In Banjarmasin Islamic Hospital Ibnu Rusyd Ward

Name Age Gender Religion Address

: : : : :

Mr. J 59 years Male Islam Antasan Raden RT. 20 A No. 15 G

Main Complaint The weakness of left part of the body (stroke), and his family said that the client feel dizzy and cant do any activity, client cant eat, and the pain scale is 2, and its come suddenly

History of Present Disease Client family said that the client feel the weakness of right part of the body since morning of July 10th followed by vomiting, headache, the swollen of feet and hands since the third stroke, hypertension, lip oblique to the left, and at the same morning his family bring him to islam hospital

History of Previous Disease Client said that he had the same disease for three times. History of Familys Disease Almost all clients family members had been hospitalized but with different disease.

General Condition Client is in full consciousness, the client looks weak and he cant do activities by himself. Eye : The client able to open his eyes spontaneously, but there is a little disturbance in his vision. Verbal : The client able to speak, but difficult to understand. Motoric : The client has difficulty in moving his extremity. Vital Signs Blood Pressure Pulse Respiration Temperature : : : : 160/90 mmHg 96x/minute 22x / minute 36,7 C

Focus Data
Subjective Data Clients family said that the Clients family said that the Client does activities. Clients family said that the The pain comes suddenly Clients family said that the Clients family said that the Clients family said that the neck. Clients family said that the clients head is dizzy. headache appears when the pain scale is 2, bearable pain. Client cant do any activity. Clients family got a fever. Client feels the pain in the Client doesnt want to eat

Objective Data
Inspection Client looks weak Activity scale is 4 (fully dependent) Muscle scale 3333 4444 3333 4444 Temperature : 36,7 C Client looks weak
Percussion Palpation Pulse : 96x/minute Respiration: 22x/minute Skin turgor back in 2 seconds Auscultation Blood Pressure: 160/90 mmHg Hearts Sound: single S1S2

1. Headache r.t increase in cerebral vascular 2. Nutrition less than body needs r.t incapable in absorbing 3. The damage of physical mobility r.t decreased muscle strength

Diagnose I Examination of pain characteristics. Observe vital sign Maintaining bed rest Collaboration with medicine

Diagnose II Feeding the patient via oral. Examination of nutrition status Collaboration in giving medicine

Diagnose III Examine the limitation of activity and muscle strength. Change the position of the Client periodically. Give help in Clients activity

Thanks For Your Attention