NURSING CARE AT Mr.

T
WITH MEDIC DIAGNOSE HEPATITIS
AT ROOM CEMPAKA REGIONAL HOSPITAL CILEGON
A.Study
1. Identity
a. Client
Name :Mr.T
Age : 26 years old
Sex : Male
Religion : Moslem
Education : Senior ig scool
!ccu"ation : Teacer
Address : Eart Sudiang #ermai
Status o$ material : Single
%ate enter to os"ital : %esem&er 21
t
' 2(12
%ate o$ learning : !cto&er 22
t
' 2(12
No. cm : )*+,2
%iagnose : -e"atitis
&. .nder /riter
Name :Mr.R
Age : +6 years old
Sex : Male
Religion : Moslem
Education : Senior ig scool
!ccu"ation : Em"loyee
Address : Eart Sudiang #ermai
Relationsi" : 0ater
2. Client helth hi!t"ry
a. Es"ecial sigt.
Client. Com"lained "ain in te u""er rigt a&doment.
#. Pre!ent helth hi!t"ry
!n desem&er 21
t
'2(12'Client a$ter consuming alcoolic &e1erages' te
client 1omiting'anorexsia and com"lained "ain in te u""er rigt
a&doment'"ain in te a&doment $elt to increase i$ client a lot o$ mo1ement'
"ain in a&doment scale ).
( : no "ain
1 : tere "ain in a&doment
2 : a little more "ain
) : agoni2ing
* : se1ere "ain controlled
+ : se1ere "ain not controlled

Client also com"lained nu!e
$. P!t Helth Hi!t"ry
Client told tat e ne1er ex"osed HEPATITIS %
d. &'ily Helth Hi!t"ry
Client told in tat e $amily' no one ad e"atitis 3
(. Phy!i$l
a. 4enerality
Client $ace loo5ed "ale' $ace ex"ression /ince a/areness conm"os
mentis
)itl !i*n
3lood "ressure : 12(67(
mm-g
-ealt rate : 7( times $or
a minutes
Res"iratory rate : 2) times
$or a minutes
Tem"erature : ),
(
C
C. Re1ie/ o$ system
Re!+irt"ry !y!te'
Symmetrical nose $orm'tere isn8t magni9cation o$ adenoid'&reating
1oice 1esicular /it $re:uency o$ &reate 2) times $or a minute.
Hert nd ,en"u! !y!te'
Symmetrical &est $orm' tere isn8t lesion' "ain in a&doment de"ress'
/en do te auscultation eard &y 1oice o$ lu" ; S1 an S2< /it rytm
o$ regular.
G!tr"inte!tinl !y!te'
Symmetrical est $orm' dam" li" mucosa' teet seen rater dirty'
1isi&le and rose colored tongue' mo1ement o$ $ree tongue tere are
no stomatitis' tere are no tonsillitis client can8t $eel &elo1ed'"ositi1e
"u5ing re=ect' a&doment is not symmetrical tere is enlargement o$
te e"ar' tere are "ain in te u""er rigt a&doment de"ress.
Eyes sigt system
Le-t eye
>cteri5 sclera'anemia con?uncti1a'gro/t eyelas and eye&ro/
=atten'"u"il o$ meiosis moment gi1en &y excidement /it ligt
&y touc /it cotton s"iral at cornea.
Ri*ht eye
>cteri5 sclera' anemia con?uncti1a'gro/t eyelas and eye&ro/
=atten'"u"il o$ meiosis moment gi1en &y excidement /it ligt
&y touc /it cotton s"iral at cornea
Er! '"uth nd tl.in* !y!te'
Mout can ma5e a mo1e $reely' tongue loo5 a little dirty'
symmetrical ear $orm' tere are no edema at "inned' tere are
no cerument' tere are no dry &lood at &ot and "inna o$
canali2e external auditor' client can orient to time' "lace' "eo"le.
Client can communication /it nurse' "ro1en o$ client can
ans/er / at is as5ed &y nurse.
Intre*u'ent !y!te'
4ood us5 tugor can return lees tan 1 second' us5 do not
eyanosis.
Urinry !y!te'
%o not &e attaced &y cateter do/er.
Mu!$ul"!.eletl !y!te'
o Ta" extremity
Is attaced &y 5nac5 in$use 2( dro"6minute at le$t
extremity =uent strem elastic us5 turgor "ositi1e "atella
re=ect strengt o$ muscle *.
o 3ottom extremity
Tere are no odem tere no lesion elastic us5 turgor'
"ositi1e "atella re=ect strengt o$ muscle *.
o Endocrine system
Tere are no magni9cation o$ gland o$ tiroid.
o Ner1ous system
Ner1ous ol$actory ;I<
Client can sell eucaly"tus oil smell
Ner1ous o"tics ;II<
Client can see &etter' client can road nurse name
&adge' &etter in distance @ 1 M /itout using
s"ectacles.
Ner1ous o5ulomatorius ;III<
Ta5ing a &at
Cut is nail
Aasing air
Teet &rus
o 2 times $or a day
o 1 times $or a
/ee5
o !nes $or a day
o 2 times $or a day
e. P!y$h" !"$iety dt
Client loo5 /ea5en and a dirty' client seen ?um"y' $ace ex"ression /ince'
client tell "ain in
te u""er rigt a&doment' client tell to /is :uic5ly recor1er.
-. Reli*i"n dt
Client a moslem' client $eel sure tat te disease o$ /ill recor1er.
*. Su++"rt dt
-emoglo&in : 1( g6dl
S4!6S4#T : *(6*B
Al&umin : )'+ g6dl
N
"
1
Di/erent dt
S%
Client tell 1omiting
Anorexsia
Nausea
S%
Eti"l"*y
Inade:uet
e inta5e
Pr"#le'
Nutrition
2 Client com"laint #ain
in te u""er rigt
a&doment.
Scale "ain in
a&doment.
>imited mo1ement
#ain
Nur!e di*n"!e
1. Nutrition to te situation anorexsia' gastrointestinal "ro&lem.
S%
Client tell anorexsia'nausea and 1omiting.
!%
Client loo5 /ea5en
Client loo5 nausea
1. #ain in te u""er rigt a&doment to in=ammation "rocces mar5ed
&y :
S%
com"laint in u""er rigt a&doment
!%
Scale "ain in a&doment is )
N
O.
1
Nur!e Di*n"!e
Nutrition relate to te te
anorexsia' gastrointestinal
"ro&lem.
S%
Client tell anorexsia and
1omiting.
!%

Client loo5 /ea5en
Tr*et
A$ter
conducted
Action &y
treatment
during t/o
e:uals
t/enty $our
our
Ex"ected
&y /it
Inter,enti
"n
C#ro1ide
$ood little
and o$ten
according
to te diet.
C
Colla&oratio
n o$ nurse
and doctor
Rti"nl
CMinimi2ing
anorexsia and
nausea in
connection /it
uremic status.
C to eliminate
nausea6 1omiting
and oral inta5e
can increase.
2
Client loo5 nausea
#ain in te u""er rigt
a&doment to in=ammation
"rocces mar5ed &y :
S%
Client com"laint in
u""er rigt a&doment
!%
Scale "ain in a&doment
is )
criteria :
CIncreased
a""etite
clients say
CClient does
not loo5
nausea.
A$ter
conducted
Action &y
treatment
during t/o
e:uals
t/enty $our
our
Ex"ected
&y /it
criteria :
Cclient say
te "ain
disa""eared
Study6note
status o$
neurologist
regulary
and
com"are
/it 1alue
o$ 4CS
Studying te
existence o$
tendency at le1el
a/areness o$
Intra cranial
"ressure and
use$ul in
determining
extension
'location.
NURSING CARE AT Mr. T
WITH MEDIC DIAGNOSE HEPATITIS
AT ROOM CEMPAKA REGIONAL HOSPITAL CILEGON


%isusun ole:
RI01I HAM0AH &ANSHUR2
NIM.(344354435
#R!4RAM ST.%I %III DE#ERAAATAN
SED!>A- TIN44I I>M. DESE-ATAN 0A>ETE-AN
SERAN4C3ANTEN
2(12
Dily $ti,ity
N".
1
A$ti,ity
Nutrient :
a. Eat
&. %rin5
At h"'e
0re:uency : )
times $or eac day
Rice'9s'1egeta&le
s and $ruits
#ortion : 1 "ortion
9nised
0re:uency : *C6
glass eac day
Mineral /ater'tea
At h"!+itl
0re:uency : )
times $or eac day
Rice'9s'1egeta&le
s and $ruits
#ortion :
E
"ortion
not 9nised
0re:uency : +C6
glass eac day
Mineral /ater
2 Elimination
a. %e$ecate
&. Ta5e a "ee
0re:uency : 1C2
times $or eac day
Consistency:
=a&&y
Colour: 3ro/n
Smell: ty"ical
0re:uency: +C6
times $or day
Colour : Fello/
clean
0re:uency : 1
times $or eac day
Consistency:
=a&&y
Colour: 3ro/n
Smell: ty"ical
0re:uency: )C*
times $or day
Colour : %ra5 clean