A.

ASSESSMENT
1. Data Collection

a. Client Identity
Name : Tn.N
Age : 18 years old
Gender : male
Education : SMK
Job :-
Religion : Islam
Tribe / Nation : Sunda / Indonesia
Marital Status : Not Married
Address : Kp.Cisaranten Rt03 / 01
Admission Date : September 25, 2014
Date of Review : September 26, 2014
Medical Diagnosis : DHF

b. Identity of Responsible Person

Name : Tn.W
Age : 39 Years
Job : Entrepreneur
Education : High School
Gender : Male
Religion : Islam
Address : Kp.Cisaranten Rt03 / 01
Relationship With Clients: Dad

c. Medical history
1. Current Health History
Clients complain of fever, no appetite, nausea and weakness, since 5 days ago, the
client on minikan febrifuge but no improvement
o Major Complaints During Hospital Entry
Client complained already 1 hot week the body did not go down
o Major Complaints When Assessed
The client said that the client complained of heat, felt in the flush of hot water and
felt in the whole body S: 38˚C at night
2. Past Health History
The client's family says that the client has never experienced the disease as it was in his
pain
3. Family Health History
The client's family says no other family member has the same illness as the client

d. Physical examination
1. General Client Condition:
 Appearance: Composmentis
 Vital sign:
- TD: 100/60 mmHg Temperature: 38,3˚C
- Respiration: 20x / minute pulse: 78x / min
2. Skin: Sawo is ripe, skin turgor is poorly proven in <3s
3. Head and Hair
 Head
Shape : Spherical, Symmetrical
 Hair: Distribution: Evenly distributed
Color : Black
Cleanliness: Clean
Rebound : Do not fall out
4. Face and Neck
 Face : Shape: Symmetrical
 Color : Redness
 Lesions : None
 Traumatic Former : None
 Neck : Symmetrical no bumps
5. Eyes
 The shape of both eyes : Symmetrical
 Kongjungtiva : Pale
 Pupil : Right
 Sklera : White color
 Light reflection : Fine, reflex pupils of light are proven when the pupil
light contracts and when the light in the pupil dilates dilated
 Vision function : Normal (client can read newspaper with distance less
than 25cm)
6. Ear
 Shape : Symmetrical
 Cleanliness : Clean
 Hearing Function : Normal, the client can hear the sound / sound
7. Nose
 Nose shape : Symmetrical
 Lesions : None
 Secret : There is, liquid mucus and no impurities
 Nose Mucosa : Slightly reddish
 Cleanliness : There is no dirt
 Smell function : Normal, the client can distinguish the smell of eucalyptus and
the smell of perfume
8. Mouth
 The shape of the lips : Symmetrical
 Circumcision : Dry, cracked
 Teeth : Complete amount of 32 Fruits
 Tongue : Clean
 Taste Function : Clients can taste sweet, bitter, sour and salty
9. Chest
 Shape : Symmetrical
 Pulmonary breathing : Vesicular (low pitched)
 Pulmonary percussion : Resonant (normal lung percussion sound)
 Breathing pattern : Regular (regular)
 Pulmonary expansion : Balanced
 Heart Rhythm : Regular (regular)
 10. Abdomen
 Shape : Symmetrical
 Tenderness : None
 Bowel sounds : 14x / min
 Lesions : None
11. Repreductions
 Genetal state : Clean
 Lesions : None
 Catheter : Not installed
 Hemoroid : Nothing
12. Up / down extremities
 Top:
Shape : Symmetrical and complete
Nail circumstances : Short, clean
Movement : Limited in left hand due to impregnated infusion 30gtt / min
intravenous fluid Ringer Lactate, muscle strength (4/5 4 5
 Bottom: Shape: Symmetrical and complete
Nail circumstances : Short net
Movement : Unlimited but weak, normal patellar muscle reflex (+ / +) is
evident with stimulation using a direct hamer reflex to move the
reflex forward, muscle strength (5/5)
e. Psychological Data
 Emotional Status : Client's emotions seem stable, proving the client is always calm
 Anxiety : Clients look a little anxious
 Koping Pattern : The client says leave it completely to the medical team about
the condition of the illness. In solving problems clients often ask for help from others
 Communication Style: Client can communicate well
 Self Concept
 Self-image : The client appears patient in accepting the pain in suffering
 Self-Esteem : Clients want to get home quickly to reassemble with family and
friends
 Role : Clients act as the 1st child of 2 siblings
 Self Identity : The client is male, the client feels helpless
 Ideal Self : Clients can interact with student nurses
f. Social Data : Clients say want to get well soon to get school as usual
g. Spiritual Data
 Implementation of worship : Selamadi care for clients perform worship in bed
 Trust / Religion : Confident (Clients pray a lot
h. Supporting data
No Types of Checking result Normal Unit
1 Hemoglobin 15,5 g/dl L: 14-17, P: 12-16 g/dl
2 Leukocytes 3,500/mm Adults: 4.000-10.000 /mm
3 Pcv 40% 40-50% %
4 Platelets 31.000/mm 150.000-450.000 /mm
 Medical therapy
• Ringer Lactate Infusion 30gtt / min
• Ceftriaxone (including class of cephalosporin / belactam antibiotics) 2x1 g injection (iv)

i. Program and treatment plan

No Type of Drug How to Administer Jam Function of Drugs
pemberian
1 Paracetamol Oral 07.30 febrifuge, painkillers
2 Antipiretik Oral 07.30 Reduces body temperature, lowers heat
3 Imunos Oral 07.30 To stimulate the body's immune system
4 Ondansentron Injeksi 08.00 Reduces nausea

2. DATA ANALYSIS
No Data Interpretasi (penyebab) Masalah
1 Ds: - Clients complain of disease process hypertermi
body heat
Do: - The temperature of
the client is 38˚C
- Clients seem limp

2 Ds: - Clients complain of nausea Impaired nutrition

nausea fulfillment is less than
Do: - The client looks requirement
nauseous
- Bowel sound 14x /
minute

3. Diagnose Nursing
No Diagnose Nursing Date found
1 increased body temperature associated with 26-09-2014
disease process
2 Impaired nutritional needs are less than the 26-09-2014
need for nausea
 B. PLANNING
Diagnose aim intervention
increased body After the nursing action is  Observation of TTV
temperature expected normal body  Encourage clients to drink extra
associated with temperature with 36˚C- 200cc every 1 ° C rise in
disease process 37˚C client temperature temperature
criteria  Encourage warm compresses
 Encourage wearing a thin suit and
easy to absorb sweat

Impaired nutritional After the nursing action is
needs are less than expected the client's
the need for nausea nutritional needs can be
met with the criteria:
• The client does not
complain of nausea
• Normal bowel sounds
• Eat 1 serving
 Serve the food in warm form
 Encourage clients to eat small
portions but often
 Encourage clients to eat distractions
such as biscuits

C. evaluation

No dx Evaluation Initial
1. S:Clients say the body temperature is reduced -
O: Body temperature 37.3˚C
A: Partially resolved problem
P: Continue interventio

2. S: Client says nausea -

O: Food portion ¾ exhausted
A: Partially resolved problem
P: Continue intervention