Professional Documents
Culture Documents
1. Personal Data
Name : Mrs. H Register Number: 581902
Age : 18 years old
Sex : Male
Religion : Islam
Address : Jl.Sukahati,Cibinong Bogor
Occupation :-
Date of Admission : -
Date of Assessment : September 23, 2014
Blood Group : Not Assessed
Medical Diagnosis : typoid
2. Chief Complaint
Patient said that he fever since three days ago liquid chapter nausea, vomiting
and pain stomach scale 4 .
3. History of Present Illness
Patient said that he with complaint the agency still fever, nausea and vomiting.
Stomach pain and liquid chapter patient brought to the Installation of Kediri
Baptist Hospital to get nursing care.
4. History of Past Illness
Patient said that he had no history of hereditary diseases. Recently, she had
complaint of abdominal tenderness and pain when passing water.
5. History of Family Illness
Patient said that her family had no hereditary and infectious diseases such as
hypertension, Diabetes Mellitus, and TBC
Genogram
I Information :
or = Die = Patient
= Staying at home
9. Vital Sign :
0
a. Temperature : 38 C
b. Heart Rate : 80 x/menit
c. Blood Pressure : 120/70 mmHg
d. Respiratory Rate : 20 x/menit
e. Weigth / Heigth : 40 kg, .................... cm.
Student’s Signature
Eka faridatul
DATA ANALYSIS
Patient’s Name : Mr. H
Age : 18 yers old
Register Number : 581902
Subjective Data Problem Etiologi
Objective Data
Subjective Data : Comfortable disorders Salmonela thyposa
Patient said that stomach pain
pain with a scale of 4. Digistive tract
Objective Data :
1. Patient looks weak. Absorbed by the smal
2. Patients seem intestine
grimaced in pain.
3. Patient appears Bacteria in the systemic
holding his stomach blood flow
in the left lower
quadrant. Liver
4. Pain scale 4
Hematomegali
Nutrion less than body
requirements Pain palpability
NURSING ACTIONS
PROGRESS NOTES