Neurological Examination

- Patient feel dizzy, sometimes the feet fell pain,

Complete examination

- Hb = 8,6

- Leukosit = 12.010

Theraphy

- Kalnex = 2x50

- Ranitidin = 3x50

- Metaclo = 3x5

Malang, 8 September 2014

Nurse

2. DATA ANALYSIS

DATA ANALYSIS

Name : Mr. K

Age : 75 years old

Register :357216

Sign Problem EtiologiSubjective Data

- Patient said he is weak, have a stomachache, seldom to eat

Objective Data- Urine color is

dark yellow, amount of input 2500cc/24 hours, output at least 1750cc/24 hours, the color of feces is rather dark, impuls: 70x/minute, blood pressure: 100/70 mmHg, temperature: 37 degree celcius

- Intake of water: at least 1000cc/day

- Output of urine: at least 1500cc/day

- Intake of food:

Amount of fluid is increase

Intake and output aren’t good

at least 6- Output of

feces: at least 50cc/day (with melena)

- Hb: 8,6

Subjective Data- Patient said

that he always need a help when he was doing his activity

Objective Data- Impuls:

70x/minute- Blood

pressure: 100/70 mmHg

- Temperature: 37 degree celcius

- Respiratory: 25x/minute

- CRT: good- Muscle power

3 3

3 3- Activity: take a

bath and walk =need a help, sit= he an do it by him self, stand= he need a help, eat= he need a help, drink= he can do it by himself

Activity intolerance Process of healing

Subjective data- Patient said that

he is seldom to take a bath, he take a bath 1x/day, he don’t brush his teeth

Objective Data- There is a

grime- His breath is

stink- His toungue is

dirty- His body is

stink and dirty

He wasn’t care himself enough

inability