Nama : Riza Wahyuni

Nim : 19301118

Class : 3C

NURSING ASSESSMENT

Nama : Mrs Tr

Date : January 13 2013

Time of assessment: 09.30 am

Vs: - T : 38.5 C

- BP : 124/66 mmH
- P : 72
- R : 14 per min
- O2 Sats :

Neuro/MSK

LOC : Oriented

Orientation : Person, Time, Place, Self

Speech : Normal

Swallowing : Normal

Behaviours : Calm

Mobility : Normal

Joints : ROM

Resp

Rhythm : Regular

Depth : Normal
Quality : Normal

Dyspnea : No

Cyanosis : No

Cough : No

Sputum :-

O2 Therapy :-

CVS

Chest pain : Yes

Apical Pulse Rhythm : Regular

Peripheral Pulses Amplitude :

Capillary Refiil : 1 Sec

Edema : No

IV :-

Site :-

SC Butterfly :-

Site Integrity : No

Skin

Intact : Yes

Colour : Normal

Tempetarure : Warm

Pain :0

GI & Renal
NPO Since Date/Time :-

Diet :-

Enteral tube type :-

Tube insertion site :-

NG Suction :-

Abdomen : Soft

Bowel Sound : Normal

Bowel : Normal

Voiding :-

Catheter :-

Urine :-

Weight 65 kg height 160 cm