client complained of crowded,
cough with white plegm and thick, and the client felt that crowded was decrease after
evaporation (nebulizer). Client looked anxious. Client claimed to has no desire to eat.
Client also said to have a history of asthma since childhood and the client said that there
is one family member who has a history of asthma, namely her mother.
From result of observation got result which were awareness level was
compostmentis and result of vital signs there were 130/70 mmHg blood pressure, 36
x/min respiratory rate, 76 x/min pulse, 37oC temperature. Client was currently receiving
therapy which were IVFD RL 20 drop/min, Pulmicort, Ventolin, Bisolvon and O2 with 2
L nasal cannula. On chest X-ray/ thorax investigation, the lung results were obtained
within normal limits.
 3. History of Nursing :
a. Current of medical history
The main complaint was chest tightness and cough. The main complaint trigger
factor was nothing. The incidence of complaints was suddenly. The complaints
happened since 1 week ago. The problem solving was going to Health Center.

b. Past medical history

Her medical history is ashtma. She has no allergy. She has taken medicine salbutamol
as ashtma drug

c. Family health history (Genogram and description of three generations of clients)

patient

Note:
Died : Female :
Male : Living together :
Line of Married : Line of Generation :

She was the second of four children. She has married and has two children. In her family,
only she who has asthma besides her mother.
 d. Disease experienced by a family member who becomes a risk factor
The client's mother is also suffering from the same illness as the client

e. Psychosocial and Spiritual History

The client’s communication pattern and decision within the family is two-way
communication and discussion. The effect of the client’s illness to the family was her
husband can’t work because accompanying her in hospital The client expected rapid
recovery and get home earlier.

4. Physical Assessment:
a. General Physical Examination
The physical examination was conducted on 17th April 2018. The client
weight was 54 kg and decreased 2 kg after illness. Her height is 155 cm. The general
circumstances of the client was not bad. She didn't have enlarged lymph nodes.

b. Vision System
The client had position symmetry eyes. The eyelid and eyeball movement
was normal. Corneas was normal. Her conjunctivas was anemis. The client had an
isokor pupil. The client had good visual function. She didn't signs of inflammation,
didn’t use glasses or no contact lens. She had a good reaction to light.

c. Hearing System
Her middle ear condition was normal. There was no fluid, feeling full, tinitus
or otalgia. She had normal hearing. Her hearing function was good. She didn’t have
balance disorder. She didn’t use tools.

d. Speech System
Speech system was normal. There was no problem with Aphaisa, Aphonia,
Dysartria, Dysphasia or Anarthia.

e. Respiration System
The airway was blocked because there was sputum. She had a breathing crowded.
She had a breathing frequency of 36 x/min. Her rhythm was regular. The type of
breathing was spontaneous. She had shallow breathing. She had a productive cough
with sputum and thick consistency. There wasn’t blood. She had symmetrical chest.
Her chest percussion was resonant. She had a wheezing breathing sound, and no pain
 when breathing. She use respiratory muscles with chest retraction. She use nasal
kanul 2 l/min.

f. Cardiovascular System
1) Peripheral Circulation
The pulse was 76 x/minute. Her rhythm was regular and the pulse was
strong, Blood pressure was 130/70 mmHg. There wasn’t jugular venous
distention in left and right. Her skin temperature was warm and the color was
pale. It took 3 seconds to feel capillary. There wasn’t edema.
2) Heart Circulation
The apical pulse rate was 77 x/minute. The rhythm was regular. There
wasn’t heart sound abnormalities. She didn’t chest pain.

g. Hematological System
The color was pale. There wasn’t bleeding found.

h. Central Nervous System

She not complained of vertigo or migrain. The awareness level was compos
mentis. The glasgow coma scale (GCS) was E ( eye): 4, M (motorik) : 5, and V
( verbal ) : 6. There wasn’t improvement of intracranial pressure. She didn’t have
disturbance of nervous system. The physiologic reflex was normal and there wasn’t
phatologic reflex.

i. Digestive System
Nutrition
She had caries. She didn’t use of dentures. There wasn’t sprue. Her tongue was
clean. She had a saliva was normal. The appetite was less because being sick. She
didn’t have nausea and vomiting. She wasn’t pain in stomach area. There wasn't
hepar enlargment and bloated abdomen. She was not installed NGT and the pattern of
eating habits at home was three times a day.
Elimination
Her noise intestines was 5 x/min. She didn't have diarrhea. She didn’t have
constipation and she didn’t use laxative. Her pattern of defecation habit at home has
once a day.
j. Endokrin System
There wasn't thyroid gland increase. The breath didn't smell like ketones. She
didn’t have polyuria, polydipsia, or polyphagia. She didn't have gangrene wound.

k. Urogenital System
Her urinary pattern was normal and the color was clear yellow. She didn't have
bladder distension. There wasn't back pain complaints. She didn't use catheter.

l. Integumen System
The skin turgor was elastic. She had skin temperature was warm and the color
was pale. Her skin condition was good. She didn't have decubitus. She didn’t
abnormalities of the skin. The condition of the area of the skin was good and not
swollen. The hair had good texture and cleanliness. The patterns of personal hygyne
at home was she takes a bath twice in a day.

m. The Musculoskeletal System

She didn't have difficulty in his movement. She didn't pain in his bones, joints and
skin. She didn’t have fracture and bone joint difference. She didn’t have vertebra
structure difference. Her muscles strength was good.
The muscles strength was

5 5 5 5 5 5 5 5

5 5 5 5 5 5 5 5
5. Supporting Data ( Diagnostic test that support problem : Laboratory, Radiology ,
Endoscopy. Etc.)
The test was laboratory and x-ray thorax and the result was 15,5 gr % Hb, .

17000/mm leukosit, 260000/mm trombosit, 47 vol % Ht, and the x-ray thorax was .

normal .

6. Management ( Therapy/Medicine diet including )

The diet given was rough porridge diet .

The therapy given was IVFD RL 20 drops/min, pulmicort, ventolin, bisolvon, .

And given the oxygen with nasal canule 2 /min .