A.

ASSESSMENT
NURSING HISTORY
Admission Date : Dec 9
th
, 2013 Time : 07.00 pm
No. Reg : 175001599 Medical Dx : Gastritis
Hospital : Ratu Zalecha Hospital
Date of Assessment : Dec 9
th
, 2013
1. Biographic Data
a. Name : An. R
b. Age : 25 years
c. Sex : Female
d. Race : Banjar
e. Religious orientation : Moslem
f. Education : Teachership faculty and science
g. Marital status : Be married
h. Occupation : Civil servant
i. Health care financing : ASKES
j. In charge of patient : Tn. A
k. Relationship : Husband
l. Job : Teacher
m. Address : Banjarbaru
2. Chief complaint or Reason for Visit
Pt. had abdominal pain for the past five days.
3. History of Present Illness
a. Usual health status
Pt. fell to weaken or terrible, often nausea and vomiting, stomach felt
very is not comfortable.

b. Chronologic story
Patient had been suffered abdominal pain since five days
ago,sometimes missing sometimes appears. The pain is like
winding,there are nausea and vomiting. She had been taken medicine
from public hospital, but she hasnt recovered from her illness, and
she is still suffering, weak condition. So, she went to hospital for
treatment.
c. Relevant family history
Patient tell there no family disease history.
d. Disability assessment
In the patients daily life, patient momentum in managing household
(child and husband) becoming to decrease because its stomach pain
in bone which sometime recurrence.
4. Past History
a. Childhood illnesses
Scarlet fever, chicken pox, parotitis, stomach disorder.
b. Childhood immunizations
Polio, measles, hepatitis.
c. Allergies
Patient said no allergies to drugs or animal, but she is allergic to food
(shrimp).
d. Accident and injury
Patient said she had never an accident or injury.
e. Hospital for serious illness
Patient said she never suffered serious illness, usually come back to
home swiftly after medicinize to hospital.
f. Medications
Patient said often she consume Paracetamol and Amoxilin when
headache, influenza and other, mefenamic acid when toothache.


5. Family History of Illness
Parents and her grandparents never suffered gastritis disease.
6. Review of Systems (ROS)
Vital sign:
BP 130/90 mmHg Temp. 37 C
RR 20 x/minutes P. 88 x/minutes
Abdomen
Inspection:
Abdomen in form of is symmetrical, there no injury and seen respiration
of stomach.
Palpation:
There no magnification of organ, there is pain in bone depress at part of
epigastrium, there no magnification of liver.
Percussion:
Tympani stomach sound.
Auscultation:
Noisy of intestine heard is normal.
7. Life-Style
a. Personal habits
Patient said had never smoked and consume to alcohol. But patient
like to drink tea, in one day she earn to drink about 3 times one day.


b. Diet
Patient said she pattern eat not regular, Sometime only 2 times one
day because busy. She usually going shopping food and cooking for
family. Her favorite food is soto and dislikes food is curry. she are
allergic with prawn food.
c. Sleep/rest patterns
Patient said usually sleep at 11 pm and wake up at 5 am. During at
the hospital patient said sleepless and often woke up by sleep
moment.
d. Activities of daily living (ADLs)
Patient said no problem in activity, like eating, grooming, dressing,
eliminating, and locomotion.
e. Recreation/hobbies
Patient like to go to swimming with her family. And usually she visit
to parentss house one week once from Banjarbaru to Amuntai.
8. Social Data
a. Family relationship/friendship
Patient lived with husband and child. Her husband which always
there is moment she require.Patient always get support from husband
and her child and also family. Because her disease in this time
patient cant work.
b. Ethnic affiliation
Patient and family from South Borneo or banjar tribe. In all day,
patient speak with vernacular , dressy like people. There no habit
which is special to be conducted.

c. Education history
Highest education which is in this time reached for by patient is to
get education college degree. Patient admitted no difficulty in
learning and interacting with others.
d. Occupational history
Patient work as civil servant. Because in this time is taking care of,
she get permission in order not to enter job recover. She have never
conducted mistake in working. She is known better by superior and
her friend. Patient very like with her work.
e. Economic status
Her finances is fine. To paying for medical care patient get health
insurance (ASKES) from her work. Besides her husband even also
work as teacher in a school.
f. Home and neighborhood conditions
In a condition in this time, patient do not too much playing a part in
ripe matter and others, become her husband which must cooking and
do housework replace herself. patient nor can come in contact with
her friends either in office and also in house environment.
9. Psychologic Data
Occurence making patient very stress is moment she will bear, she very
worry, nervous about etcetera. To overcome that moment stress of her
husband accompanying moment she will bear and at ones back.
10. Patterns of Health Care
Patient said has not a family physician or specialists, usually she and her
family only go to the nearest health clinic.