LAPORAN PENDAHULUAN

DENGAN DIAGNOSA PENYAKIT JANTUNG KORONER (PJK)

RSUD ULIN BANJARMASIN

Disusun Oleh :
ARSIAH 1614401110009

UNIVERSITAS MUHAMMADIYAH BANJARMASIN

FAKULTAS KEPERAWATAN DAN ILMU KESEHATAN
PROGRAM STUDI D3 KEPERAWATAN KELAS REGULER
TAHUN AKADEMIK 2017/2018
 PROGRAM STUDI DIII KEPERAWATAN

FAKULTAS KEPERAWATAN DAN ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH BANJARMASIN

LEMBAR PERSETUJUAN PEMMBIMBING

Nama : Arsiah

Npm : 1614401110009

Ruang/Tempat Praktik : Ruang poli jantung/RSUD Ulin Banjarmasin

Judul Laporan Praktik : 1. Penyakit Jantur koroner (PJK)

Banjarmasin, Juli 2018

Mahasiswa

(Arsiah)

Menyetujui

Pembimbing Clinical Teacher Pembimbing Klinik

(Anita Agustina N.s M.,kep)

Name : Mrs. A

Age :

Years :

Family :

Last education :

Elementary school :

Occupation :

Address : Banjarbaru

Hospital admission date : RSUD Idaman Banjarbaru

Diagnostic medic :
B.HEALTH HISTORY

1) Main Complaint
At the time of assessment Monday, February 26 at 12:10. Mrs.A complained his body was very

weary. Mrs.A said feeling nauseous.

2) Health History of Current Disease
Mrs.A said five days before brought to RSUD Idaman Banjarbaru her body feels very weary and

after that brought her husband to check to Puskesmas Banjarbaru and at check blood glucose >

500. Mrs.A said very shock to find out because the previous did not have a history of diabetes

mellitus. After that for three days Mrs.A stay home only, but his body still feels weary and does

not diminish. Finally husband Mrs. A brought him to the hospital RSUD Idaman Banjarbaru to get

further treatment and hospitalized.

3) Health History of Previous Disease
Mrs. A said previously never been hospitalized of suffering from disease such as shoe.
4) Health History of Families Disease
Mrs. A said that his family had diabetes mellitus, his father.

C. FOCUS DATA

Subjective data : Mrs. A complained his body was very weary

Mrs. A says insomnia
Objective data
 1. Inspection : Mrs. A looks lethargic
Mrs. A looks sleep deprived
Activity scale 2
2. Palpation : There is no abdominal pain
Liver is not palpable and there is no enlargement of the liver
3. Percussion : There is no tenderness in the chest
Percussion of the tympanic abdominal
4. Auscultation : No additional breath sounds on Mrs. A chest
Intestinal peristaltic 14x per minute
Vital sign :
BT : 36,2◦c
BP : 130 Per 80 mmHg
HR : 88x Per minute
RR : 21x Per minute

E. DATA ANALYSIS

N DATA PROBLEM ETIOLOGY

o
1 DS : Fatigue Increasead physical weakness
- Mrs. A
complained his
body was very
weary
- Mrs. A says
insomnia
DO :
- Mrs. A looks
lethargic
- Mrs. A looks sleep
deprived
- Activity scale 2
 - Vital sign :
BT : 36,2◦C
BP : 130 per 80
mmHg
HR : 88x per
minute
RR : 21x per
minute
- Supported
Examination :
Monday, February
23,2018
Bloood Glucose
(BSN) In the time
that : 493

D. SUPPORTED EXAMINATION

1) Monday, February 23, 2018

N Examination Normal Value Results

o
1 Blood Glucose (BSN)
In the time that - 11 mg/100 ml 493
Blood Glucose is abnormal, four hundred and ninety-three milligrams per milliliter.

2) Tuesday, February 24, 2018

N Examination Normal Value Results

o
1 Blood Glucose (BSN)
In the time that - 115 mg/100 ml 282
Blood Glucose in abnormal, two hundred and eighty-two milligrams per milliliter.

3) Wednesday, February 25,2018

No Examination Normal Value Results

1 Blood Glucose (BSN)
In the time that - 115 mg/100 ml 112
Blood Glucose is normal, one hundred and twelve milligrams per milliliter.