NURSING CARE

IN PATIENT An. A WITH THYPOID FEVER

IN JASMINE ROOM KELET RSUD

A. ASSESSMENT
1. Patient identity
Name : Nn.A
Gender : Female
Age : 22 years old
Religion : Islam
Education : S1
Address : Kelet 6/10
Marital Status : Single
Ethnic Group : Indonesia
Job : College Student
Date of Entry Hospital : 21 Februari 2014
Date Of Assessment : 21 Februari 2014
Hours Of Entry Hospital : 09.00
Hours Of Assesment : 10.00
2. Emergency Contact
Name : warsini
Gender : Female
Age : 49 years old
Religion : Islam
Education : SMA
Address : Kelet 6/10
Marital status : married
Ethnic Group : indonesia
Job : housewife
Relationship with patients : parents
3. Chief Complaint
Nausea
4. Medical Diagnosis
Typhoid Fever
5. Illness History
a. Main complaint :
The patient complained of nausea, vomiting 3x, hot body since 4 days ago,
heartburn
b. Current Health History:
Patients who came with complaints of heat, dizziness, nausea, vomiting 3
times, had been examined by a paramedic, but because of the heat again, they
were immediately taken to the hospital.
c. Past Health History:
The patient said that he had never been sick like this and had never been
hospitalized.
 d. Family Health History:
Patients say no family member suffers from this illness and there is no other
declining disease.
6. Physical Assessment
General condition
a. Awareness: Composmentis, the patient looks weak.
TTV: TD: 110/70 mmhg
N: 89x / minute
T: 39.5 C
RR: 24x / minute
BB before illness: 48 Kg
BB when reviewed: 46 Kg
b. Head, neck and axilla
- Head: Normochepalic, black hair, short and straight, no lesions, no
dandruff
- Neck: Symmetrical neck shape, no wounds, no enlargement, thyroid,
trachea located in the center,
- Axila: Looks clean, no lesions, no lumps or period
- Breasts: Symmetrical, not palpable mass or lumps
c. Integumentary system
Brownish skin color, no lesions, smooth texture, good skin turgor, patient's
skin feels hot.
d. Vision System
The shape and size of the eyes are symmetrical, the anemic / pale
conjunctiva, the non-jaundiced sclera, the isococcal pupil, there is no
compressive pressure.
e. Hearing System
The shape and size of the ears are symmetrical, the ears appear clean, there
is no cerumen. Clients can hear well.
f. Respiratory system
- Nose: Breathing does not use the nostrils, no polyps, clean.
- Inspection: Symmetrical shape, no mass, right and left normal with a
frequency of 20x / minute.
- Palpation: There is no pain,
- Percussion: resonant sound in the chest
- Auscultation: Vesicular, not wheezing or ronchi
g. Cardio-vascular system
- Inspection: Symmetrical chest, no right or left chest enlargement
- Palpation: There is no tenderness
- Percussion: No squeak
- Auscultation: Heart sounds (lub) da S2 (dub), gallop (-), murmur (-)
h. Digestive system
Mouth and esophagus: Symmetrical lip shape, no lesions, slightly dry lips,
slightly dry oral mucosa, pink color, ovules located in the middle, tonsils
located symmetrically, tongue looking dirty, caries on the teeth.
 i. Stomach
- Inspection: Flat shape, no lesions
- Auscultation: Bowel sounds 15x / minute
- Palpation: palpable liver does not enlarge, there is tenderness at the top.
Pain scale 2.
- Percussion: Timpani
j. Genetalia
No complaints.
K . Musculoskeletal System
No complaints. Joint movements according to type, ROM is good.

7. Analysis :
Data Etiologic Problems
Subyektive:
The patient said the
fever had gone up and
down had been 5 days
TTV The process of traveling
the disease Hipertermi
TD: 110/70 mmhg
N: 89x / minute
T: 39.5 C
RR: 24x /
minute
Obyektive :
The patient's body
feels hot
Dry lip mucosa
Enough skin turgor
The patient looks
nervous and weak

B. PLANNING (SHORT AND LONG TERM GOALS)

1. Monitor temperature as often as possible
2. Monitor skin color and temperature
3. Blood pressure monitor, pulse and RR
4. Monitor decreased levels of consciousness
5. Monitor WBC, Hb, and Hct
6. Monitor intake and output
7. Give anti piretik:
8. Manage Antibiotics
9. Cover the patient
 10. Give intravenous fluids
11. Compress the patient on the groin and axilla
12. Increase air circulation
13. Increase intake of fluids and nutrients
14. Note blood pressure fluctuations
15. Monitor hydration such as skin turgor, mucous membrane moisture

c. IMPLEMENTATION:
Measuring temperature, pulse, patient's blood pressure, Encourage patients to drink
plenty of water, Gives regular water compresses on the axilla and forehead, Involve
the family in planning patient meals by persuading patients to eat, Assess patient
patterns and eating habits, View and pay attention to how much food is spent from the
portion provided, Encourage families to give small but frequent meals
Re-observe vomiting Collaborating with doctors in the provision of antipyretic and
antiemetic therapy, namely paracetamol 500mg, mucosta tab, allinamin tablets.

d. EVALUATION:
S:
The family said it had compressed the client dry once in 10 minutes
The patient said he had drank a lot of white since earlier
The patient says he is still nauseous and wants to vomit after eating
O:
 The client's mother feeds the client while eating
 Food served is spent ¼ portion
 The patient looks weak
 TD: 110/80 mmhg
 N: 88x / minute
 T: 38.5 C
A:
Problems 1 and 2 have not been resolved

P:
 Advanced intervention:
 Monitor skin color and temperature
 Blood pressure monitor, pulse and RR
 collaboration with antibiotics, antiemetics and antipyretics
 Give compress
 Monitor hydration such as skin turgor, mucous membrane moisture)
 Monitor nausea and vomiting
 Monitor paleness, redness, and dryness of conjunctival tissue
 Encourage drinking
 Maintain IV line therapy