Nursing Assesment Thypoid Fever

Room: Lambu Barakati Children

Entry date: July 10, 2018

Hours: 12:30 p.m.

No.RM: 48 05 36

A. Assesment
Patient identity
Name : An. S.
Date of Birth : March 25, 2006
Religion : Islam
Education : Middle School
Occupation :-
Marital Status : Not Married
Address : BTN Tawang Alun
Medical Diagnosis : Typhoid Fever
Date of assessment : July 12, 2018
Hours : 7.45
Person in Charge Identity
Name : Mrs. L.
Age : 45 years
Religion : Islam
Education : high school
Occupation : IRT
Marital Status : Married
Address : BTN Tawang Alun
Relationship : Mother

B. History of disease
1. Main complaint
Fever patient
2. The main reason for entering the hospital

The client said stomach pain since 2 days before entering hospital, fever since 3 days

before entering the hospital. Appetite lost, weak. Kien did not seek treatment before

taken to the hospital and not taking any medicine, then the client is taken to the hospital

Bahteramas entered the emergency room at 07.10, TD: 110/70 mmHg, N: 90x / minute,
RR

15x / min, S: 38 C, given Ringer Lactat IVFD therapy 12 tpm, inj.ranitidine

50mg, inj.ondansentron, ketorolac 30 mg.l. Main complaint Fever patient

3. Past medical history

The client has never been treated at a hospital before, the client has a history of stomach
ulcer

since 2 years ago, and doing outpatient treatment.

4. Family health history

None of the client's family has a history of such offspring

hypertension, diabetes mellitus, heart disease, asthma, tuberculosis.

5. Genogram
 Genogram descrption

= Male
= Famale
= Live at home

= Sick family
= Family relationship
= Family member who died due to illness but not
known cause of illness. There is no hereditary disease and
family infectious disease

6. Current medical history: Upper abdominal pain, quadrant I since 2 days before
hospital admission, constant pain, fever since 3 days before entering the house sick,
at home have been taking drugs to buy at the stall because there has been no change
then taken to the Baheteramas General Hospital, in the emergency room an Ringer
lactate infusion was performed and inj.ketorolac and inj.ranitidin at 07.10, then the
patient was moved in the ward inpatient namely in the Lambu Barakati Children's
Hospital Bahteramas.
7. Treatment / allergy history: The client has no treatment history, neither does the client
do not have a history of allergies to food, drink or medication
8. Physical examination
a. General Conditions
Aches / pains:
P: The client feels abdominal pain since 2 days before entering the hospital.
Q: prickling pain
R: upper right abdomen quadrant 1
S: scale pain 5
Q: continuous pain
b. Attitude: Restless Awareness CM GCS = 15 E3 M6 V5
c. Hearing
The client can hear normally, the functions of the left and right ears are good, no
wearing hearing aids, no hearing loss
d. Vision
Clients can see normally, do not wear visual aids, conjunctival ananemics, non-
jaundice sclera, 2 / 2mm isochoric pupils, no blindness and no cataracts
e. Taste
The client says the taste is bitter, the tongue is dirty, looks white.
f. Sniffs
The client's sensory perception system is good and normal, there is no disturbance
g. Feeler
the client's sensory perception system is good and normal, there is no interference
with the sensory perception system.
h. Respiratory System
The client has no history of bronchitis, asthma, tuberculosis, emphysema,
pneumonia, non-smoking, 3 ml nasal nasal oxygen implants. Frequency 15 x / m,
depth: abnormal (slow and shallow), symmetrical chest development between right
and left, clean breath sounds, use of accessory muscles, no nasal lobe breath,
symmetrical palpable fremitus between right and left, no cyanosis. Symmetrical
lung development, irregular rhythm
i. Cardiovascular System
Blood Pressure: 110/70 mmHg
Pulse: 90 x / m
Temperature: 38.04 ° C
Rhythm: organized
Strength: strong
Akral: warm
Capillary refill: <2 seconds
Edema: Nothing
j. Central Nervous System
Awareness: Composmetis
GCS: 15 E3 M6 V5
Speak: normal
Pupil: right / left isochore size: 2/2
Time orientation; Clients can mention the time well that is when assessing morning
time.
 People orientation: Clients can name themselves and recognize the people around
them.
Place orientation: The client knows that he is in the hospital.
k. Gastrointestinal System
Loss of appetite: clients say appetite decreases.
Nausea / Vomiting: the client does not nausea vomiting
Allergy: no food allergies
Chewing or swallowing problem: none
Normal body weight before illness: 41 kg
Weight after illness: 40 kg
change in body weight: -Weight now: 40 kg
Height: 140 m
Body shape: normal
Skin turgor: moist
Mucosa: cyanosis
l. Mosculoskeletal System
Range of motion: limited
Balance of walking: robust
Ability to meet ADL: assisted
Muscle Strength:
55
55
m. Intergumen System
Skin color: white
Skin turgor: Good / moist
Bruises: Nothing
Other: -
n. History of Immunization
1) BCG: complete
2) DPT: complete
3) Polio: complete
4) Measles: complete
5) Hepatitis: never
 o. Growth and Growth History
1) Physical growth
- Weight: Do not know
- Height: Don't know
- Teething time: Forgotten, month, tooth date: Not yet
2) Development of each stage
-Roll over: The client's mother says forget
- Sitting: The client's mother says forget
- Concurrently: The client's mother said she forgot
- Stand up the client's mother said forget
- runs 1 Year
- Smile to someone else the first time: The client's mother says forget
- First talk: The client's mother says forget
- Dress without help: The client's mother says she forgo

C. Supporting data
Laboratory examination
Date of inspection: July 10, 2018
Laboratory examination
Hematologist
Automatic Blood Package Results Unit Normal Value
Hemoglobin L 11.5 g / dL 11.3-15.5
Leukocytes 5.1 10 ^ 3 / uL 3.6-11.0
Hematocrit 35 % 35-47
Erythrocytes 4.6 10 ^ 6 / uL 3.80-5.20
Trombocytes 300 10 ^ 3 / uL 150-400
MCH L 25 Pg 26-34
MCHC 33 g / dL 32-36
MCV L 76 FL 4-8
DIFF COUNT
Eosinophils 1.80 % 1-6
Basophils 0.20 % 0-1
Neutrophil 54.30 % 50-70
 Lymphocytes 36.00 % 22-40
Monocyte 7.70 % 4-8
Blood type O
Immunology
TYPHI O POS 1/400
TYPHI H Negative
PARATYPHI Negative
O-A
PARATYPHI Negative
O-B

D. Given Therapy
Therapy
Given Therapy Gift Hour

IVFD Ringer
Lactat 12 Tpm
Inj.ceftriaxone 1 x 8:00 a.m.
1000 mg
Inj.ranitidhin 2 x 8:00 a.m. 8:00 p.m.
50 mg
Inj.Hexilon 3 x 20 8:00 a.m. 4:00 p.m. 24.00
mg
Sucralfat 3x 1 cth 8:00 a.m. 4:00 p.m. 8:00 p.m.

Paracetamol 3 x 8:00 a.m. 4:00 p.m. 8:00 p.m.

500 mg
Curcuma 3 x 200 8:00 a.m. 4:00 p.m. 8:00 p.m.
mg
E. Data analysis
Client Name: An.S Day / Date: Thursday, July 12, 2018
No. RM: 48 05 36 Room : Lamb Barakati Child

Data analysis
SYMPTOM ETIOLOGY PROBLEM
DS: bacteria enter the Acute pain
- The client says pain in bloodstream
the right upper ↓
abdomen inflammation of the liver
P: The client feels & lymph
abdominal pain since 2 ↓
days before entering Activating chemical
the hospital. mediators (histamine
R: upper right and bradykinin)
abdomen quadrant 1 ↓
S: scale pain 5 Stimulates the release of
Q: persistent pain prostaglandins in the
DO: hypothalamus
- Composmetis (GCS: ↓
14 E3 M6 V5) Perceived pain (colic
- face looks painful pain)
- TD: 110/70 mmHg ↓
RR: 15 x / minute Acute Pain
N: 88x / minute
S: 38 oC
CRT: <2 seconds
- THYPI POST 1/400
lab
DS: Bacteria enter the Hyperthermia
- The client says limp bloodstream
↓
DO: Bacteria secrete
- the client looks endotoxins
nervous ↓
- Akral warm Hypothalamus
- Dry mucous ↓
membrane Hyperthermia
- TAKE 70-80cc, 2-3x
/ day
- TD: 110/70 mmHg
RR: 15x / minute
N: 88x / minute
S: 38 oC
DS: Salmonella thypi Nutrition is less than
- The client says the bacteria necessary bod)y
tongue feels ↓
bitter, decreased appetite Enter through food
DO: ↓
- client looks weak Digestive tract
- The client looks weak, ↓
pale, no appetite. Stomach
- BB before entering 41 ↓
kg Decreased appetite
BB After entering 40 kg ↓
- BK diet, finished ¼ The risk of
portion 250cc, drink 1 nutrition is less
glass 300cc than the body's
- BMI 17.9kg / m2 needs
- Hb L11,5 g / dL
- Lymphocytes 36%
F. Nursing Diagnosis (Based on Priority)
1. Acute pain associated with biological injury agents (00132)
2. Hippertermia is related to the infection process (00007)
3. Nutrition is less than the body's needs associated with decreased appetite(00002)
THE NURSING ASSESMENT OF TYPHOID FEVER

DISUSUN OLEH
LATIFAH NUR AZALIA
P1337420217049
3B

KEMENTRIAN KESEHATAN REPUBLIK INDONESIA

POLTEKKES KEMENKES SEMARANG
PRODI DIII KEPERAWATAN PURWOKERTO
2019