NURSING HEALTH HISTORY HIPERTENSI

Group 1

Member :

- Amelia Putri Naazhira

- Nur Hikmah
- Rahmat Rizki Ramdhani
- Risda Nurul Husna
- Sri Agustina Anggrainie

POLTEKKES KEMENKES BANJARMASIN MINISTRY OF HEALTH OF THE

REPUBLIC OF INDONESIA DEVELOPMENT AND EMPOWERMENT OF HUMAN
RESOURCES HEALTH YEAR 2021/2022
 NURSING HEALTH HISTORY HIPERTENSI

1. Biographic Data

1. Name : MR
2. Place / date of birth : Kambang, 15th February 1985
3. Gender : Man
4. Marital Status : Married
5. Religion : Islam
6. Education : People’s School
7. Occupation : Farmer
8. Address : Kambang Market, Lengayang District
9. Medical Diagnosis : Hypertension
10. Responsible

1) Name : RZ
2) Occupation : Housewife
3) Address : Kambang Market, Lengayang District
4) Relationship : Wife
2. Chief Complaint Or Reason Visit

At the time of the assessment on the head with complaints of headache, neck/neck feels
heavy.

3. History Of Present Illness

Clients came to the center on 09-07-2017 hours 10.00 with a major complaint : headache,
dizzy, nape feel heavy, insomnia, grumpy.

4. Past History

Clients have been diagnosed with hypertensive diseases and have been treated with
hypertension two years ago in the Rsud Muara labuh.

5. Family History Of Illness

The client stated that the client's biological mother suffered from hypertension and had a stroke
while the other family did not suffer from hypertension.

6. Review Of System (ROS)

1. The respiratory system:

● Inspection: the patient appears short of breath, there is nostril breathing

● Palpation: blood pressure 180/90 mmHg
● Percussion: dullness to the heart
● Auscultation: heart sounds, crackles are heard in the lungs

2. Cardiovascular System:

● Inspection: The conjunctiva is not pale (anemic)

 ● Palpation: KGB not palpable
● Percussion: no increase in JVP
● Auscultation: regular heart sounds

3. Digestive system

● Inspection: symmetrical lips

● Palpation: flat abdomen not palpable
● Percussion: chewing reflex improved
● Auscultation: there is no discharge in the anus

4. Nervous system :

a) Cranial Nervous System

● Nervus I : Good sense of smell, marked by the smell of eucalyptus oil.

● Nervus II : Good eyesight, marked by being able to see beside him with a
glance.
 ● Nervus III : The client can lift the eyelid up.
● Nervus IV : The client can move the eyes up and down.
● Nervus V : The client can chew well.
● Nervus VI : The client can move the right and left eyes following the nurse's
index finger.

● Nervus VII: Taste function is good, indicated by the client saying no

complaints at mealtime and good appetite. The client can smile.
● Nervus VIII : Clients can communicate well with nurses and their
environment.
● Nervus IX : The client can swallow well.
● Nervus X : Swallowing function is good, when instructed said aaa.aaa uvula
raised and remained in the median.
● Nervus XI : Movement of the head and shoulders is disturbed due to pain in
the head.
● Nervus XII : The client can move his tongue (controlled).

b) Motor System The client's body functions are upright, muscle tone is weak
c) The client's motor system is able to respond to stimuli and can identify objects
and reflections
 d) Client's Cerebral System does not experience interference in communicating,
client communication using verbal language
e) Reflex - Reflex

● Patellar Reflex: OK
● Triceps Reflex: OK
● Babinski reflex: OK
● Pupil reflex: OK

5. Endocrine System: No palpable enlargement of the thyroid gland. The client has a
history of hypertension
6. Musculoskeletal System: The client's muscle strength is full: there is no edema.
7. Integumentary system and immunity: Warm akral, temperature 36.5°C, dry skin,
especially in the lower extremities, there are some small scars and brownish skin, hair
looks dull.
8. Speech system and ENT: the client can speak normally and well and his hearing has
decreased.
9. Vision system: Blurred vision when looking far.
7. Life-Style

Activities of daily living (ADLs)

1. Nutrition pattern:

● Healthy:

– Eat: rice, side dishes, vegetables

– Drink: 5-6 glasses a day, water, coffee

● Sick:

– Eat : 2 times a day

– Drink : 3-4 glasses a day
 2. Elimination Pattern:

● Defecation : 1 time a day

● Urination : 4-5 times/day

3. Sleep or rest patterns:

There is a nap but night sleep is difficult and often wakes up at night

4. Working pattern:

Clients work as farmers, leave for the rice fields in the morning and return home
in the afternoon

8. Social Data
 Clients can socialize with the surroundings.

9. Physiological Data

 Emotional status: The client says easily angry and emotional

 Anxiety: the client said he was worried about the disease he was suffering from now.
 Coping pattern: coping with the client in dealing with illness is good by always
telling his problems to his family and consulting with his wife and children.
 Communication style: Clients can communicate well and cooperatively. Self concept

10. Patterns Of Health Care

The family physician

REFERENCES

source from Aprizal, Perintis Padang high scholl of Health Science Student in 2018.
http://repo.stikesperintis.ac.id/153/1/31 APRIZAL.pdf