Name : Duvan Reynaldy Omega

NIM : 01.2.17.00599

Case Study

Patient named Mr. R is 49 years old and is a Christian male, works as a private
employee, Batak tribe, married status, and his address is Jl. Paus no. 50C, date of hospital
admission 10 September 2020, Medical Record number 1096970, with a medical diagnosis of
typhoid fever.

The patient was brought to Baptis Private Hospital on September 10 th 2020 by his
wife, Mrs. L at 10.00 a.m. Nursing assessments were conducted on September 10 th , 2020 at
11.00 a.m.

patient complains of abdominal discomfort, nausea and bloating and a fever that does
not go away. The patient said that he felt bloated and nauseous and had a fever that appeared
during the day and gradually normalized towards the evening for 5 days, but because it was
considered as common cold, he was not taken to the doctor and treated by coin-scratching-
body-theraphy and given paracetamol. The situation did not improve, instead the patient was
getting weaker because he had no appetite. The condition of the patient is cooperative during
the examination, the family pays attention to the health problems of other family members, if
sick, they try to cure them with traditional methods before checking them with a doctor. The
patient had a history of typhoid about 15 years ago.

The general condition of the patient is weak, pale and the level of consciousness is
compos mentis. The patient feels dizzy and has muscle aches. The patient's vital signs with a
blood pressure 120/80 mmHg, a weak pulse 80 x/minute, an axillary temperature of 38.9 oC,
hot acral, and a respiration rate of 15 x/minute, SpO2 was detected 99%. In the upper
extremity of left hand was attached 0.9% 14 drops per minute NaCl infusion. The patient's
mouth was found to be dry oral mucosa and oral thrush, tenderness in epigastrium area.

patient eat 3 times per day only ¼ portion of meals with a diet of TKTP (High
Calorie High Protein) refined porridge from the hospital. The patient said he lacked appetite
so that the family fed him. During illness, the patient drinks approximately six glasses (250cc
/ glass) per day with warm water or hot tea.

During hospitalisation, the patient said sleep 5 hours per day at night, can not take a
nap due to the noisy environment and too bright lighting. The patient's activities are assisted
by family and nurses because the patient feels limp and does not have the energy to do
activities.

Medical Therapy:

a. IV injection of antibiotic Azithromycin 1x1 500mg

b. Oral paracetamol 3x1 500mg

c. Infusion of IV NaCl 0.9% 14 tpm

Based on the data above, find 3 nursing problem using data analysis! Then prioritize it
from high to low priority.

Write it down in Ms. Word. The deadline for submission of assignments at 23.00 p.m on
11 September 2020

Note : If the desired data is not in the case study, consider the data as normal.

-- Good Luck --
 Data Etiology Nursing Problem

Subjective Data : the patient said Process Infection Hipertermi

he had a fever that appeared during
the day and gradually normalized
at night for 5 days, had been given
paracetamol but did not improve

Objective Data : The patient

appears weak, pale, and a
compositional level of
consciousness.

the patient's mouth is dry and

canker sores

The patient's temperature was 38.9

° C, the acral felt hot and the left
hand was attached with 0.9% Nacl
infusion 14 drops per minute

Subjective Data : The patient's weakness activity intolerance

family said they were weak and related to weakness
could not carry out their daily
activities

Objective Data : patients are

assisted by their families and
nurses in carrying out their daily
activities

Subjective Data : The patient said Discomfort to Environment Lack of sleep is

he slept 5 hours per day at night, associated with sleep
could not take a nap due to noisy due to a lack of
environment and too bright environmental
lighting comfort

Objective Data : the patient

appears weak and pale and
conscious is compostable