A.

Identitas klien

Nama : an.R
Umur : 1 tahun
Jenis kelamin : laki-laki

B. Diagnose medis

Diare

C. Riwayat kesehatan sekarang

Dari keterangan ibu klien , seminggu sebelum masuk hospital, klien mengalami demam
keesokan harinya klien muntah –muntah dan rewel dank lien tampak lemah, akhirnya si ibu
memutuskan untuk membawa klien ke hospital untuk mendapatkan perawatan.

D. Keadaan umum

- Klien tampak lemas

- Klien tampak mual

E. Pemeriksaan tanda-tanda vital

Nadi 100x menit

Pernafasan 25x menit
Suhu 38,2oc
A. Client identity

Name: an.R
Age: 1 year
Male gender

B. Medical diagnosis

Diarrhea

C. Current medical history

From the client's mother's statement, the week before entering the hospital, the client had a fever the next day
the client was vomiting and fussy and the lien seemed weak, finally the mother decided to take the client to the
hospital to get treatment.

D. General situation

- Clients seem limp

- The client looks nauseous

E. Examination of vital signs

Nadi 100x minutes

Breathing 25x minutes
Temperature 38,2 oc