Assessment

NURSING HISTORY
Admission Date : May 18 th, 2004 Time : 09.00 a.m
No. Reg : 04051xxx Medical Dx : DM Type II
Hospital : Hospital Maha Srhat

Date of assessment : May 18 th, 2004

I. Patient identity
a. Name : Ny. Y
b. Age : 50
c. Sex : Female
d. Race : Java
e. Religion : Moslem
f. Education : Junior High School
g. Occupation : House Wife
h. Address : Jl. Cihangseur Hilir RT.01/02 Cicodat

II. HISTORY OF PRESENT ILLNESS

1. Chief complain : client complain of swollen cheeks, runny nose, stuffy nose and
dizziness
2. Present Ilness Story : since three days ago the client complained of swollen cheeks,
previous clients complained of colds, nasal congestion and
dizziness. the client has a history of hypertension and diabetes
mellitus

III. PAST NURSING HISTORY

1. History of contagious Disease : yes, with the same symptoms like now. but over
the past few years the client has not felt any
complaints and does not regularly check her blood
sugar levels

2. Heredity Disease : none

3. Aallergic History : none

IV. FAMILY HEALTH HISTORY

Her father had been suffered diabetes mellitus disease
 Genogram of family :

Advert
Male

Female

Living together

Ever sick with DM

V. OBSERVATION AND PHYSICAL EXAMINATION

Vital signs : BP : 190/100 mmHg, P : 85 x/ min, RR : 24 x/min, T : 36,5 0 C