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Physical examination
Appearance : Composmentis
Vital sign:
TD : 100/60 mmHg
Temperature : 38.3˚C
2. Skin : Brown
Head
Hair
Distribution : Equally
Color : Black
Cleanliness : Clean
Face
Form : Symmetrical
Color : Redness
Lesions : There is no
Neck
Symmetrical no bumps
5. Eyes
Shape both eyes : Symmetrical
Kongjungtiva : Pale
Pupil : Good
Reflex light : Fine, the reflex pupils of light are proven when in the light of the pupil
contract and when the light in the pupil dilate dilated
Vision function : Normal (client can read newspaper with distance less than 25cm)
6. Ear
Form : Symmetrical
Cleanliness : Clean
7. Nose
Lesions : There is no
Olfactory function : Normal, the client can distinguish the smell of eucalyptus and the smell
of perfume
8. Mouth
Tongue : Clean
Tasting Function : Clients can taste sweet, bitter, sour and salty
9. Chest
Form : Symmetrical
10. Abdomen
Form : Symmetrical
Tenderness : There is no
Lesions : There is no
11. Repreductions
Lesions : There is no
Hemorrhoids : There is no
Up
Movement : Limited in left hand because of infusion 30gtt / menit infuse of Ringer
Laktat infusion, muscle strength (4/5)
Under
Movement : Not limited but weak, patellar muscle reflex (+ / +) normal proven
with stimulation using a direct hamer reflex to move the reflex forward, muscle strength (5/5)
f. Psychological Data
Emotion Status : Client emotions seem stable, proven clients always calm
Koping pattern : The client says leave it completely to the medical team about the
condition of the illness. In solving problems clients often ask for help from others
Self Concept
Self-Esteem : Clients want to get home quickly to be reunited with family and
friends
g. Social Data : Clients say want to get well soon in order to school as usual
h. Spiritual Data