Assessment Form for The Older Adults

By Focus Group 6
Alfi Nurul Imani Novi Margiyati
Karlina Nur Fitria Tsaabitah Rizqilla

Hospital Name : RSUD Pasar Minggu

Admission Date : 29-03-2020

Register Number : 025184

I. IDENTITY
A. Name : Mrs. Suminah
B. Gender : Women
C. Age : 85 years old
D. Religion : Islam
E. Marital Status : Married
F. Last Education : Junior High School
G. Last Occupation : Housemaid
H. Address : Jl. Jendral Sudirman No. 3 Rt 003 Rw 04
Kelurahan Sukabumi Utara, Kecamatan Kebon Jeruk, Jakarta Barat

II. HOSPITAL ADMISSION COMPLAINTS/REASONS

Acute confusional state and hyponatremia

III. HEALTH HISTORY

1. Health problems that have been experienced and are experienced at the
moment:
a. The patient has a history of recurrent stroke and is currently
experiencing hemiparesis.
b. The client experiencing ineffective cough and has an excessive sputum
but hard to released
c. In the sacrum area there is grade 3 pressure ulcer.
2. Familial or genetic health problems
- There are no family history of hereditary diseases
- There are no family member has ever experienced patient's illness
IV. DAILY HABITS
A. Biological
1. Eating pattern :
❏ Patient eats frequently (2-3 times a day)
❏ Patient says she lost appetite in the last few days
2. Drinking pattern :
❏ Patient drinks adequately (8 glasses a day)
❏ Patient says that she often feels thirsty lately
3. Sleeping pattern :
❏ Patient complains midnight awakening
❏ Patient complains difficulty in falling back to sleep
❏ Patient still manages to get sufficient sleep
4. Elimination pattern :
❏ Patient says that she defecates less frequent as she ages but
does not experience constipation
❏ Patient says that she can not hold bladder for too long
5. Self-hygiene :
❏ Patient needs assistance from others to do self-hygiene due to
hemiparesis

B. Psychological
1. Cognitive and affective function:
❏ Patient says that she often forgets recent things
2. Psychologic function :
❏ Patient experiences changes in her languange fluency
C. Social
1. Family support :
❏ Patient’s family is involved in taking care of the patient and
fulfilling patient’s basic needs
2. Relationship with others :
❏ Patient says that she has good friends around her age who do
religious things together (Quran recitation)
D. Spiritual/Cultural
1. Religious activity:
❏ Patient often asks her child to help her with wudu so that she
can do her prayer on bed
❏ Patient often prays and asks others to also pray for her
 2. Keyakinan tentang Kesehatan:
❏ Patient says that she tends to ignore the symptoms that she
experiences and her child is the one who takes care of her
health
E. Daily Activities
○ Walking around the house
○ Pray and do Quran recitation with friends
○ Watching TV
F. Recreation
○ Patient likes to take a walk around her housing
G. Condition of Surrounding Environment
○ Patient is surrounded with heavy smokers

V. Physical Assessment
A. Vital Signs
● General state: moderate
● Consciousness: compos mentis
● Temperature: 370C
● Heart Rate: 89x/minutes
● Blood Pressure: 159/89 mmHg
● Respiratory Rate: 25x/minutes
● Body Height: 151 cm
● Body Weight: 40 kg
B. Physical Assessment
1. Head
- Hair
a. Inspection: hair hygiene is maintained, whitish hair
- Eyes
a. Inspection: decreased visual ability (close
visibility), not using a glasses
- Nose
a. Inspection: symmetrical nose
b. Palpation: there is no bumps or nodule on the nose
- Mouth
a. Inspection: bluish lips and dry, there’s no bleeding
in the gums and the color is pink
- Ear
a. Inspection: good auditory response, she’s not using
hearing aids
 2. Neck
- There is no enlargement of the thyroid gland
3. Chest/Thorax
- Chest
a. Inspection: Asymmetric respirations
- Lungs
a. Inspection: rapid breathing, RR 25x / minute, use of
respiratory muscles: dyspnea
b. Palpation: sign of tactile fremitus
c. Percussion: sonor sound
d. Auscultation: ronchi sound in the right apex
- Heart
a. Auscultation: Regular sound and rhytm
4. Abdomen
● Inspection: flat shape, no enlargement and no tenderness
● Auskultation: intestinal peristalsis sound 12x / minute
● Percussion: the liver is not palpable
● Palpation: tympanic sounds
5. Musculoskeletal
a. symmetrical shape, there is pressure ulcer in the sacrum
area grade 3
6. Others

VI. SUPPORTING DATA

A. Medical Diagnosis : Community Acquired Pneumonia (CAP)
B. Laboratory test : - Leukocyte count
- Sputum gram stain
- Blood culture
- Urine antigens
C. Medical therapy : - IVFD NaCl 0,9% 500cc/8 hours
- Oral macrolide
- Oral beta lactam
- Ventilator
- Bronchoscopy

[ CITATION Tab141 \l 1033 ]

 Data Analysis

Data Nursing Problem

Objective Data Ineffective airway clearance

● Dyspnea [ CITATION Her182 \l 1033 ]
● Bluish lips and nails
● Ineffective cough
● Ronchi sound in the right apex
● Patient’s using an NGT
● Vital Sign:
- RR: 25x/minutes
- Pulse: 89x/minutes
- BP: 159/89 mmHg
- Temp: 370C

Subjective Data
● Client said that she has an excessive
sputum but hard to release it
● Client said that she often feel
restlessness

Objective Data
Acute Confusion
● She is 85 years old
● Acute Confusional State (ACS) [ CITATION Her182 \l 1033 ]
● A history of recurrent stroke and currently
having hemiparesis.
Defining Characteristic
● Agitation
● Alteration in cognitive functioning
● Alteration in level of consciousness
● Alteration in psychomotor functioning
● Hallucinations
● Misperception
● Restlessness
● Lasts less than 3 months
Population at risk:
Age ≥ 60 years old
Stroke history
Related conditions:
● Delirium
● Dementia
● Impaired metabolic functioning
● Infection
● Pharmaceutical agent

Objective Data
Risk for Pressure Ulcer
● Client have grade 3 decubitus wound
in sacrum area [ CITATION Her182 \l 1033 ]
Risk factors
● Client attached with foley catheter and
ngt (decrease in mobility)
● Inadequate nutrition
● Hyperthermia
● Age 85 years old
Subjective Data
-

Bibliography

Herdman, T., & Kamitsuru, S. (2018). NANDA international, inc. Nursing diagnosis: Definitions
and classification. New York: NANDA International.
Tabloski, P. (2014). Gerontological nursing. New Jersey: Pearson.