Name : Ardaninggar K.R.N.A.W.

NIM : 01.2.17.00594

Nursing assessment :

The assessment was carried out on September 23, 2020 at home. Data obtained from
clients, family, and medical records

1. Identity of the patient

Name Mr. A, 53 years old, sex male. Street address in Blitar city, marital status is
widower, Christian, Javanese, junior high school education, work as a farmers. Have a
past medical history of Hypertension.
2. The main complaint
Mr. A complained that his head often felt dizzy and sometimes it was difficult to start
sleeping at night. Mr. A. said he likes to eat foods that tend to be salty and contain
coconut milk. He often does sports such as cycling and jogging. Mr. A said it was
difficult to maintain a low-salt diet and keep making foods with salt and flavorings,
sometimes they also like to eat sweet foods. Mr. A said he had been out of control to the
hospital for 3 months because he was busy working.
3. Physical examination
I did a general check on Mr. A. Blood pressure 160/110 mmHg, pulse 84x/minute, breath
21x/minute, temperature 36.8°C, height 170 cm and body weight 65 kilograms.

Interventions used:

1. Monitor blood pressure

2. Encourage clients to minimize activities that can cause headaches, for example: long
coughs and bending over
3. Collaboration with doctors for therapy
4. Review food patterns
5. Describe the correct low salt diet
6. Motivate clients to stay in control routine
Goals setting with SMART :

1. On September 25, 2020, Mr. A and their families are able to adopt a low-salt diet. The
day after doing the assessment I will provide an explanation of the low salt diet and leave
a leaflet for them
2. On September 25, 2020, patient complaints will be reduced because I will collaborate
with doctors to prescribe hypertension drugs so Mr. A will be easier to sleep at night
3. Mr. A blood pressure will be controlled because my diet will improve and I will control
my blood pressure every 2 days
4. Mr. A will carry out control to the hospital, after I explain the bad effects or
consequences if I do not carry out routine controls, besides that I will collaborate with
Mr. A to motivate