1. ASSESSMENT
I. BIODATA
A. Identification of Patients
Name: An. W.S
Age: 7 years
Gender: Male
Marital Status: not married
Tribes / Nations: Batak / Indonesia
Religion: Christian Protestant
Education: Primary school
Occupation: Student
Address: Jln.Km.2 Sidikalang
Dates: December 24, 2010
Medical Diagnosis: Poliomielisis
No.Register: 190 403
Rooms: Bed
B. Responsible person
Name: Ny.L
Occupation: Self Employed
Family Relationships: Parents
Address: Jln.Km.2 Sidikalang
B. Past Medical History
patients never suffered from the same disease
C. Family Health History
No family illness as experienced by patients, families grandparents died due to aging.
Genogram:
patient was the fifth child of six siblings
IV. Routine
A. Biological
1. Nutrition
2. Drink / liquid
3. Sleep
4. Elimination
a. BAKBefore entering the hospitalAfter hospital admission:
b. CHAPTERBefore entering the hospital:After hospital admission
5. Activitya. Before entering the hospital:
b.Sesudah hospitalized:
6. Personal Hygienea. Before entering the hospital:b. After hospital admission:c. Barriers to implementing personal hygiene:
7. Recreation
Watching television.
B. Psychological
C. Social
D. Spritual
V. PHYSICAL EXAMINATION
A. Vital Signs
1. Patient's general condition: Weak
2. Awareness: Composmentis
3. Body temperature: 38.2
4. Blood pressure:
5. Nadi:
6. Breathing:
7. Height:
8. Weight loss: 20 years
9. Characteristics: thin, tall
B. Head to toe examination
1. Head:2. Hair:3. Eyes:4. Nose / smell:5. Ears / Hearing:6. Mouth:* Oral cavity:* Teeth:* Tongue:
* Tonsils:
* Pharing7. Neck:8. Thorax and respiratory function:9. Heart:10. Abdomen:11. Reproductive / sexual organs:
12. Ekstermitasa). Above:b). Below:
VI. THERAPY / MEDICAL ACTION
data analysis and intervention please click here,,,,,,,!!!!!!!!
Data Analysis
Intervention
