I. Assesment A. Patient Details [PDF]

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I.



ASSESMENT A. Patient Details Name



: Child. Z



Medical record



: 676020



DOB



: 5 March 2010



Age



: 10 years



Gender



: Female



Tribe/nation



: Sasak/Indonesia



Religion



: Islam



Maritalstatus



: Single



Occupation



:-



Education



: Elementary school



Address



: pengadangv



Hospital admissiondate



: 2 September 2020



Medical diagnosis



: Dengue Hemoragic Fever



Reason for being treated



: Fever fluctuates



Responsible details Name



: Mrs. B



Age



: 40 years



Gender



: female



Religion



: Islam



Education



: Senior high school



Address



: pengadang



Relation with patient



: patient’s mother



B. Nursing story 1. Main complain The patient says fever goes up and down 2. The mixed complain



The patient’s mother says that his child is dizzy, fever nausea from vomiting, no appetite, the patient appears weak, lethargic,heartburn, like stabbed, a scale of pain 6, 15-minutes loss, pain in motion 3. The effort has been made The patient said it went tothe medical center during the fever of day and was given a fever reducing drug. 4. History of modern illness The patient mother say that his child’s had fever for 2 days and was taken to Pengadanghealth center, in there she had been got three days of treatment, and there’s no progress and then the patient was taken to RSUD Praya through the ER, after that the patient brough to the Tunjung II room. 5. History of ancient diseases Client’s mother says the client was treated at age 4 in Praya hospital with the same disease. 6. Family health history Client’s mother says they have the same disease as his older brother, and no other family has hypertension, DM, and any other disease. 7. Relationships with the family at the hospital, the client’s mother and father always accompany the client. 8. Home environment The client says his house is clean and the light is bright. ( saraslanjut ) C. Psycho and social biological history Daily Activities 1. Nutrition Pattern & Metabolism Before getting sick: patients say eating a day can be 3-4 times, drinking approximately 7-8 glasses per day.



When sick: patients say only eat a small amount of food provided by the hospital only 1-2 tablespoons, drink + 4 glasses per day. 2. Elimination Pattern Before getting sick: patients say defecate 1 time a day and pee 4-5 times a day When sick: His mother say Z can be pee up to 4 times per day, defecate 1 time a day is not necessarily. 3. Sleep Rest Pattern Before getting sick: the patient's mother says sometimes his child naps and sleeps at night after praying isya until dawn at 05.00 is up, the sleep is 8-9 hours. When sick: the patient's mother says her child can sleep but is not well because often sudden fever especially during the day and evening, sleep 4-5 hours. 4. Activity Patterns & Exercises Before getting sick : the patient says in the morning often play with his friends When sick: the patient says he can't play as normal 5. Sexual Pattern & Reproduction Before getting sick: not reviewed When sick: not reviewed 6. Sensory & Cognitive Patterns Before getting sick: the patient says there is no disturbance to the five senses When sick: the patient says there is no disturbance in all 5 of his senses but still feels limp 7. Mechanism Pattern/Stress Management Before getting sick: the patient says if the patient is sad she always tells the story and talks to his mother and father When sick: the patient's mother says her daughter becomes cranky and often to cries



8. Perception Pattern & Self Concept Before getting sick: the patient says she always enjoys playing with his friends When sick: the patient says she wants to recover quickly and go home 9. Perception Patterns & Healthy Living Procedures Before getting sick: the patient's mother says pay attention to a healthy way of life, because knowing so important is healthy. When sick: the patient says she wants to be healthy quickly in order to play with his friends 10. Relationship Patterns & Roles Before getting sick: the patient says she loves his mother and his father and his friends too When sick: the patient says she still loves his mother and father but can't play with his friends 11. Patterns of Values & Religion Before getting sick: the patient says always teach to pray When sick: the patient's mother says she still teaches her son to pray even though it is not as usual D. Observation and physical examination 1. General Condition: Weak 2. Consciousness



: Composmentis



3. Vital signs: a. blood pressure: 120/80 mmHg b. Temperature: 39.2OC c. Respiratory rate: 20x/minute d. Pulse: 92x / minute 4. GCS



: 4E 5V 6M



5. Physical examination



- Chief Inspection: oval shape, long black hair, evenly distributed hair. Palpation: no tenderness, lumps, edema, or wounds. - Eyes Inspection: symmetrical, no lesions, conjunctiva anemic, clean sclera white. Palpation: no tenderness, no edema. - Nose Inspection: symmetrical nostrils, no secretions, fluid and bleeding Palpation: no tenderness, no edema / lumps - Mouth Inspection: moderate lip mucosa, teeth still missing Palpation: no tenderness in the area around the mouth. - Ears Inspection: symmetrical, no lesions, scar tissue, fluid and also bleeding, clean ear holes Palpation: no tenderness - Neck Inspection: no lesions and scar tissue, no lymph enlargement Palpation: no tenderness, no palpable enlargement of the thyroid gland - Chest Inspection: symmetrical, no chest wall traction, no lesions Palpation: no tenderness Percussion: sonor lung sound and deafening sound in the heart Auscultation: vesicular breath sounds, single S1 S2 heart sounds - Abdomen Inspection: even skin tone, no lesions, no enlargement of the abdomen Auscultation: bowel sounds 9x / min Palpation: no tenderness Percussion: timpani - Genetalia



Inspection: the patient looks grimacing in pain - Extremities On Inspection: symmetrical, no lesions, edema, put RL infusion 20 tpm in the right hand Palpation: CRT