Translated from Indonesian to English - www.onlinedoctranslator.

com

A. Assessment
1. Biodata
a. Name : Mr. Sudaryo
Gender : Man
Age : 78
Education : SD
Occupation : Farmer
Religion : islam
Address : RT/RW 03/06 Pandegan, Majenang Cilacap, Central Java
Medical diagnosis : CKD
Admission date : November 11, 2024
Assessment Date : November 13, 2024
Register no : 494945

b. Responsible person
Name : Mr. Eru
Gender : man
Age : 64
Education : SD
Occupation : trader
Religion : islam
Address : The same

2. Health History
a. Complaints upon admission to the hospital:
Pain in the legs, can't walk
b. Complaints during assessment:
During the assessment on November 13, 2024, the client complained of lower
back pain that radiated to the right leg, the client also complained of nausea and
appeared weak. The family said that the patient had not eaten for 10 days, and
only ate 1-2 spoons. The patient appeared restless and avoided pain, the patient
appeared to wince when the leg was moved. The patient also said that the pain
decreased after being given medication. The patient's muscle strength decreased
so that activities were assisted by the family.
P: The pain feels worse when moving.
Q: The patient said the pain felt like being stabbed.
R: waist that extends to the right leg
S : scale 5 from range (1-10)
T : when moved
c. Current health history
The patient complained of lower back pain that spread to the right leg, the client
complained of nausea and appeared weak.
d. Past health history
The family said the patient had no history of similar illnesses before.
e. Family Health History
 The family said the family did not have a disease similar to the patient's.
3. Function pattern
Activity At home In the hospital
Nutrition
a. Eat
- Types of food Rice, vegetables, fish Porridge (RP diet)
- Frequency 2x a day 3x a day
- Taboos There are no taboos There are no restrictions
- Dietary habit 1 serving 2 spoons
- complaint No problem Unable to finish food,
b. drink anorexia
- types of drinks Water + coffee
- frequency 5-6 glasses Water
- amount +_ 1000 cc 4-5 glasses
- taboo There are no restrictions +_ 900cc
- complaint No complaints There are no restrictions
No complaints
Fecal elimination
- frequency 1x a day Not yet pooped
- pattern Normal Abnormal
- consistency Mushy -
- smell Typical feces -
- color Typical feces -
- amount +_ 90cc -
- problem No problem No desire to defecate
Urinary Elimination
- frequency 3-4x a day 2-3x a day
- pattern Normal Normal
- color Yellow Deep yellow
- amount Not reviewed +_900cc
- problem No problem Catheter in place

Rest and sleep

a. Evening
- pattern Normal Abnormal
- number of hours 8 hours More than 8 hours
- sleeping habits Not reviewed The lights are not turned
- difficulty sleeping There is no difficulty off
b. Afternoon Constantly restless
- pattern Normal
- number of hours 1-2 hours Abnormal
- sleeping habits There is no habit More than 2 hours
- difficulty sleeping There isn't any There isn't any
There isn't any
Daily activities
- activity Independent Assisted
- type of activity Gardening -
- habit Sit Sit and lie down
Personal hygiene
 a. bathe 2x a day 1x a day
b. brush your teeth 2x a day Not reviewed
c. shampoo 1x a day Do not wash your hair
d. cut nails Not reviewed while in the hospital
e. problem No problem Haven't cut your nails yet
Assisted by family

4. physical examination
a. general condition: compos mentis
b. vital signs
- BP : 140/90
- RR : 13x/minute
- Temperature: 36.6
- Pulse: 62x/minute
- Spo : 92

c. BB/TB
- Weight: 60 Kg
- Height : +_ 165 cm

d. Head to Toe
1) Head: oval head shape, thin hair, black with gray hair
2) Eyes: anemic conjunctiva, no signs of inflammation, icteric sclera
3) Nose: symmetrical and clean shape
4) Ears: right and left ears are symmetrical, clean
5) Lips & mouth: the shape of the lips is not symmetrical, clean, the oral mucosa
is moist, there are white spots on the tongue.
6) Neck: no swelling of the thyroid gland
7) Thorax: symmetrical chest shape, normal breathing rate, slow breathing
rhythm, vesicular breath sounds, and snoring.
8) abdomen: the abdomen is symmetrical, there is mild ascites, tympanic sounds
are heard, there are bowel sounds, there is tenderness
9) genitalia: normal, no signs of inflammation, urinary catheter installed
10) anus: no problems in the anus area
11) upper extremities: right and left hands are symmetrical, IV line installed in the
right hand
12) lower extremities: right and left legs are symmetrical, no edema, right leg
cannot be moved and hurts when moved
13) skin: brown skin color, patient's body feels warm, skin turgor is not elastic,
CRT < 3 seconds
5.
B.