Name: M.

Luthfianoor Ryfani NPM: 010 028 Day / Date of Assessment: Thursday, January 12, 2012 Rooms: Nilam Assessment A. IDENTITY A. IDENTITY OF CLIENT Name: Mrs. M Gender: Female Age: 22 Years Address: Saka Permai Education: Occupation: Housewife Marital Status: Married Religion: Islam Tribes / Nations: Banjarese Check-in: RS: 10 - 01-2012 Medical Diagnosis: Typhoid Fever No. RM: 149 370 2. IDENTITY OF PERSON IN CHARGE Name: Noor sidah Gender: Female Age: 42 Years Occupation: Housewife Address: Saka Permai Relationships with clients: Mother B. Medical History A. Main complaints At the time of the assessment dated January 11, 2012, the client says that clients feel dizzy. 2. History of Health / Current Disease Clients say that fever up and down for 2 days, the fever is also followed by vomiting. After that, the fever did not go down, the client's family agreed to bring clients to the hospital H. Moch. Ansari Saleh to get further treatment. 3. History of Health / Former Diseases It is the first time of the client having this disease, and the client had not previously been hospitalized 4. Health history / family illness Client's family has never experienced the disease that the clien has now, or other infectious diseases.

C. Physical examination A. General Situation At the time of the assessment dated January 11, 2012; the level of clients awareness is Compass Mentis, which is fully conscious. Clients can answer questions from nurses with GCS 4, 5, 6, namely: Eye: 4 (spontaneous eye opening) Verbal: 5 (well oriented) Motor: 6 (following orders) The physical examination includes checking vital signs, as follows: TD: 100/60 mmHg N: 72x/min R: 24x/min Q: 35o C 2. Skin Client's skin felt warm and dry. There are no cuts or abrasions on the skin of the client. Clients skin turgor is good (back in less than 2 seconds). 3. Head and Neck Head of the client does not have any disorder, equitable distribution of the clients hair, but the client's hair looks pretty long. In general, the state of the client's head looks normal. At the clients neck, there is no enlargement of thyroid gland and no enlargement of lymph nodes in the clients neck area. Clients also have limited neck motion. 4. Sight and Eyes Structure of the left and right eyes are symmetric, the client's eyes look clean, there is no discharge in the eye, and the client does not use visual aids. 5. Smell and Nose Client nose pretty clean; there is no secretions that come out. There is no bleeding or inflammation. Olfactory function is good (can distinguish body odor) 6. Hearing and Ear Ears structure look symmetric, the client's ear looks clean, no dirt / secretions that come out. Function

7. Mouth and Teeth State of the mouth and teeth clean enough. Clients lips mucosa looks not damp. There was no inflammation in the oral cavity and gums. There is no problem in tasting, chewing, and swallowing function

8. Chest, Breathing, and Circulation Normal chest shape, movement/expression of the chest cavity is normal, symmetrical during inspiration and expiration. Client breathes normally through the nose, but coughing occassionally.

9. Abdomen Abdoments general condition is good, spontaneous breathing movements, there is no lump in the clients abdomen, but clients sometimes complain of nausea. 10. Genital and Reproduction Client is a female and have one child. 11. Upper extremities and lower extremities Upper extremities are symmetrical between dekitra and sinistra, infuse is inserted in the right upper extremity. There was no abnormality in the upper extremities. Lower extremity is symmetrical between right and left, no lower extremity deformity. Scale muscle strength 5555 5555 (strong against gravity) 5555 5555 The scale of the clients activity is2, needs help from others for aids, supervision, and teaching. D. Physical Needs, Psychology, Social, and Spiritual. A. Activity and Rest At home: 22-year-old client. Client is a housewife. Client rest and sleep 6-8 hours a day In the hospital: the client just lying in bed. 2. Personal hygiene At home: client takes a shower 2 times a day, brush her teeth 3 times a day, and change clothes two times a day. In the hospital: in the hospital, the client cannot bath, but the client swabbed by her family. 3. Nutrition At home: eat according to the needs of clients; clients eat 3 times a day with a fairly balanced diet, such as rice, side dishes, and vegetables. In the hospital: sometimes the client difficult to eat because of nausea, so that clients has no appetite. 4. Elimination At home: Toilet (BAB): 1 times per day Urinating (BAK): approximately 4 times per day In the hospital: Toilet (BAB): 1 times per day Urinating (BAK): approximately 4 times per day. 5. Sexuality Female clients, aged 22 years, and had 1 child. 6. Psychosocial Psychotherapy: the client does not know about the disease. Social: nurse questions can be answered by the client. Families often ask clients about the action that was given to the client. Client relationship with the family quite well, a lot of relatives who come to visit the client. A relationship with doctors, nurses and other medical team is good enough.

7. Spiritual Islamic religious clients. The client receives for her illness. However, the client looks a little worried about her illness. E. Data Focus Ds: - The client told pain in his head - The client said it was not able to spend a portion of which is provided - The client says do not know what disease she suffered Do: - Client sometimes wince - Client cannot finish her food - Client looks worried - The mucosa of the client looks dry Palpation: pulse: 72 x / minute Temperature: 35o C Percussion: Auscultation: Blood pressure: 100/60 F. Investigations Laboratory results on January 10, 2012 G. Pharmacological Therapy Inj. Antrain 1 amp 3x1 Inj. Ondonsentron 1 amp 3x1 Inj. Renitidin 1 amp 3x1 Inj. Ceftriaxone 2x1 RL 20 drops / minute

Data Analysis No 1 Data Ds - The client claim pains in the head Q: Headache due to the disease process Q: Tingling Pain R: Pain is uncertain S: Scale of pain 2 Q: Pain arrived in the morning Do - Clients sometimes wince - Ds - The client said she was not able to finis all food portion Do - Clients only spent half of a given portion - Clients mucosa looks dry Ds - The client says do not know the illness she suffered. Do - The client looks worried Problem Pain Etiology The disease process

Nutrition is less than body requirements

Lack of apetite, nausea

worried

Lack of knowledge about the disease.

Priority issues 1. Pain associated with the disease process 2. Nutrition less than body requirements related to the lack of appetite 3. Anxiety associated with lack of knowledge about the client's illness

Intervention No Diagnosis 1 Pain related to the disease process, characterized by: - The client claimed the pain in the head Q: headache due to heat Q: tingling pain R: Pain is uncertain S: Scale 2 Q: The pain occurs in the morning - Clients sometimes wince 2 Nutrition less than body requirements b.d. lack of appetite, characterized by: - The client said it was not able to spend a portion of the food provided - The mucosa appears dry Objectives Within 3 days of nursing care, the problem can be solved with the following criteria: - Clients no longer complained of pain - Clients no longer wince Intervention 1. Assess characteristics of pain 2. Teach relaxation techniques 3. Adjust the position of the client as comfortable as possible 4. Collaboration with the medical team in the delivery of anti-pain medication (Antrain 3x1 ) via inj. Rational 1. Knowing the form of client pain 2. To reduce the pain of the client. 3. To reduce the pain of the client 4. Reduce the client's pain

Within 3 days of nursing care, nutritional problems can be solved with the following criteria: - Clients are able to spend a portion of food - Appetite client back - The mucosa moist clients - Within 3 days of nursing care, anxiety problems can be solved with the following criteria: - Clients no longer worried - Clients are more calm about the disease. A. Asse ss characteristics of pain

1. Examine food preferences / dislikes 2. Encourage clients to eat and drink while warm 3. Encourage clients to eat little but often

1. Knowing the client's food preferences 2. Increase appetite client 3. Reduce nausea

3 - Anxiety b.d. client's lack of knowledge about the disease - The client does not know about his illness - The client looks worried

1. Assess client's knowledge about the disease. 2. Assess the level of anxiety 3. Provide information about the illness 4. show empathy

1. Knowing the extent to which knowledge of the client 2. Knowing the level of anxiety 3. Reduce anxiety 4. Reduce anxiety

Implementation

No Date/Time 1 Wed, 11-01-12 21.30

Dx I

Implementation 1. Examines the characteristics of pain

Evaluation Q: tingling pain R: pain is uncertain S: pain scale 2 Q: when you wake up the morning Client understands and can perform relaxation techniques alone Clients still looked uneasy

2. Teach relaxation techniques 3. Adjust the position of the client as comfortable as possible 4. Collaborate in the provision of anti-pain medication (Antrain 3x1) via injection P: headache caused by the disease process 1. Assessing food preferences / dislikes client 2. Encourage clients to eat and drink while warm 3. Encourage clients to eat little but often 1. . Assessing the client's knowledge about the disease 2. Assessing the level of anxiety 3. Shows a sense of empathy. 1. Examines the characteristics of pain

Clients look rather calm

II

1. Client likes warm food

2. Client likes warm food\ 3. Client does what nurses say 1. Clients do not know about his illness 2. Client's anxiety level light 3. Clients look more relieved P: headache caused by the disease process Q: tingling pain R: pain is uncertain S: pain scale 2 T: when wake up in the morning Client understands and can perform relaxation techniques alone Client looks calm

III

Thurs, 12-1-12 07.30

2. Teach relaxation techniques 3. Adjust the position of the client as comfortable as possible 5 II 1. Assessing clients food preferences / dislikes 2. Encourage clients to

1. Client likes warm food

2. Client likes warm food\

3. 6 III 1.

2. 3. 7 Fri, 13-1-12 15.00 I 1.

eat and drink while warm Encourage clients to eat little but often Assessing the client's knowledge about the disease Assessing the level of anxiety shows a sense of empathy Examines the characteristics of pain

3. Client does what nurses say 1. Clients do not know about his illness 2. Client's anxiety is level light 3. Client looks more relieved P: headache caused by the disease process Q: tingling pain R: pain is uncertain S: pain scale 2 Q: when wake up in the morning Client understands and can perform relaxation techniques alone Client looks calm

2. Teach relaxation techniques 3. Adjust the position of the client as comfortable as possible 4. Continuing anti-pain medication (Antrain 3x1) via injection 1. Encourage clients to eat and drink while warm 2. Encourage clients to eat little but often 1. Assessing the client's knowledge about the disease 2. Assessing the level of anxiety 3. Provide information about his illness 4. Show empathy

Client looks calm

II

client prefers warm food

Client does what nurses say clients did not know about his illness

III

Client's anxiety level is light Clients already know about the disease Clients feel relieved, calm

No 1

Date/Time Wed, 11-1-12 22.00

Dx I

II

III

Thurs,12-1-12 08.00

II

III

Fri, 13-1-12 15.00

Evaluation S: clients still feel pain O: The client was restless A: nutritional problem is not resolved P: continue intervention 1. examine the characteristics of pain 2. teach relaxation techniques 3. set the Position of the client as comfortable as possible 4. continue the provision of anti-pain medication (Antrain 3x1) S: the client says no appetite O: the client does not spend the amount of food provided by the hospital A: The client's nutritional problem is not resolved P: continue intervention 1. encourage clients to eat and drink while warm 2. encourage clients to eat little but often S: client does not know about his illness O: clients look worried A: anxiety problem is not resolved P: continue intervention 1. assess the client's knowledge about the disease 2. assess the level of anxiety 3. show empathy S: clients still feel pain O: The client was restless A: The problem of pain is not resolved P: continue intervention 1. examine the characteristics of pain 2. teach relaxation techniques 3. set the Position of the client as comfortable as possible 4. continue the provision of anti-pain medication (Antrain 3x1) S: the client says no appetite O: the client was able to spend the amount of food provided by the hospital A: The client's nutritional problem is not resolved P: continue intervention 1. encourage clients to eat little but often 2. encourage clients to eat while warm S: clients still do not know about his illness O: the client is still worried A: anxiety problem is not resolved P: continue intervention. 1. review the client's knowledge 2. assess the level of anxiety 3. provide information about the client's illness 4. show empathy S: client complains of pain O: the client holding the pain A: The problem of pain is not resolved P: continue intervention 1. examine the characteristics of pain 2. teach relaxation techniques

II

III

3. Position of the client set 4. continue the provision of anti-pain medication (Antrain 3x1) S: client said appetite is back O: The client almost finish her food A: nutritional problem is resolved P: the intervention is stopped S: clients already know about the disease O: the client is more calm A: anxiety problem solved P: the intervention is stopped