NAMA : MUTIA ADELINE

NPM : 1614401110053
SEMESTER / PRODI : IV / D3 KEPERAWATAN KI
TUGAS : NURSING ENGLISH 2

PATIENT REGISTRATION FORM

Name : Baby N
Age : 2 years 4 months old
Address : Kurnia street
City, State : Banjarbaru, Indonesia
Phone : 08134533xxxx
Religion : Moslem
Marital Status : Unmarried
Health Insurance : BPJS
Primary Care Physician :-
Current Occupation and Title : Underage
Next of Kin : Mr. T (father)
Reason for Contact : Febrile Convulsion

PHYSICAL EXAMINATION
Weight = 11 kg
P = 140 x/minutes
RR = 32 x/minutes
T = 400C
Subjective Data
Client’s mother said “My son has a very bad fever, and after that he suddenly seizures about
once every fifteen minutes. Then he vomited once and defecated five times since this
morning”.
Objective Data
Client look weak because of his seizures. His face color was red and skin felt hot, the
temperature was 400C. Client defecated five times and the feces was liquid. Because he
always vomited and defecated, his skin and lips mucous is dry. Client’s bowel sound was 35
times per minutes because of the diarrhea.
P = 140 x/minutes, RR = 32 x/minutes, T = 400C, Weight = 11 kg,
 LABORATORY RESULT
Full blood count (FBC) Value Range Unit
Haemoglobin (Hb) 85 115 –165 g/L
Haematocrit (HCT) 0.24 0.37 – 0.47 L/L
White cell count (WCC) 5.96 4.0 – 11.0 109/L
Low platelet count (LPC) 357 100 – 400 109/L

1. Haemoglobin is low level in blood hae. lab results, eighty five grams per litre
2. Haematrocit is low level in blood hae. lab results, zero point two four litres per litre
3. White cell count is within normal limits, five point nine six times ten to the power
nine per litre
4. Low platelet count is unremarkable, three hundred fifty seven times ten to the power
nine per litre

DATA ANALYSIS
DATA ETIOLOGY PROBLEM
Subjective data: Infection process Hypertermia
Client’s mother said her son
has a very bad fever since
this morning.
Objective data:
His face color was red and
skin felt hot, the temperature
was 400C
Subjective data: Biochemical dysfunction Risk for injury
Client’s mother said after (hypertermia and
her son has a fever, he convulsions)
suddenly seizures about once
every fifteen minutes
Objective data:
Client look weak because of
his seizures
Subjective data: Active fluid volume loss Deficient fluid volume
Client’s mother said her son
vomited once and defecated
five times since this morning
Objective data:
Client defecated five times
and the feces was liquid. His
skin and lips mucous is dry.
Client’s bowel sound was 35
times per minutes because of
the diarrhea