EMERGENCY NURSING CARE OF TN.

“K”, A PATIENT
WITH MEDICAL DIAGNOSIS SUSPECT DHF GRADE 1
IN THE TRIAGE MEDICAL ROOM M.DJAMIL PADANG HOSPITAL
JANUARY 15, 2019

1. Nursing Assessment

▪ Date of entry : January 15, 2019

▪ Hours of entry : 12:00 p.m.
▪ Hospital : RSUP Dr. M. Djamil
▪ No.RM : 09875
▪ Date of study : January 15, 2019
▪ Client name : TN. K
▪ Age : 28 years old
▪ Gender : Male
▪ Job : Entrepreneur
▪ Education : High School
▪ Marital status : Not married
▪ Address : Jl. Marapalam No. 98 Padang
▪ Name of person in charge : TN. P
▪ Main complaint
A patient come with fever, nausea, vomiting and decreasing both appetite and drink,
with dizziness and pain in the head and joints scored 5 (0-10 scale) as pressed

 History of the disease

Patient complained a fever from 3 days ago, the body also felt sore and pain in the head.
Patient said this feel it when waking up. Due to unresponsive treatment , patient going to
RSUP Dr. M. Djamil Padang
 Past medical History :
Patient's family said that the patient never had any illness before
 allergy history:
Patient said that he had never experienced of drug allergies
 a.Primary Survey
1. Airway
After the airway examination there is no obstruction or interference on patient’s airway

2. Breathing
Patient is spontaneously breathing without interruption or using breath assist devices

3.Circulation
▪ Pulse: Patient’s pulse strong ; 80x / minute
▪ CRT: Returns to normal in less than 2 seconds
▪ Skin color: normal client's skin is not pale or dry
▪ Bleeding: There is no bleeding in the client
▪ Skin turgor: patient’s skin turgor is good

4.Disability / neurological
▪ Response: Conscious
▪ Pupil: isocorous pupil (both side)
▪ Reflex: normal reflex
▪ GCS : E4 V5 M6
A. Secondary Survey
General condition
 Consciousness : Composmentis
 Weight : 65 kg
 Height : 170 cm
 Vital Signs :
- BP : 110/80 mmHg
- P : 80 x/minutes
- RR : 20 x/minutes
- T : 38,1 0C
Diagnose : Suspect DHF grade I

Falls Risk Assesment

Date 17/09/13 17/09/13
No. Item Point Time 08.00 09.00
Score IA 1
1. Age
a. Less than 60 years 0
b. More than 60 years 1 0 0
c. More than 80 years 2
2. Neurologic deficit
a. Not bifocal glasses 0
b. Bifocal glasses 1
 c. Hearing disturbance 1 0 0
d. Multifocal glasses 2
e. Cataract/glaucoma 2
f. Unable to see 3
3. ACTIVITY
a. Independent 0
b. DLA helped a bit 1 1 1
c. Fully helped DLA 2
4. PAST FALL HISTORY
a. Never 0
b. Fallen <1 year 1 0 0
c. Fallen <1 month 2
d. Fall and recently at hospital 3
5. COGNITION
a. Good Orientation 0
b. Hard to understand order 2 0 0
c. Memory Disorder 2
d. Confusion 3
e. Disorientation 3
6. THERAPY AND MEDICAL TOOL’S USAGE
a. <4 kind of therapy
b. Antihipertension/hipoglycemic/antidepressant 1 1 1
c. Sedative/psychoactive/narcotic 2
d. Infusion/epidural/spinal/dower catheter/traction 2
2
7. MOBILITY
a. Independence 0
b. Using walker tool 1
c. Worse balance 2
d. A bit Aid 3 0 0
e. Fully aid/bed rest/nurse assist 4
f. Environment with full of furniture 4
8. URINATION AND FECAL
a. Routine 0 0 0
b. Incontinence urine/feces 1
c. Nocturia 2
d. Urgency/frequency 3
9. COMORBIDITY
a. Diabetes/heart disease/stroke/UTI 2 -
b. Central nervous system disorder/Parkinson 2 -
c. After Surgical treatment 0-24 hour 3
All score 2 2
Note :
 Low Score 0-7 √ √
High Score 8-13
Very high Score ≥14

 Complementary Diagnostic Test

- Laboratorium Test
Blood test result at 20 September 2013
Test Result Normal Units
WBC 1,55 5,2 – 12,4 10e3 / µL
HGB 14,1 14 - 18 g / dL
HCT 38 42 - 52 %
PLT 98 130 - 400 10e3 / µL

- Medical Therapy
 Infuse NaCl : 15 tpm
 Paracetamol : 3 x 3
 Ondamcentron : 3 x 8 gr

I. NURSING DIAGNOSE
A. Data Analysis
No. Data Etiology Problem
1. DS : Patient feel fever since 3 Dengue Virus Thermoregulation
days and not comfortable with it ↓ problem :
DO : Viremia hyperthermia
- Vital Sign : ↓
 BP : 110/80 mmHg Hypotalamic
 P : 80 x/menit Response
 RR : 20 x/menit ↓
 T : 38,1 0C Hyperthermia
2. DS: Patient feel pain like Virus Pain
pressed head and joints ↓ uncomfort/disorder
Viremia
DO : ↓
- Pain score 5 (score 0-10) Pathology of disease
- Patient grinned ↓
Pain

3. DS : Patient feels vomit and Hyper permeability Nutrition

nausea membrane receivement
↓ disorder: Less than
DO : Plasma leakage to normal intake
- Patient feels vomit and extravascular
nausea abdomen
- Patient feels limp ↓
Vomit and nausea
↓
 Nutrition receivement
disorder
4. DS : Patient feels less urge to Viremia High risk liquid
drink ↓ volume deficit
Hyperthermia
DO : ↓
- Patient feels vomit and Increasing
nausea permeability of blood
- Patient feels limp vessel
- Body temperature = 38,1o C ↓
- Mucous on lips not dry High risk liquid
volume deficit

B. Summary
1. Thermoregulation disorder: hyperthermia correlated with viremia, its sign consist
of fever in 3 days, Vital sign : BP : 110/80 mmHg; P : 80 x/min; RR : 20 x/min
and T : 38,1 0C
2. Pain uncomfort/disorder correlated with disease pathology process with pain over
patient’s head and joints. Scored by 5 (score 0-10), patient also grinned due to that
3. Nutrition receivement disorder: Less than normal intake correlated with vomit and
nausea, make the patient limp
II. INTERVENTION
a) Prior Problem
 Thermoregulation disorder: hyperthermia
 Pain uncomfort/disorder
 Nutrition receivement disorder: Less than normal intake

b) Plan
Day/ Dx Goal Intervention Reason
Date
15 I After treated 1.Correlate fever 1.Identify fever pattern
Janu within 15 minutes 2.Vital sign observation 2.Vital sign is an indicator toward
ary Thermoregulation (temperature, blood patient’s condition
2019
disorder: pressure,pulse, 3.Patient should drink a lot of water
hyperthermia in respiration rate) due to side effect of vaporizing in
patient reduced within 3 hour. patient’s body because increased
with normal 3.Educate patient to body temperature
criteria: keep drink water 4.Vasodilatation increase vaporizing
- Patient feels (2,5 litre/24 hours.±7 process so able to reduce body
comfortable glass) temperature
- Normal Vital 4.Warm compression 5.Thin cloth allow patient’s
Sign. 5.Educate patient to not vaporizing slow down
wearing thick cloth / 6.Liquid giving should be done to
blanket. patient with high fever condition
6.Collaborate with
doctor’s programme
toward patient’s
therapy
15 II After treated 1.Correlate pain 1.Identify intensity of patient’s pain
janu within 10 minutes 2.Make patient rest in 2.Reduce the pain
ary pain his/her comfort 3.With relaxation, patient able to
2019
uncomfort/disord position and forget the pain
er in patient environment 4.Analgetic can press and reduce the
reduced with 3.Educate patient how pain symptoms
normal criteria: to relax
- Patient feels 4.Analgetic
comfortable
- Pain score
scale within 0-
3
15 III After treated 1.Observe vomit, pain 1.Decide how to settle the symptoms
janu within 10 minutes and nausea in patient 2.Step of food reserved for patient
ary nutrition 2.Observe food induce patient’s will to eat
2019
receivement reservation for patient 3.Help patient to reduce limp
disorder: Less 3.Give patient easy- sensation
 than normal digest food such as 4.Reduce vomit and nausea sensation
intake in patient pouridge 5.To know nutrition need on patient
reduced with 4.Give small portion of 6.Antiemetic help patient to reduce
normal criteria: food in frequent vomit and nausea symptoms
- Patient able to 5.Write down daily
eat based on food portion of
his/her daily patient
intake 6.Collaborate with
- Patient not doctors regard
feeling limp antiemetic drug.

15 IV After treated 1. Observe patient’s 1.Identify patient’s problem

janu within 10 minutes condition (Limp, 2.Evacuate shock symptoms
ary High risk liquid pale, takikardi) and immediately
2019 volume deficit in vital sign. 3.Intravenous is important for take
patient reduced 2. Observe shock care less body liquid directly from
with normal symptoms blood vessel
criteria: 3. Give intravenous 4.Liquid needed to increase body
- Moist lips liquid volume
- Normal 4. Educate patient keep 5.To identify liquid balance
temperature drink a lot
- Good Intake 5. Count intake and
output.
III. IMPLEMENTASI KEPERAWATAN
Nama klien : Tn.”K”
Umur : 28 tahun
No. RM : 09875
Hari/ Dx Jam Implementasi Respon hasil Paraf
tanggal
15 january I 12.20 1.Identify fever pattern 1.Patient feel fever
2019 since 3 days and not
WITA 2.Vital sign is an indicator
toward patient’s comfortable with it
2.Vital Sign :
condition
 BP :
3.Patient should drink a
110/80 mmHg
lot of water due to side  P : 80 x/menit
effect of vaporizing in  RR : 20
patient’s body because x/menit
increased body T : 38,1 0C
temperature 3.Patient said will drink
4.Thin cloth allow a lot
patient’s vaporizing 4.Patient seems to
slow down follow the instruction

15 january II 12.30 1.Correlate pain 1.Pain Scale Score 5

2019 2.Make patient rest in (Score 0-10)
WITA
his/her comfort position 2.Patient comfortable in
and environment semi-fowler position
3.Educate patient how to 3.Patient antusiast and
relax able to do relaxation
technic

15 january III 12.40 1. Observe vomit, pain 1.Patient still feel vomit
2019 and nausea in patient and nausea
2. Give small portion 2.Patient will eat in
of food in frequent small portion but
3. Write down daily frequent
food portion of 3.Patient eat 1 until 1 ½
patient plate daily

Jum’at, IV 12.50 1. Observe shock 1.Patient doesn’t have

15 januari symptoms shock symptoms
2019 2. Give intravenous
liquid 5.Patient said will drink
3. Educate patient a lot
keep drink a lot
4. Count intake and 2.Patient drinks 3 until
output. 4 glasses daily and
 urinate 300 - 400 cc

3.Patient receive:
 Infuse NaCl : 15
tpm
 Pct 3 x 3
 Ondamcentron : 3 x
8 gr
IV.EVALUATION
Patient name : Tn.”K”
Age : 28 tahun
No. RM :

Hari/ta Dx Jam Catatan Perkembangan Paraf

nggal
15 I 14.00 S:
january WITA Patient feels fever and uncomforable
2019
O:
- Vital Sign :
 BP : 110/70 mmHg
 P : 78 x/min
 RR : 21 x/min
 T : 37,9 0C

A:
Thermoregulation disorder: hyperthermia not
treated

P:
Continue to treat

15 II 14.00 S:
january WITA Patient still feels pain in head and joints
2019
O:
- Pain scale score 4 (score 0-10)
- Patient is grinned

A:
Pain uncomfort/disorder treated a bit

P:
Continue to treat

15 III 14.00 S:
january WITA Patient still feels nausea but not vomit
2019
O:
- Patient still nausea without vomit
- Patient still feels limp
A:
Problem solved without vomit
P:
Continue to treat
15 IV 14.00 S:
january Patient will try to drink a lot
2019
O:
- Patient already drink frequently in low amount
- Patient still nausea
- Patient still limp
- Body temperature = 37,9o C
- Lips not dry

A:
High risk liquid volume deficit problem treated a
bit
P:
Continue to treat