KEDIRI BAPTIST HOSPITAL HEALTH SCIENCE COLLEGE UNDERGRADUATE UNDERGRADUATE NURSING STUDY PROGRAM MEDICAL-SURGICAL NURSING DOCUMENTATION
NURSING CARE TO PATIENT WITH TYPOID IN OUT-PATIENT INSTALLATION OF KEDIRI BAPTIST HOSPITAL
1.
Personal Data Name : Mr. H Register Number: 581902 Age : 18 years old Sex : Male Religion : risten Address : Sumbere!o" Ngasem#$ediri %&&u'ation :# (ate (ate o) Admi Admiss ssio ion n :# (ate o) Assessme Assessment nt : Se'tember Se'tember 2*" 201+ ,lood -rou' : Not Assessed Medi Medi&al &al (ia (iagn gnos osis is : ty'oi ty'oid d 2. C!e" Co#$la!nt atient atient said t/at /e )eer sin&e t/ree days ago liuid liuid &/a'ter nausea" omiting
and 'ain stoma&/ s&ale + . %& H!sto H!stor' r' o" o" Pres Presen entt Illne Illness ss atient said t/at /e it/ &om'laint t/e agen&y still )eer" nausea and omiting. Stoma&/ 'ain and liuid &/a'ter 'atient broug/t to t/e 3nstallation o) $ediri ,a'tist Hos'ital to get nursing &are. (& H!st H!stor or' ' o" Past Past Illn Illnes esss atient said t/at /e /ad no /istory o) /ereditary diseases. Re&ently" s/e /ad &om'laint o) abdominal tenderness and 'ain /en 'assing ater. )& H!sto H!stor' r' o" Fa#!l Fa#!l' ' Illnes Illnesss atient said t/at /er )amily /ad no /ereditary and in)e&tious diseases su&/ as /y'ertension" (iabetes Mellitus" and 4,
-enogram
3 3n)ormation : or
6 (ie
6 atient
6 Male
6 marriage relations/i'
6 7emale
6 des&endant relations/i'
6 Staying at /ome *& H!stor' o" Ps'+o-So+!al an, S$!r!tal
sy&/o#
:
so&ial /istory S'iritual
atient &an intera&t ell it/ )amily mambers and nurses in /os'ital" 'atient s'eas aaness and 3ndonesian 4/e 'atient as a risten"
/istory .& A+t!/!t' Da!l' L!/!n0 1Eat2 Rest3Slee$2 El!#!nat!on2 A+t!/!t'2 Personal H'0!ene2 an, Se4al5
No
A&tiity (aily
3n t/e /ouse
3n t/e Hos'ital
iing 1.
A(; 7ul)illment %)
Nutrition
>uantity : #
>uantity :
And 7luid
4y'e
4y'e
Need
:#
1; Ri&e : 1 times=day
5; Ri&e :
2; Side dis/es :
; Side dis/es :
*; ?egetable :
B; ?egetable :
+; (rining : @ 100
8; (rining :
&&=day
2.
:
Abstinen&e :
Abstinen&e : #
(i))i&ulty eating =
(i))i&ulty eating =
drining :
drining : #
<))orts to oer&ome
<))orts to oer&ome
di))i&ulties :
di))i&ulties : # Crinating :2 #* times=day
Crinating : >uantity : (e)e&ate :
>uantity : # (e)e&ate : *#+
onsisten&y : . roblems and /o to
times=day onsisten&y : Not
oer&ome :
mus/y not slimy liuid roblems and /o to *.
Rest=Slee'
oer&ome : # 3n t/e a)ternoon : @ 2 /ours 3n t/e eening : # /our 3n t/e nig/t : B#8
3n t/e noon : 3n t/e a)ternoon : 3n t/e nig/t : Slee' disturban&es : Cse o) slee' medi&ation :
/ours Slee' disturban&es : # Cse o) slee' +.
ersonal Hygiene
medi&ation : # 7reuen&y o) bat/ing : 2 times=day Hair as/ing )reuen&y : * times=ee 7reuen&y o) toot/ brus/ing : 2 times=day Nail &ir&umstan&es :
7reuen&y o) bat/ing : Hair as/ing )reuen&y : 7reuen&y o) toot/ brus/ing : Nail &ir&umstan&es : /ange &lot/es :
&lean /ange &lot/es : 2 times=day a)ter bat/ing 5.
%t/er A&tiity
1; Routine A&tiity : atient as learning and s&/ool. <eryday" /er a&tiity is at&/ing and 'laying 2; A&tiity in leisure time : atient said t/at s/e )ill t/e leisure time it/ at&/ing 4? and &ome toget/er it/ /er )amily.
1; Routine A&tiity : 2; A&tiity in leisure time :
8. Con,!t!on 3 A$$earan+e 3 General !#$ress!on o" te $at!ent 6 a. atient loos dry li's and )eer. b. atient loos 'ale and ea. &. atients seem grima&ed in 'ain in t/e stoma&/. d. atientDs general &ondition is good" aareness is &om'osmentys.
9. ?ital Sign : a. 4em'erature
:
*8
0
b. Heart Rate
:
80
x=menit
&. ,lood ressure d. Res'iratory Rate e. Eeigt/ = Heigt/
: : :
120=B0 mmHg 20 x=menit +0 g" .................... &m.
10. /ysi&al
!.
5 6 %rientation good 6 7ollo orders ell Mental status
11. aboratory Result (ate : No assesment No
Result
Normal ?alue
3nter'retation o) result
1. 2. *. +. 5. 12. 3m'lementation=4/era'y 1.
Am'isilin * x 1 tablet
2. $loram )enlol 250 mg *x1 *. $ontrimosasol 2x2 tablet +. ara&etamol 500 mg RN tablet; 1*. lient=7amily ex'e&tations it/ res'e&t to t/e disease atient said t/at s/e anted to re&oery )rom /is illness and &ould do t/e !ob = a&tiity as usual day.
StudentFs Signature
<a )aridatul
DATA ANALYSIS
atientFs Name
: Mr. H
Age
: 18 yers old
Register Number
: 581902
Sub!e&tie (ata
roblem
%b!e&tie (ata S78e+t!/e Data 6
atient said t/at stoma&/
om)ortable disorders
Salmonela t/y'osa
'ain
'ain it/ a s&ale o) +.
(igistie tra&t
O78e+t!/e Data 6
1. atient loos ea.
Absorbed by t/e smal
2. atients seem
intestine
grima&ed in 'ain. *. atient a''ears
,a&teria in t/e
/olding /is stoma&/
systemi& blood
in t/e le)t loer
)lo
uadrant. +. ain s&ale +
ier
Nutrion less t/an body
Hematomegali
reuirements ain 'al'ability S78e+t!/e Data 6
atient said t/at /e nausea an omiting.
om)ortable disorders 'ain
O78e+t!/e Data 6
1. debilitated patients
2. mucosal dry lips
the lymph nodes of
*. Pale
the small
+. hot body, bowel 6
intestine
x / min
5. dry turgor . since three days ago defecate
plaque peyeri in the terminal ileum
liquid ulcers
nausea vomiting
lack of nutrients the body needs
LIST OF NURSING DIAGNOSIS
atientFs Name
: Mr. H
Age
: 18 yers old
Register Number
: 581902
No
DATE
NURSING DIAGNOSIS
APPE
E
AR 9&
2*
om)ortable disorders 'ain se'tem
asso&iated it/
ber
in)lammatory boel /i&/
201+
is &/ara&teriGed by abdominal 'ain 'atients say t/e 'ain s&ale +" t/e 'atient a''ears ea" grima&ing 'ain)ully.
:&
2* se'tem ber 201+
SIGNATUR
Nutrition less t/an body reuirements related to t/e nausea and omiting t/at is &/ara&teriGed by saying nausea and omiting" debilitated 'atients" mu&osal dry li's" 'ale" /ot body" boel x= minute" turgor dry" sin&e t/ree days
ago de)e&ate liuid.
NURSING ACTIONS
atientFs Name
: Mr. H
Age
: 18 yers old
Register Number
: 581902
No
DATE AP
NURSING ACTIONS
L;ED
AR
2*
1. %bseration o) ital se' tem
signs ,lood 'ressure :120=B0
MmHg 4em'erature : *8 201 ulse : 80 x= minute ,reat/ : 20x=minute + 2. 4ea&/es dee' breat/ing
ber
relaxation te&/niues and distra&tions. *. roide a sa)e and &om)ortable enironment +. ollaboration it/ '/ysi&ians in t/e :&
OF RESO
PE 9&
DATE
deliery o) analgesi&
SIGNAT URE
drugs.
1. -ie to eat little but 2*
o)ten" t/e )ood is )ine. se'
7or exam'le 'orridge"
tem ber 201 +
ri&e baby. 2. roide oral /ygiene be)ore eating. *. ress&ribe % be)ore meals to 'reent nausea and omiting. +. ollaborate it/ nutritionsist on nutrition 'ur&/ases s'eader lig/t so)t )iber diet.
PROGRESS NOTES
atientFs Name
: Mr. H
Age
: 18 yers old
Register Number
: 581902
No
9&
No
1
HO
D
U
<
R
E;ALUATION
SIGNAT URE
18.0
S: 'atients say stoma&/ still a&/ed
0
it/ s&ale *. %: # 'atients a''ear ea # 4enderness in t/e le)t loer #
udrant. -rima&ing 'ain)ully.
A: t/e issue is resoled in 'art : 1#5 &ontinued interention in t/e
'atients /ome out'atient return
:&
2
S: atients say t/ey nausea and 18.0 0
omiting. . %: # (ebilatated 'atients # Mu&osa dry li's. # ,ody /eat # ,oel x=minure # 4urgor dry # * liuid boel moement. A: 'roblem /as not been resoled : 1#5 &ontinued interention in t/e 'atients /ome out'atient return