NURSING CARE of Child.

Y WITH
THERMOREGULATION DISORDER: HYPERTERMIA
at SHOFA ROOM OF THE HOSPITAL PKU
MUHAMMADIYAH CEPU
Supporting Lecturer : English Team

Arranged By :
Name : Uji Maulana Hadi
Grade : 2 A
NIM : (P1337420417057)
 CHAPTER II
CASE REVIEW

Student Name : Uji Maulana Hadi

Place of Practice : Shofa Room PKU Muhammadiyah Cepu Hospital
Practice Date : November 5, 2018. 01:15 p.m
• ASSESSMENT
1. Biodata
▫ Patient Identity
Name : Child. Y
Age / Date Of Birth :15 years old / August 22, 2003
Work :-
Education : Vocational High School
Gender : Female
Religion : Islam
Address : Karanganyar Rt05/Rw08 Randublatung, Blora
Date of Hospital Admission : November 5, 2018 at 12.00 a.m
Date of Review : November 5, 2018 at 01.00 p.m
Registration Number : 135688
Medical Diagnosis : DHF
• Identity of the Person Responsibility
Name : Mrs. D
Age : 45 years old
Work : Entrepreneur
Address : Karanganyar Rt05/Rw08 Randublatung,
Blora
Family Relationship : Mother

2. Main Complaint
The patient complained that her body felt hot since five days ago,
accompanied by nausea, vomiting and dizziness a day ago
3. Medical History
The patient came to the emergency room at PKU Muhammadiyah
Cepu hospital on November 5th 2018 at 12.00 a.m with her body
complaints feeling hot since five days ago. The patient said nausea
vomiting after eating one day ago. The patient also said his head
was dizzy when used to stand too long. From the results of the
examination in the emergency room obtained data, vital signs of the
patient are :
Blood Pressure : 90/60 mmHg, Pulse : 120 x/minute, Respiratory
Rate : 20 x/minute, Temperature : 400C, Weight : 48 kg. Therapies
obtained include ringer lactat infusion 20 drops/minute, injection
of Ranitidine 2x1 (1 amp/2ml), Parachetamol tablets 3x1 (500 mg).
The patient is taken to the shofa room (room number 1) at 12.30
p.m with the condition attached to the Ringer Lactat infusion 20
drops/minute, in the left hand. From the results of the examination
obtained data, the patient's vital signs are : Blood Pressure : 97/55
mmHg, Pulse : 122x/minute, Respiratory Rate : 20 x/minute,
Temperature : 40,50C.
4. Past Medical History
The patient said he did not have a history of decreased disease such as
asthma, militus diabetes, tuberculosis, hypertension, heart disease and
others.

5. Family Health History

The patient's mother said there was no family member who had a history
of decline, such as asthma, tuberculosis, diabetes mellitus, hypertension,
heart disease, etc.

6. Physical Examination
▫ General condition of the patient : Weak
▫ Level of consiosness : Composmentis, GCS: 15, E4V5M6
▫ Height : 154 cm
▫ Weight : 48 kg
• Vital Signs are
Blood Pressure : 97/55 mmHg
Pulse : 122 x/minute
Respiratory Rate : 20 x/minute
Temperature : 40,50C
• Head
Shape : Mesochepal
• Eye : The conjunctiva is not anemic, isocorous pupil, the sclera is
not jaundiced, and do not use assistive devices.
• Nose : no polyps, no secret
• Ears : There is no hearing loss, there is no cerumen.
• Mouth : Pale lips, dry lips mucosa, clean teeth.
• Neck : No enlargement of the thyroid gland.
• Thorax : I = The shape of the chest is symmetrical, the frequency of
breathing is regular and there are no injuries.
P = No lumps, tympanic.
P = No tenderness
A = Normal sound S1 S2 heart.
• Abdomen
Shape : Symmetrical
Peristalsis : 10 times per minute
Percussion : Thympani
Palpation : No tenderness

• Extremities
Upper limb : left hand attached ringer lactat infusion 20 drops per
minute, no swelling, nails of the left hand thumb long.
Lower extremity : no swelling, no lesions, good skin turgor.

7. Assessment of Functional Patterns According to Gordon

 Patterns of Perception - Health Management
The patient said that he had high blood pressure for the first time up to
five days and don’t know how to handle it.
 Nutrition - Metabolic Pattern
Before getting illness: the patient says he eats 2 to 3 times a day, menu
that patient like include vegetable soup and rice. The patient said he had
no history of food allergies. The patient says he drinks 200 cc of water a
day.
During illness : The patient says he eats 3 times a day with the hospital
menu and only consume half a portion.
 Elimination Pattern
A. Defecation Elimination
Before getting illness : The patient defecate twice a day with the
consistency of soft stool, yellow stool colour.
During illness : The patient says he defecate once a day with consistency
of soft stool, black colour and frequency of feces around 200 cc.
B. Urine Elimination
Before getting illness : the patient says urinating 5 to 6 times a day with
the colour of yellow urine, urine frequency 1500 cc a day
During illness : the patient says urinating 3 to 4 times a day with the
colour of yellow urine, urine frequency 1000 cc a day
 Activity Training Pattern
Before getting illness : The patient said before being sick, he could carry
out daily activities independently
During illness : The patient said during illness, when he was going to the
bathroom, he was told by his mother.

 Perceptual Pattern
Perceptual sensory : the patient says dizziness in the head when he wants
to get up from the bedroom, his body is hot since 5 days ago accompanied
by a little nausea and vomiting.
Cognitive perceptual : the patient says already know what dengue High
Fever is, because there are many people who suffer from the same disease
in the area where they live. however, both patient and families do not
know how to treat and prevent Dengue High Fever.
 Sleep Rest Pattern
Before getting illness: the patient says his sleep is always sound, with a
frequency of sleep 8 hours a day.
During illness: the patient says his sleep is disturbed and often wakes up
when he feels his body is hot, the patient says he has just slept for 2 hours,
then wakes up.

 Self-Concept Pattern - Self Perception

The patient said he was anxious about him, especially with his current
illness.

 Role-Relationship Pattern
The patient said the relationship with his family was fine and there were
no obstacles or problems.
 Reproductive Patterns
Patients are female and there are no problems with their reproductive
health.

 Coping-Mechanism Pattern
The patient still spends a lot of time resting and the family supports every
nursing action given.

 Pattern of Values-Beliefs
The patient said he was Muslim and prayed 5 times.
8. Therapy

▫ Asering infusion 20 drops / minute

▫ Injection of Ranitidine 2x1 (1 amp/2ml) : Intravenously
▫ Amoxillin (3x1) : Oral
▫ Aviter (1x1) : Oral
▫ Immunos plus (2x1) : Oral
▫ Paracetamol Tablet (3x1) : Oral
▫ Ulsafas Syrup (3x1) : Oral
▫ Methylpresmisolon (3x16mg) : Oral
▫ Kalnex (3x1) : Oral
9. Supporting Investigation
▫ Laboratory Examination
Results of laboratory tests on November 5, 2018
REFERENCE
HEMATOLOGY RESULTS UNIT METHOD
VALUE

Hemoglobin 13,8 12 – 14 g/dl Colorymetric

Hematocrit 39,4 37 – 43 % Analyzer

Leukocytes 2,03 4 – 10 103/ul Impedance

Platelets 79 150 – 400 103/ul Impedance

Erythrocytes 78 81 – 99 fl Analyzer

MCV 27 28 – 33 Pg Analyzer

MCH 35 32 – 36 g/dl Analyzer

MCHC 5,02 3,5 – 4,5 106/ul Impedance

Results of laboratory tests on November 6, 2018

REFERENCE
HEMATOLOGY RESULTS UNIT METHOD
VALUE

Hemoglobin 13,7 12 – 14 g/dl Colorymetric

Hematocrit 38 37 – 43 % Analyzer

Leukocytes 1,7 4 – 10 103/ul Impedance

Platelets 54 150 – 400 103/ul Impedance

Erythrocytes 4,85 81 – 99 fl Analyzer

MCV 78 28 – 33 Pg Analyzer

MCH 28 32 – 36 g/dl Analyzer

MCHC 36 3,5 – 4,5 106/ul Impedance

DATA ANALYSIS
No Date Data Cause Problem

1. November Subjective Data : process of hypertermia

5, 2018 The patient complained that her body felt hot disease or
since five days ago. infection
Objective Data :
 Vital Signs are
Blood Pressure: 97/55 mmHg
Pulse : 122x/minute
Respiratory Rate: 20 x/minute
Temperature : 40,50C
2 Subjective Data : Nutritional
The patient says nausea and vomiting. imbalance is less
Objective Data : than the body's
The patient's condition is weak needs
II. NURSING DIAGNOSES

1. Hypertermia associated with the process of virus infection

is characterized by the patient saying his body is hot since
five days ago, the general condition is weak, the patient's
vital signs : Blood Pressure : 97/55 mmHg, Pulse :
122x/minute, Respiratory Rate : 20 x/minute,
Temperature : 40,50C

2. Lack of nutritional imbalance from the body needs to be

connected with nutritional intake that is not strongly
connected with nausea and vomiting.
THANK YOU