1.

DEMOGRAPHIC DATA
a. The Identity Of The Client

Name : Mrs. V

Age : 38 years old

Sex : Female

Religio : moslem

Job` : Housewife

Address : JL. Raja Basa No. 1 Way halim

Room : Jamine

Medical Diagnosis : Asthma Bronkhiale

Date of sign in : January 10th 2017

Date for The Assessment : January 10th 2017

b. Identity of caretaker

Name : Mr. W

Age : 40 Years old

Sex : Male

Religio : moslem

Address : Jl. Raja Basa No. 1 Way Halim

Relation With Client : Husband

2. THE MAIN COMPLAINT

The client complained of shortness of breath

3. DISEASE HISTORY NOW

The client comes to the way halim local government clinic on January 10th 2017 at 09.00 am
with short of breath complaint with a pain is her chest (pain like suppressed), shortness of breath
which she felt was continuous since on week ago with coughing and hard to throw the phlegm
from her throat. This complaint was often suffer a relapse then recover repeteadly since 15 years
ago. This complaint will felt when the weather is changing, when she was doing activity, a lot of
thinking and too many dust. To decrease this complaint, usually the client wears sweater when
the weather was cold and avoid the dust. If this way can not exceed he complaint, usually the
client come to the local government clinic continuously and will un concerned, if she drink a
medicine from local government clinic.

4. A HISTORY OF THE DISEASE IN THE PAST

The Client said has a history of asthma since 15 years ago.

5. THE FAMILY DISEASE HISTORY

The client said there is not family member who suffered from diseases such as client.

6. PSYCHOSOCIAL HISTORY
a. Psychological History

Client said was afraid his condition now, client ask about the condition of his health.

b. Social aspects

During sick client relationships with family, and good health officer, client is cooperative in
answering every question the officer.

c. Spiritual Aspects

Client the moslem, client gives a quick prayed that healing.

7. DAILY ACTIVITY PATTERNS

a. Eat pattern

The client said that she always eats 3 times/day with a meal rice, a variety of side dishes,
vegetable and fruit. She likes hot side dish much everyday. Now, the client doesnt have appetite
for food because she feels queasy, so she was only eat 5-6 spoon the food that available
everyday. She usually drinks 6 until 7 glass/day (1200 until1400 cc/day).

b. Sleep pattern

The client said that sometimes she couldnt sleep well because the attack was happen at night
because of shortness of breath, so she can sleep only 5-6 hours/day.

c. Elimination pattern
The client urinate 5-6 times/day, defecate once/day.

d. Pleasant

The client said if the weather is cold, the shortness of breath will flared up and felt painful in her
chest, so then feeling of safe and comfortable will disturb and the client cant do an activity if
she does many activity, the sound wheezing will heard, so it can disturb another people who
sleep around her.

8. PHYSICAL EXAMINATION
a. General condition : good
b. Vital sign in

Blood pressure: 120/80mmhg

The pulse: 84times over the minute

Temperature: 37.5c

Respiration rate: 30 times over the minute

c. Examination of head to toe

Skin: normal
Head: normal
Eyes: the client looks sleepy
Nose: the tip of the nose breathing
Ear : normal
Lip and mouth : there is sianosis on the lip and the mouth mukosa, the client breathe through
the mouth and speaking interrupted
Neck : there is no expansion thyroid gland and vena jugularis.
Thorax
Inspection
- It seen using extra muscles when breathing (the reaction of sternum the shoulder lifted up
while breathing).
- Retraksi intercosta inspiration.
- The breathing fast and shallow.

Palpation

- Fremitus tactile weakened on the both to chest

- Retraksi the sternum and intercosta

Percussion

- Hipersonor with characteristic.

- Intensity : very strong
- Frequency : very low

Auscultation : a wheezing sound was heard when ekspirasi.

Abdomen
- Inspection : normal
- Palpation : There is no pain and fluid press
- Percussion : a timpani sound was heard
- Auscultation : the intestinal noise (+) 13 times/minute on the right and left quadrants.
Back
- Inspection: the breathing fast and shallow
- Palpation : There is no pain and fluid press
- Percussion : a resonan was heard at interkosta 1-2, hipersonor at interkosta 5-6.
- Auscultation : a wheezing sound was heard when ekspirasi.
Hand / a up extremity
- There is no clubbing finger at the fingers (-)
- Cyanosis at fingernail (-)
- Flofing tremor (-)
- Great pulse
- The hand was sweat
Walk / a bottom extremity : there is not edema.
Genetalia : no attached catheter
9. DIAGNOSTIC EXAMINATION
 HB : 11,2
LED : 41
Erythrocytes : 4,2
Lekosit : 8,4
Hematrokit : 36,8
MCV : 87
MCH : 26,5
MCHC : 30,4
RDW : 13,8
Platelets : 224
Type blood : B
The results in a photo of thorax, the client suffered bronchial asthma.
10. MEDICINAL TREATMENT
Aminopilin 3x1 tab
Dexametason 3x1 tab
Calcium Lacktat 3x1 tab
Vitamin B complex 3x1 tab

DATA ANALYSIS

No. Sympton Etiology problem

1. SD: The increase in the Clear the

production road of breath is
The client said its was hard to breathe of secret, tough phleg not effective
The client said its was hard to throw secrete from her m out
throat, uneffective.

OD:

The breath was fast and shallow

Rr 24 times/minute
Breathe by mouth
Wheezing (+)
2. SD: Chest pain Impaired sense
of comfort.
The client said the feeling of comfort disturbed
because of shortness of the breath.
The client felt painful in her chest.

OD:

The expression of face hold the pain

The client looks restless
The client was hard to breathe
Pain scale 5-6

3. SD: Shortness of breath Interference of

sleep pattern
The client said she couldnt sleep well because she
felt shortness of the breath.
The client said she feels shortness of the at night

OD:

The client often yawn

Her eye redness because a lack of sleep

THE LAST OF DIAGNOSIS / PROBLEM

1. Clear the roads ineffective breath is associated with increased production of mucus which is
characterized by cough and sputum are hard out
2. Impaired sense of comfort associated with the chest pain is marked with a
client complaining of chest pain
3. disorders of sleep and rest patterns associated with coughing and shortness of breath that
settled the perceived