Nama : Azzra Chairunnisa

Nim : 19301090

Class : 3C

NURSING ASSESSMENT

Nama : Mrs Tr

Date : January 13 2013

Time of assessment : 09.30 am

RN/LPN :

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