A.

Assesment
NURSING HISTORY :
Admission Date : April 4th, 2018
No. Reg : 1071xxx
Hospital: X General Hospital
Time: 10.000
Medical Dx : Stroke Haemoragic
Date Of Assessment :
I. Biographic Data:
a. Name : Mr. M
b. Age : 50th
c. Sex : Male
d. Race : Java
e. Religion : Moeslim
f. Education : High School
g. Occupation : Driver Go Jek
h. Address : Street Kemuning Banjarbaru
II. Chief complaint or reason for visit
Question :- “what is troubling you?”
- “what brought you do to the hospital or clinic?”
Answer : - “he has speaking unclear and can not motion left of
body
III. History Of Present Illness
a. Usual health status :
Speaking unclear and can not motion left of body
b. Chronologic story :
Family client’s said from Tuesday at afternoon after work at 13.00 pm
after watching television suddenly client’s speaking unclear, then at 18.00
p.m client’s taken to the ….. hospital and treated in the internal medicine
room on the Thursday at the time of going back to bed, in the toilet client
 can not stand, left leg and left upper arm feels weak then the client is
concluded to the nerve room and finally treated in the nerve room.
c. Relevant family history :
Family client’s said there are family members suffering from
hypertension, the patient's wife

d. Disability assessment :
No defects

IV. Past History

1. Childhood Illness
2. Childhood immunizations
3. Allergies
Drugs
4. Accident and injuries
None
5. Hospitalization for serious Illness
the client's family said the client had previously been treated in hospital
X with a diagnosis of hypertension
6. Medications
the client's family says the client is taking anti-hypertensive medications
from a doctor's prescription

V. FAMILY HISTORY of Illness

VI. Life-Style
1. Personal Habits
The use of tobacco type cigarette, one of packs and smokes per day from
fifteen years old until now.
 Consumption of coffee and tea
2. Diet

3. Sleep/Rest Patterns
the client's family says the client usually sleeps at 11:00 pm, the client is
having trouble sleeping if not taking an antihypertensive medication
4. Activities Of Daily Living (Adls)
client families say clients usually work as go-jek drivers, clients usually
eat 3 times a day with a small portion, bathe 2 times a day, defecate 3
days and urinate once a day
5. Recreation/Hobbies
the client's family says the client never exercised, rarely took a vacation
and spent time with family or friends

VII. Social Data

1. Family Relationship/Friendship

the client's family says the client's relationship with family and friends is
good
the client's family says the client is living with his wife and two children,
when clients need help with clients with their first wife and child. when
clients need emergency assistance the client contacts the local village head
the client is closer to his wife, so the income of the family is reduced due to
hospitalization in hospital due to his illness

2. Ethnic Affiliation

the client's family says the client comes from madiun, the client uses
Javanese language and usually eats the staple food of rice

3. Educational History

the client's family tells clients to go to high school

4. Occupational History
 5. Economic Status

the economic status of lower middle-class clients

6. Home And Neighborhood Conditions

the client's family says the client's home is around

residential residents and the client's home environment is
less clean

VIII. Psychologic Data