Name : Fitri Mulyaningsih Nim : P17210184110

Study program : D3 Nursing / 2B Subject : English

BASIC NURSING ASSESSMENT FORMAT

A. ASSESMENT

I. BIODATA
a. Client identity
Name : Mr. Wibowo
Age : 50 years
Gender : Male
religion : Islam
Address : Street. Venolia No. 85
Occupation : Privat
No. medrek : 567811
Room : Tulip
Dx. medical : Chronic Kidney Disease
Date of entry : September 25, 2019 at 13.00
Date of assesment : September 25, 2019 at 15.00
b. The identity of the
person in charge
Name : Mrs. Parmi
Age : 45 years
Gender : Male
Address : Street. Venolia No. 85
Religion : Islam
Relationship with client : Wife

c. Main Complaint
Shortness of breath and nausea

d. Current Medical History

Patient complained Shortness of breath 1 month before entering the hospital. The complaint felt
worse when do activity and improved if a break. The patient also experienced limp, nausea and
vomiting of food mixed fluid,chest pain, limp body and a cough with sputum are white yellow
for 3 days. Patients also complain of no appetite. The patient also complained that the left leg of
the leg was swollen and felt thick, and also the left foot was swollen.

e. Medical History first

The patient said have been hospitalized with illnesses of constriction of the heart and
hypertension 3 month ago.

f. Family health history

 The patient said in his family did not have a history of disease like a patient and other infectious
diseases

g. Psychological aspect
The patient expressed anxiety about the disease. But patients are always obedient in following all
the suggestions from the health team. The patient said that he had resigned himself to the
situation he was in.

h. Social aspect
1. Communication relations
The patient is very listening and responds well when invited to communicate.
2. Cultural factors
The patient is a private employees
3. Dependency level
Patients are still able to fulfill their basic needs independently. Patients do not need the help
of others to meet their basic needs.

i. Spiritual aspect
Patients and families adhere to the religion of Islam, families always pray for the good of the
patient and healing the patient. Patients say that they are always obliged to perform the 5 daily
prayers on time.

II. PHYSICAL EXAMINATION

 General Conditions :
1. Impression of pain : Medium Awareness : Composmentis
2. BMI : 17,7 Height : 150 cm Weight : 40 Kg
3. Vital sign :
- Blood pressure : 145/100
- Temperature : 36,8 °C
- Pulse : 122 x/minute
- Respiratory rate : 26 x/minute
4. GCS : 456
5. Head and neck examination :
 Head shape : mesochepal, White hair, straight, evenly distributed, anemic conjunctiva (+),
jaundice sclera (-), dry mucosa, pale face
6. Press pain: positive in the epigastric region
7. Auscultation Lungs :
- breathing rhythm : Irregular
- Additional sounds: ronchi ++ / + rough wet, wheezing is absent
8. Abdomen Examination
- Inspection
Form : flat Movement of breath time : Normal
- Palpation
Abdominal wall: soft, supple P
Ress pain : positive in the epigastric region
 Basic needs
a. Fluid :
Fluid Requirement : 2.200
intake: 1500 + 700 = 2200
output: 600
iwl: 750
fluid balance: 2200 – 1350 = +850
b. Food: 3x a day
c. Sleep pattern : 6-7 hours
f. Elimination: 2x/ days
 Supporting Investigation
1. Blood Lab Examination at 25 September 2019
- Blood complete
Hemoglobin : 9,2 (N : 14-18g/dL)
Hematorit : L. 27 (N : 35-50 gr/dl )
Leukosit : 14.000 ( N : 4000-10000 /μL)
Eritrosit : L 3.2 ( N : 1,2 million – 1.5 million /μL )
Trombosit : 200.000 ( N : 150.000 – 350.000 /μL )
- The chemistry of blood
Ureum : H 155,3 ( N : 3.500 – 10.000 / μL )
Creatinine : H 9.98 ( N : 0.7 – 1.5 mg/dl )
III. DATA ANALYSIS

NO DATA PROBLEM ETIOLOGY

1 DS :
Patients says of Shortness of Ineffectiveness of the Airway obstruction
breath airway clearance

DO :
1. dyspneu Mucous hypersecretion
2. Respiratory rate : 26 x/minute
(tachypnea)
3. Pulse : 122 x/minute
(tachycardia) secretions retained in the
4. Sputum ( + ) respiratory tract
5. Ronchi ( + )
6. Cough is not effective
7. Breathing rythm : Irreguler
ronchi

Ineffectiveness of the
airway clearance

2 DS :
 Patient says nausea, vomiting of nutritional imbalance: Chronic Kidney Disease
food mixed fluid, and no appetite less than the body's needs

DO :
1. nutritional status : BUN, Creatinin
BMI : 17.7
Weight : 50 kg
Height : 150 cm
2. vomited once after eating and Waste production in the
drinking bloodstream
3. dry mucosa
4. anemic conjunctiva
5. hemoglobin : 9.2 gram/dl
(N : 14-18g/dL) In the GI channel
6. hematokrit : 27 gram/dl
(N : 35-50 gr/dl )

Nauseous, vomit
 Nutritional imbalance: less
than the body's needs

3 DS :
 The patient complained that the Excess fluid volume Chronic Kidney Disease
left leg of the leg was swollen
and felt thick, and also the left
foot was swollen.
Decreased blood protein
levels
DO :
1. there is edema in the left leg
2. Ureum : H 155,3
( N : 3.500 – 10.000 / μL ) Fluid out to the
3. Creatinine : H 9.98 extravascular
( N : 0.7 – 1.5 mg/dl )
4. fluid balance results : +850

Hydrostatic pressure
increases

Edema

Excess fluid volume

B. DIAGNOSA KEPERAWATAN

NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN TANGAN
PERAWAT
C. RENCANA TINDAKAN KEPERAWATAN

NAMA & TANDA

DIAGNOSA TUJUAN DAN
NO INTERVENSI RASIONAL TANGAN
KEPERAWATAN KRITERIA HASIL
PERAWAT
 NAMA & TANDA
DIAGNOSA TUJUAN DAN
NO INTERVENSI RASIONAL TANGAN
KEPERAWATAN KRITERIA HASIL
PERAWAT
D. IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

NAMA & TANDA

NO TANGGAL JAM TINDAKAN KEPERAWATAN TANGAN
PERAWAT
E. EVALUASI

DIAGNOSA TANGGAL
N KEPERAWAT
O
AN

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Mengetahui,
Pembimbing Klinik Mahasiswa

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NIM.