PERSONAL DETAIL

Name : Mrs.Sonia Silver

Preferred name : Sonia Silver
Date of Admission : 2005/08/29

Gender : Female
Permanent Admission Room No Respite Admission
Date of Discharge / /

Last Fixed Address : 121 Main Street,Montclair NJ (New York) 07043

Marital Status : Single
Date of Birth 25 year old Medicare
No
Expiry Date
Country of Birth
Pension No
DVA No Colour
Religion : Christian
Language Spoken : English
Interpreter Required : No
Private Health Insurance : No
Health Fund Name : No

Electoral Roll Status : Active

EMERGENCY CONTACTS/PERSON RESPONSIBLE
Name : Mr Jhon Wellesley
Relationship : boyfriend
Address : 121 Main Street,Montclair New York 07043
Phone 555 7316
FINANCIAL MANAGEMENT
Self : Yes Other : Name Relationship

Address
Ph
Nama : Ahmad Syuhada

NIM :

Tutor : Ns. Edy Irawan Nasution S.Kep

 NURSING ASSESSMENT
Date : 2005/08/29 Time of assessment : 10.00 am

VS : T 37C BP 110/70 mmHg P 80 tm/mnt R 16 tm/mnt

N
E LOC : Oriented - Disoriented - Unresponsive
U Orientation : person,time,place,self is normal
R
Speech : Normal - Dysphasia - Aphasia :
O/
Exp/Receptive/Global
M
U Swallowing : Normal - Dysphagia
SC
UL Behaviors : Calm - Restless- Agitated - Withdrawn

A Mobilty : Normal - Altered Balance/Gait

R
Joints : ROM - Redness - Edema - Stifness - Spasms

Refer to special clinical record : Neuro(GCS) . Ortho

P
A PAIN SCALE
I
0 1 2 3 4 5 6 7 8 9 10
N
Increased right lower quadran pain 7-10

G Anorexia - Nausea - Emesis -

AS Describe : Dehydrate
ST
R Abdomen - soft - Tender - Firm - Distended - Rigid
OI - Tympanic - Dull
ST
Bowel sound - Normal - Hypoactive- Absent
ES
TI Bowel - Normal - Constipation - Diarrhea - Melena
N -
AL
Movement : LBM occasional diarrhea 2-4 loose
SK Intact
stools a day : Yes - No,refer to wound care flow sheet
IN
 Colour : Normal - Pale - Fllushed - Jaundice - Mottled

Temperature : Warm - Hot - Cool - Dry - Diaphoresis

ST Coping - With illness - With Hospitalization -

AT Compliance
US Mood - Normal - Anxious - Sad - Depressed

Given client clinical course, assessment and

multidisciplinary goals,client is :

- Stable - improving - Deteriorating -

Tranferable to ALC