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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



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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: 812x / 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