CASE REPORT

NURSING CARE OF An. A WITH STIFF

IN THE C1L1 (PEDIATRIC WARD)
DR. KARIADI HOSPITAL SEMARANG

Arranged By:

Puma Adi Rosiyanto

1.1.10497

NURSING STUDY PROGRAM

HEALTH POLYTECHNIC OF SEMARANG
2007

CASE REPORT
NURSING CARE OF CHILDREN WITH STIFF
IN THE PEDIATRIC WARD DR KARIADI HOSPITAL SEMARANG
ASSESSMENT
Date of assessment

: March 14, 2007

Practitioner

: Puma Adi R

Time

: 09.00

SRN

: 1.1.10497

Room

: C1L1 Pediatric Ward

Registered Number

: 5479586

Identity
Name

: An. A

Age

: 7 Years Old

Sex

: Male

Ethnic/Nation

: Java/ Indonesia

Religion

: Moslem

Education

: Primary School

Profession

: Student

Address

: Bangsri, Jepara

Time of Entry

: March 7, 2007

Guarantor
Name

: Mr. S

Age

: 38 Years Old

Relation with patient : Father

Sex

: Male

Ethnic/Nation

: Java/ Indonesia

Religion

: Moslem

Education

:-

Profession

: Civil Servant

Address

: Bangsri, Jepara

NURSING HISTORY
Chief Complaint
Family of patient said that her son was stiff
Present Nursing History
Since + 2 days before entering hospital patient have fever, headache and suddenly
was stiff. And then family and patient go to the doctor. After do not have good result,
patient reconciliated to Kariadi Hospital
Past Nursing History
Patient does not have disease like Diabetes Mellitus, Hypertension, or another
descends disease.
Family Health History
There is no family members that have other wafting or contagion disease. There is
no family that experience of same disease.
Genogram
GENOGRAM

Keterangan :
Laki- laki
Perempuan

Pasien
Tinggal serumah

Meninggal

Growth Assessment
Head circumference

: 46 cm

Upper arm circumference

: 19 cm

Development Assessment
Tengkurap: 4 months old
Ngremeng 5 months old
Merangkak 5 months old
Jalan tertatih-tatih 1 years old
Jalan lancar 1 years 7 months old
FUNCTIONAL HEALTH PATTERNS
1.

Perception and health management pattern

If An. A is sick, he is spoiled and crying. Family said that if gets sick, he will go
to the doctor or public health center. He never goes to the midwife, nurses, or
indigenous medical practitioner.

2.

Nutrition pattern
An. A eats three times a day, but he is very difficult if to eat. His food is a plate of
rice, vegetables, etc. he does not have prohibition food. And drink approximately 8-9
glass a day. Now in the hospital, his food is like in the home. But he only consume
2/3 portion. Patient discharged NGT. Patient drink + 3 glass of water and + 2 glass of
milk from hospital.

3.

Elimination pattern
An. As fecal elimination is once a day regularly. Its consistency is solid,
yellowness, and its smell is specifically. Then his urine elimination is not fixing based
on the intake of fluid and activities. After in the hospital, when assess patient has not
defecate since 3 days. Source of other output is from sweat.

4.

Exercise and activities pattern

Before sick, patients activities can do by his self. After sick now, all of patients
activities helped by his family because patient have decrease of consciousness.

5.

Sleeping and rest pattern

Before sick, An. A sleeps 8 hours a day every night. It starts from 21.00 until
05.00. An. A usually sleeps in the noon. It is about 1-2 hours start from 13.00-15.00.
After sick, patient lay down in his bed everyday because have decrease of
consciousness.

6.

Cognitive perception pattern

Patients sight decrease, patient can hear because when we are talking can give
response but patient speak unclear.

7.

Self concepts and perception pattern

Can not be assess

8.

Role and relationship pattern

An. A is the first child of two children in the family. He is very near with his
friends and his family. His family always in hospital to accompanied him.

9.

Reproduction and sexuality pattern

An. A is male and have not maried

10.

Coping stress pattern

An. A if feel pain just crying.

11.

Value and believe pattern

An. A is a Moslem. He had Religion education since he hasnt study in school.
Now he can pray with sitting on the bed.

PHYSICAL ASSESSMENT
Consciousness
Vital signs

: GCS: E4 M6 V4 14

: RR= 30 x/minute
Pulse= regular
Body Temperature= 384 0C
HR

Skin

: 110 x/minute

: skin turgor is bad, look pale, there is no cyanosis, skin color is yellow and
clean, there is no hiperpigentasi or hipopigmentasi,.

Head : mesosephal, little dirty, the smell is not bad, hair color is black but it is not
easy to pull.

Eyes

: symmetric, conjunctiva palpebra is anemic, sclera is not icterik, eyes

movement is symmetric.

Nose : symmetric, there is no secret, clean, there is no cuping hidung breathing, and
there is no polyp.
Ears : symmetric, clean, there is no cerumen, listen reflects is positif,
Mouth: the lips are not cyanosis, mouth mucosa is humid, the smell is not bad, there is
no stomatitis.
Neck : there is no larger or thyroid gland, there is no JVP distention.
Chest: inspection
Palpation

: the form is symmetric, there is no tumor

: chest movement is symmetric, focal fremitus is higher on the lung
area, and lower in the perifer of lung, ictus cordis is in midclavicle
4-5

Percussion

: the sound is sonor

Auscultation : vesicular sound on the lung area, there is no heart sound addition
Stomach/ abdomen : mengembung, intestine sound is 7/ minute, there is no pain
pressure.
Upper extremity

: there is IV line in the right arm; patient can move all the hand

Lower extremity

: there is no edema

SUPPORT ASSESSMENT
Laboratory test

: March 12, 2007

Analyzer hema

Normal

Hemoglobin

11.10 gr %

10,5 15,0

Hematokrit

31,6 %

36,0 44,0

Eritrosit

3.96 jt/mmk

4.00 5,20

MCH

28.00 pg

23,0 31,0

MCV

79.70 fe

77,0 101,0

MCHC

35.10 g/dl

29,0 36,0

Lekosit

10.10 A/mmk

6,0 15,0

Eosinofil

1%

1-5

Basofil

0%

0-0

Batang

1%

2-5

Segmen

75%

25-70

Limfosit

20%

30-40

monosit

3%

4-8

trombosit

300.0 ribu/mmk

150.0-400.0

glukosa sewaktu

84 mg/dL

80-110

ureum

13 mg/dL

15-39

creatinin

0.33 mg/dL

0.60-1.30

natrium

132 mmol/L

136-145

kalium

3.7 mmol/L

3.5-5.1

chlorida

98 mmol/L

98-107

calcium

2.17 mmol/L

2.12-2.52

Hit jenis

kimia klinik

elektrolit

Therapy Program
Infuse D 5% 960/40/10 tpm
+ NaCl 5% 28 cc
+ KCl

dalam 500 cc D5%

15 cc

Injeksi cefotaxime 3 x 1 gr IV
Streptomisin 1 x 375 mg
Dexametason 3 x 5 mg
Diazepam
PO

7.5mg IV bila kejang

PCT 3 x 150 mg

OAT INH 150 mg

PZA 300 mg
Vit. B6
Rifampisin 250 mg
Luminal 2 x 35 mg
Diet 6 x 100 cc vitaplus

DATA ANALYZE
Name

: An. A

No. Register : 5479586

NO Date/time
Focus Data
Etiology
1
March 14, DS : - family
said
that nutrition
2007
patient always ask to Malabsorbsi
10.00
family to give him

Risk

Problem
Initial
of
nutrition

change lack from body

need

food and drink

DO : - patient look weak
- pale
- skin turgor is bad
- discharged of NGT
2

March 14,
2007
10.00

DS : - family said thatpatient

Remitten fever

intolerant activity

body is weak
DO : - patient lay down in
the bed

Hipertermi

-Patient look weak

-His body is warm = 384

Easy to fatigue

March 14,
2007
10.00

DO: - patient weak

-temp : 384 0C
- uncontroled stiff

intolerant activity
activity of stiff

High risk of injury

NURSING CARE PLAN

Name

: An. A

No. Register : 5479586

No
1

Date/Ti
me
March
14,
2007

Dp
Risk

of

Purpose

Intervensi

nutrition After get nursing care for 1 x a. give alih baring

change lack from 24 hours patient can fulfill b. suggest

body

Initial

need

r.t. need of nutrition with criteria

nutrition

result of:

Malabsorbsi

Patient
Body

eat

rest

before have meal

with d. make

weight

good

environment to take food

is e. explain

stabile
-

take

c. doing oral hygiene

medium portion and often

-

to

about

the

important of adequate

Patients condition is

nutrition

not weak

March
14,
2007

intolerant activity

After get nursing care for 1 x a. give tirah baring and

r.t. increase of

24 hours patient can do

metabolism need

activity with criteria result

secunder to acute

of:

infection

give good environment

limit the visitor

patient

can

do b. often change the position

activity as usual

c. suggest do activity that

appropriate

with

tolerance
d. give
3

March
14,
2007

High risk of injury

r.t.
activity of stiff

appropriate

entertainment activity
After get nursing care for 1 x a.evaluate need of
24 hours injury can not

protection in patients

happen with criteria result

head

of:
-

b.explain to family
there is no lesion in

patients body

important of giving
protection
c.collaboration giving
medication (diazepam,
Glucose)

NURSING NOTE
Name

: An. A

No. Register : 5479586

Date/

DP

Implementation

initi

Response

Time
March - doing tirah baring
- Patient can do this
15,
2007
11.00 - suggest to take rest before have - Patient can take a rest
- Patient eat the food
meal

with

- make a good environment to take

good

environtment

food

- Family
explanation

- explain about the important of

heard
from

nurse
adequate nutrition
March - give tirah baring and give good - family cooperative
16,
environment limit the visitor
2007
10.00 - often change the position
- family can do this

- suggest do activity that appropriate - patient do it

with tolerance
- give

appropriate

entertainment - patient can not enjoy

activity
it
March - evaluate need of protection in Need giving the pillow
16,
patients head
2007
11.00 - explain to family important of Family undestand about

giving protection
- collaboration

giving

it
medication Thre is no sign of

(diazepam, Glucose)

PROGRESS NOTE
Name

: An. A

No. Register : 5479586

alergi, patient comfort

al

Date/Time
March 15,
2007
11.00

DP
Risk of nutrition change

Progress Note
S : family said that patient still ask to family to

lack from body need r.t.

nutrition Malabsorbsi

give him food and drink

O : patient can eat 2/3 portion
Patient still look weak
Patient look hungry
A : some of problem can be solved
P : continuing intervention
- make a good environment to take food

March 16,
2007
10.00

intolerant activity r.t.

S : family said that patient still weak

increase of metabolism

O : Patient still look weak

need secunder to acute

Patient lay down in his bed

infection

A : some of problem can be solved

P : continuing intervention
March 16,
2007
11.00

High risk of injury r.t.

activity of stiff

suggest do activity that appropriate with

tolerance
S : family said that in patients head there is
pillow
O : there is no lesion
A : problem solved
P : stop intervention

Initial