A.

PATIENT ASSESMENT DATA BASE

1. Personal Data
Client : Ms. Regina Vionna Manurung
Birth : Medan, 20 July 1991
Address : Patimura Street No.125, Pontianak
Telephone : 0561 78799
Contact person : Mr. Regart Sinambella (Husband)
Persons address : Patimura Street No.125, Pontianak
Persons address : 0561 78799
Age : 21 Years
Sex : Female
Race : Batak
Educational Background : High School
National : Indonesia
Religion : Christian
Martial status : Marry
Usual occupation : Housewife
Present occupation : Not able to work due illness
Source of income : When working, monthly income
Insurance : ASKES
Source of referral : Self
Source of history : Self
Reliability of historian : Reliable
Date of interview : 21 August 2007
Ward : Apple
No. Medical Record : 256741
Medical Diagnostic : Lung Tuberculosis
2. Medical History
a. Main Complaint
Client complained shortness of breath.
b. Present Health Status
At the time assessed on August 21, 2007, the client complained of
shortness of breath, cough with phlegm is thick and green. Tightness increases
if the client activity and relieved by rest, tired at mealtime. At the house client
 was coughing and shortness for three weeks, the scale of tightness
approximately 2 , if client feels tightness it is like a heavy object on the heap.
c. Past Health Status
General health: Around the year 2005 before the client had been
treated in hospital with pulmonary TB disease. Outpatient treatment in a way,
because of the cost the treatment not until cured.
Childhood Illnesses : Influenza, diarrhea, cough, fever, Thats all I
can remember
Immunizations : -
Current Medicaton : TB Cure Packed for 6 months, but stop at the
fourth months, because of cost.
Allergies : No Known allergies
d. Family Health History
In the client's family no one has the same disease as the client, and also
has no other infectious diseases. And hereditary diseases.
Genogram

+ +
+ +

21

: Man : marriage

: Woman : descent
marriage

: Died marriage
: Live together

21 : Client
3. Physical Examination
a) General State
Appearance : Client looking tired
Awareness : Compos mentis
Height : 157 Cm
Present Weight : 33 Kg
Past Weight : 49 Kg
Vital Sign :
Blood pressure : 90/70 mmHg
Pulse : 80 times/ minutes
Respiratory : 32 times/ minutes
Temperature : 36oC

b) Examination of Body System

1) The senses system
Symmetrical shape of the eye, pupil round isokor, not jaundiced
sclera, eksoptalmus eyeball, visual function can either view the letter
within 30 cm, smaller light reflex when given a light, not use help tools.
good auditory function, can answer questions from nurse, not use help
tools and no tenderness. good nasal function can distinguish the smell of
eucalyptus and alcohol.
2) The respiratory system
Breast forms are symmetrical retraction of the respiratory muscles,
respiratory rate 32 times / min, irregular breathing patterns, there is ronchi
when breathing at the upper left lobe, there is no nostril breathing,
coughing up phlegm, no thyroid gland enlargement, when palpable the
vocal primitus it is not same, when give a percussion the voice is deaf,
attached O2 2 liter/ min.
3) The cardiovascular system
There is no enlargement of the JVP, heart sound (S1, S2) lub dub, regular
heart rate, CRT back to the original within 2 seconds, there was no
cyanosis, conjunctival pallor / anemis.
4) The digestive system
Moist lips, there are no stomatitis in the mouth, there are 32 complete
tooth in the mouth, there are tenderness at epigastric region, the client
complained of nausea, bowel sounds 8 times / minute, it was timpani when
do a percussion, there is no enlargement of liver and spleen.
5) The urinal system
There was no enlargement of the kidneys, no tenderness.
6) The musculoskeletal system
There is the physical weakness of muscle strength 4 4
4 4
a) Upper extremities
Movement of left and right hands are free, symmetrical shape,
biceps and triceps reflexes (+ + / + +), there is no deformity, the right
hand inserted 5% dextrose infusion therapy GTT / min.
b) lower extremities
Free movement in all directions, the patellar reflex (+ +), not
mounted a therapeutic tool, there is no edema.
7) The integumentary System
Moisture, temperature 360C, tan, palpability function can distinguish
hot and cold. Turgor can quickly return to the original, there are no lesions
/ skin redness.
8) The neural System
Clients can distinguish sweet, salty, good tasting function, no
abnormalities,
9) The reproductive system
There was no bleeding, no itching, no therapy device attached.
10) The pattern of daily habits
No Pattern Habbits At Home At Hospital
1 Nutrisi
a. Type of food Rice, vegetables, Porridge, vegetables, side
side dishes dishes, TKTP
Appetite Good not eating out
Frequency 2-3 times a day 3 x daily
 b. Beverages
This type of Water Water
drinking water
Number 7-8 cups / day 3-5 cups / day
2 Elimination
a. BAB
Frequency 1x/day rarely
Consistency soft soft
Color yellow yellow
b. BAK
Frequency 3-4x/hari 2-3x/hari
Color clear yellow clear yellow
3 Bed rest
a. Night 5-6 hours / day 3-4 hours / day
b. Day not necessarily Clients say
2x a day insomnia and
sleep soundly
4 Personal hygiene
a. Bath 2x a day Not to bathe
during
hospitalization.
b. Shampoo 2x a week Not to wash
during
hospitalization.

4. Psychological Data
Clients are concerned with the state of the disease and do not understand about
the causes, processes and treatment of disease. Clients are always asking about her
condition to the nurse, the client looks worried.
5. Social Data
Clients are able to establish a good relationship with nurses and other patients.
6. Data Spiritual
Clients believe that the disease will be cured, and the client always pray that
the pain be cured by faith that God will heal him.
7. Supporting data
a. Lab results dated August 18, 2007
results Normal
Fasting blood sugar 87 mg% 70-115 mg%
urea 13.7 mg% 15-45 mg%
Creatinine 0.6 mg% 0.5-1.0 mg%
BSE 20-56 mm / h 10-20 mm / h
b. Radiology
The results of the thorax photo
Dated August 20, 2007
Clinical: Cor; sinuses and normal diaphragm
Pulmo: Hili corakan rough and growing, there are looking soft spots appear on
the two lap
Impression: active duplex KP
8. Treatment
Rifampicin 1x1 tablet / day oral
Pyrazinamide 3x1 tablet / day oral
Ethambutol 2x1 tablet / day oral
Cefotaxime 1 g IV injection
Ulcumet IV (1 AMPL) injection
Dextrose 5% 20 GTT / min infusion
O2 2 liter / min oxygen