CASE STUDY II

NURSING ASSESSMENT OF PATIENTS AND FAMILIES

 

      

ARRANGED BY:

M. SOFYANDI
058 STYC 17
 

ISLAMIC HOSPITAL FOUNDATION OF NUSA TENGGARA BARAT

HIGH SCHOOL OF HEALTH SCIENCE YARSI MATARAM
KEPERA S1 STUDY PROGRAM W ATAN
MATARAM
20 20
 
 A. Nursing Interventions

N NURSING Goals and Criteria Results Intervention

O DIAGNOSES
1 Increased body After taking nursing actions 1. Encourage the
temperature for 1x24 hours, the patient's client to warm
associated with the body temperature is compresses
inflammatory expected to be normal with 2. Encourage
process of dengue the expected results; clients to drink
virus is 1. The patient does not plenty of water
characterized by complain of overheating 3. Measuring TTV
body temperature of 2. Normal client's 4. Encourage
38ºC body temperature (36ºC) clients to wear thin
  clothing and absorb
sweat
5. Collaboration of
antipyretic drugs
 

B. Implementation provided

Nursing diagnoses Implementation Response Results

Increased body 1. Encourage 1. The patient
temperature warm compresses said it was more
associated with the on the folds and comfortable after
inflammatory head being compressed
process of dengue 2. Encourage 2. The patient
virus is patients to drink follows the
characterized by lots of water recommendations
body temperature 3. Measuring given
of 38ºC TTV 3. The patient
  TD: 90/60 mmhg said his body heat
N: 62 x / minute was still but not
S: 38.5ºC as hot when he
RR: 20 x / minute was first brought
4. Encourage to the puskesmas
clients to wear thin 4. The patient
clothing and absorb follows the
sweat recommendations
5. Providing given
antipyretic drugs, 5. The patient
namely takes the medicine
Paracetamol given

 
 C. Evaluation

Nursing Evaluation
diagnoses
Increased body S: The patient said his body heat had begun to feel a
temperature little decreased
associated with  
the inflammatory O: TTV
process of dengue     TD: 100/80 mmHg
virus is     S: 38.5ºC
characterized by     N: 60 x / minute
body temperature     RR: 23 x / minute
of 38ºC  
  A: The problem of increasing body temperature has
not been resolved
 
P: Intervention continues
 Compress still carried out
 Encourage clients to drink 1500-2000 cc of
water every day