1.

Health Assessment

a. Biographic Data

Mrs. S is 27 years old and married. Mrs. S is an Islamic religion and is

an Indonesian citizen. Mrs. S works as a teacher in one of the state

elementary schools in Malang. Mrs. S was born in Aceh and now lives in

Klojen-Malang. Indonesian is the main language.

b. Culture and Spirituality

Mrs. S was born and raised in the city of Aceh. Mrs. S lives with his

father and mother. Now, Mrs. S lives in Malang city with her husband

who has been married for 1 year. He doesn't have a child yet. His father is

a retired senior teacher and his mother is a housewife. Her husband now

works for one of the foreign companies in the city of Malang. Mrs. S and

husband are religious people. They are gentle, sharing people, and always

pay attention to their actions and sayings.

c. Past Health History

Mrs. S has never had serious illness since childhood. Daddy has a

history of diabetes mellitus since the age of 40 years and his mother has a

history of hypertension.

Ny.S does not have allergies to food or drugs. Ny.S wears glasses that

have been worn since she was in class 2 high school and every 6 months

she always controls her eyes.

d. Review of System
Mrs. S complains of pain in the lower abdomen and often bleeds from 1

week ago. The blood that came out was blackish red and smelled fishy.

Based on the results of the nurse's physical examination get:

 Head

Inspection: no lesions, patients use glasses min 3.50 in the right

and left eye

Palpation: no tenderness in the orbitals

 Neck

Inspection: symmetrical neck, no enlargement

Palpation: no enlargement

 Breast

Inspection: the mother is symmetrical, the aerola does not give off

a smelling liquid

Palpation: no lumps

 Chest

Inspection: normal chest, symmetrical chest, no lesions

Palpation: symmetrical chest movements, normal tactile fremitus,

no pulsations

Percussion: sonor

Auscultation: no additional breath sounds

 Abdomen

Inspection: no lesions
 Auscultation: bowel sounds 7 times / minute

Palpation: there is hypogastric quadrant tenderness, 6 pain scale,

palpable mass

Percussion: timpani

 Female genetalia

Inspection: there is black-red, seeping blood that smells fishy

Palpation: VT is performed, there is no mass, no pain

e. Functional Assessment

Mrs. S is a hard-working woman. Mrs. S claimed to rarely exercise

because of his busy life. however, he is consuming the food he consumes.

Ny.S has a hobby of reading and cooking when there is free time. She and

her husband like to spend time with their families and sometimes go

traveling together. Mrs. S sleep for 5-6 hours per day. However, Ny.S

rarely pay attention to his genetically healthy.

f. Conclusion

Mrs. S received a medical diagnosis of uterine myoma. It appears that

Mrs. S is worried about the health of her uterus because she doesn't have

children. However, Mrs. S can be cooperative with planned medical

actions.