DEPARTMENT OF NURSING

FACULTY OF HEALTH
SCIENCES UNIVERSITY OF
BRAWIJAYA

Student name : Prisilya Nifanngelyau

NIM : 225070209111047
Date Assessment : October, 19th 2022

A. Client Identity
Name : Mr. Ron Jones
Age : 56 years old
Date of birth : Decembar 15th 1995
Sex : Male

B. Current Health Status

The patient says overall he feels well but sometimes he feels a bit tired all the time

C. Current Health History

The patient said he was coughing and the last few weeks his cough has getting worse.
He said the cough was productive. He said the sputum seems yellowish but sometimes
appeared to be green. The patient didn’t have a fever or chills.
D. Past Medical History

1. Habitual:
Type Frequency Amount Duration
Smoke Often 2 pack a day 35 years

2. Medications used :
The patient said he took antibiotic medicine, but he said it can’t reduce his cough, so
he stopped taking those antibiotic drugs.

E. Physical examination
 Vital sign:
- Blood pressure : 150/84 mmHg - Temperature : 37 ⁰C
- Heart rate : 88 x/minute - RR : 16x/minute
 2. Head & Neck
 Lungs
- Auscultation: There are wheezing in the lower part of lungs
F. Therapy

Based on the doctor's advice, the client gets inhaler therapy and antibiotics

G. Discharge Planning

- The patient must return about 10 days to take a prescription for antibiotics