A.

Assessment
NURSINGHISTORY
Admin Date
: March 13th , 2015
Time
No. Reg
: 104888
Medical Dx
Hospital
: Ansari Saleh General Hospital

: 16.00 pm
: Hipertensi

Date of Assessment
:March 13th, 2015
1. Biographic Data
a. Name
: Ny. S
b. Age
: 65 Years
c. Sex
: Female
d. Race
: Bugis
e. Religion
: Moslem
f. Job
: Trader
g. Marial status
: Married
h. Education
: Junion High School
i. Occupation
: Swasta
j. Address
: Palembang
k. Healt Care Financing
: Jamkesmas
2. Chief Complain :
patient complained of body feels weak, tired and sometimes dizziness.
3. History Of Present Illnes
The patient came to the emergency department on 13 March 2015 at
16:00 pm by ushered her family, the patient says his head hurts, her body
limp and waist ache, the patient's family said that before being taken to
hospital when the patient falls into the bathroom.
4. Past History
Patient had been suffering from hypertension, and often complain of
headache, but
not yet treated in hospital. And Patient had no history of
food allergies and medications.
5. Family History of Illness
Patients say does not have a contagious disease and only has decreased
disease are hypertension, the patient's family said there was one family
member who has hypertension.
6. Life Style
a. Pattern of nutrients
Eat and drink
Diet before sick 3 times / day, no food restrictions.
Drink 6-8 glasses of water a day, sometimes drink coffee.
in the hospital
Diet 3 times / day, diet TKTPRG
Drink 4-6 glasses of water, sometimes drinking milk prepared.
b. Elimination
Elimination pattern
1) Before the pain

a) normal CHAPTER 2 times a day, solid, yellow.

b) normal BAK 6-8 times a day, straw color - brass
2) During the Pain
a) CHAPTER liquid 1-2 times a day, solid, yellow color, distinctive
odor.
b) liquid BAK 6-8 times a day, a distinctive smell.
c. Sleep Patterns and Rest
1) Before the pain
Patients said before sick bed 7-8 hours / day
2) During the sick
Patients only sleep 3-5 hours / day because of frequent dizziness and
sometimes difficulty sleeping if noisy environment.
d. Activity
before ill patients usually go to the market to trade starting from the
morning until the afternoon.
when in hospital patient says he just sat there as weak, but if to the
bathroom he felt tired.
e.

Personal hygiene
Usually patients 2 times daily bathing, brushing teeth done after
bathing and eating.
when in hospital patients in the bathroom, but only briefly because
they feel weak and tired.

F. Recreation
Patients happy mendngar radio and watching television.
while in the hospital can not be done.
7. Social Data
a. Family Relationship
Patterns role relationships communication : The patient communicates
well with the family.
Relationships with community : Patients socialize well with the
environtment and his family, proved many relatives and friends to visit.
b. Economic Status
Financial capability : Patient can be classified n a lower class social
groups, because the patient only a small merchant.
8. Psichologic Data
a. Role of Relationship Patterns
1) Communication: In patients communicate better communicate with his
family.
2) Relationship with others: Patients socialize well with the environment and
his family, proved many brothers or relatives who visit him.

3) Financial Capability: Family of patients can be classified in a middle-class

social groups.

b. Pattern Kopping and Stress Management

1) Before the pain
Patients said they were delighted to get along with people around
2) During the sick
Patients seen saturated because diabatasi patient space.

c. Confidence value system.

1) Before the pain
Patients say the Islamic religion and diligent worship
2) During the sick
The patient did not perform ritual prayers as usual because of illness, but
the patient always pray for recovered.