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NURSING PROCESS OG CLIENT WITH

NEFROTIC SYNDROME

NAME : RISKIYANTI Y.D.BATEMO

CAMPUS : POLTEKKES KEMENKES PALU PRODI KEPERAWATAN DII


POSO
ASSESMENT :

Admission Date : Nov 20 , 2018

No. Reg : 10711xxx

Hospital : Poso Hospital

Medical : Nefrotic syndrome

Medical Assesment : Nov 20, 2018

1. PATIENT IDENTITY :
a. Name : mr. Andi
b. Age : 6 years
c. Sex : male
d. Race : Kaili
e. Religion : moslem
f. Education : Senior high school ( parents)
g. Occupation : Farmer
h. Adress : Poso

2. HISTORY OF PRESENT ILLNES


1. Chief Complain :
His son’s body is swollen troughout the body especially on the face and eyes.
2. Present Illness story :
His mother said 5 days before entering the hospital when woke up the morning of his eyes were
spawned , but the spraying was reduced in the afternoon, the spray was also spreading the stomach
and his tomorrow on both feet, since 4 days ago the tub was dark
and little.
3. PAST NURSING HISTORY
1. History of contagious Disease :
none
2. Hereditary Disease :
none
3. Allergic History :
His mother said that child no allergies to food, beverages and medications
4. FAMILY HEALTH HISTORY
His mother said in the family no one suffered from illness as his suffered .

5. Competitive Assembly
a. respiratory system :
RR: 44x /min
b. Cardiovascular system :
Nadi 112 x / mnt, blood pressure 130/80 mmHg,
c. system pressure:
None
d. Urinal system :
On complete urine examination obtained color ; yellow, Clarity ; somewhat male, weighing type ; 1,005,
PH 5.5 , glucosa (-) , bilirubin (-), blood (+2), protein (+3), urobilonogen (+1), leukoycte (+1). Since 4
days yhat lashu tub is dark and little.
e. Digestive System
Sovewise in the stomach area, HB : 10.9 g/ dl
f. Musculoskeletal system :
In the normal limit.
g. Integumen system :
His mother said 5 days before entering the hospital whwn woke up in the morning of his eyes of people
whose child is spawned , but the spraying is reduced in the afternoon, spawn also spreads on the
stomach and its tomorrow on both feet , when assessment is seen there is a ulcers of the ulcers.
h. Endocrine system :
None
i. Reprodoction system :
None
j. Parents perception
None

6. OBSERVATIONS AND PHSICAL EXAMINATION


Vital sign :
T : 36, 7 ◦ c
P : 112 X/ min
RR : 44 X/ min
BP : 130/80 mmhg

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