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e.

Physical examination

1. General Client Condition:

Appearance : Composmentis

Vital sign:

TD : 100/60 mmHg

Temperature : 38.3˚C

Respiration : 20x / min

Pulse : 78x / min

2. Skin : Brown

3. Head and Hai

Head

Form : Spherical, Symmetrical

Hair

Distribution : Equally

Color : Black

Cleanliness : Clean

Rebelled : Do not fall out

4. Face and Neck

Face

Form : Symmetrical

Color : Redness

Lesions : There is no

Former trauma : There is no

Neck

Symmetrical no bumps

5. Eyes
Shape both eyes : Symmetrical

Kongjungtiva : Pale

Pupil : Good

Sklera : White color

Reflex light : Fine, the reflex pupils of light are proven when in the light of the pupil
contract and when the light in the pupil dilate dilated

Vision function : Normal (client can read newspaper with distance less than 25cm)

6. Ear

Form : Symmetrical

Cleanliness : Clean

Hearing Functions : Normal, client can hear the sound / sound

7. Nose

The shape of the nose : Symmetrical

Lesions : There is no

Secret : There is, liquid mucus and no impurities

Nose Mucosa : A little redness

Cleanliness : There is no dirt

Olfactory function : Normal, the client can distinguish the smell of eucalyptus and the smell
of perfume

8. Mouth

The shape of the lips : Symmetrical

Circumstances : Dry, cracked

Tooth : Complete amount of 32 Fruits

Tongue : Clean

Tasting Function : Clients can taste sweet, bitter, sour and salty
9. Chest

Form : Symmetrical

Pulmonary breathing sounds : Vesicular (low pitched)

Pulmonary percussion : Resonant (normal lung percussion sound)

The pattern of breath : Regular (regular)

Pulmonary expansion : Balanced

Heart rhythm : Regular (regular)

10. Abdomen

Form : Symmetrical

Tenderness : There is no

Bowel sounds : 14x / min

Lesions : There is no

11. Repreductions

Genetal state : Clean

Lesions : There is no

Catheter : Not installed

Hemorrhoids : There is no

12. Up / down extremities

Up

Form : Symmetrical and complete

Nail circumstances : Short, clean

Movement : Limited in left hand because of infusion 30gtt / menit infuse of Ringer
Laktat infusion, muscle strength (4/5)

Under

Form : Symmetrical and complete


Nail circumstances : Short net

Movement : Not limited but weak, patellar muscle reflex (+ / +) normal proven
with stimulation using a direct hamer reflex to move the reflex forward, muscle strength (5/5)

f. Psychological Data

Emotion Status : Client emotions seem stable, proven clients always calm

Anxiety : Client looks a little anxious

Koping pattern : The client says leave it completely to the medical team about the
condition of the illness. In solving problems clients often ask for help from others

Communication Style : Client can communicate well

Self Concept

Self-image : The client appears patient in accepting the pain in suffering

Self-Esteem : Clients want to get home quickly to be reunited with family and
friends

Roles : Clients act as the 1st child of 2 siblings

Self Identity : The client is male, the client feels helpless

Ideal Self : Clients can interact with student nurses

g. Social Data : Clients say want to get well soon in order to school as usual

h. Spiritual Data

Implementation of worship : Selamadi care for clients perform worship in bed

Trust / Religion : Confident (Clients pray a lot)