Name : Baiq Azila Falasifa

Class : Class A
study program: nurse profession

Make A Nursing Case Report

A. Case
Mr. A 30 years old came to the hospital accompanied by his family with
complaints of headache in the frontal part, neck stiffness and high fever since one week
ago. The client said the pain had started since he was had meningitis and the pain
increases if he moves his head too much .the pain felt like a stabbing pain on a pain scale
of 8 (1-10) and appeared with a duration of 30 seconds. The client's wife said that the
client often had convulsions for about 30 seconds. The client's wife also said that her
husband also often complained of difficulty sleeping when he wanted to sleep. This
makes the client look weak and weak.
From the results of the physical examination, there were Krenig's signs (+),
Brudnizki's signs (+), cold extremities and a lump on the right side of the neck. Blood
Pressure: 150/80, Temperature: 38.30 C, Pulse: 60x/minute, Respiratory Rate:
28x/minute. The skin looks red and feels hot to palpation. The client appears to be in
pain. When speaking, the patient often looks at his eyes to reduce pain. The CT scan
results showed that there was edema of the head in the parietal area. After performing a
complete blood count and a lumbar puncture, the doctor stated that the patient had
meningitis.
B. Nursing Diagnoses
 data analysis

No Focus data etiology problem

1 Subjective data : Increased metabolic rate hypethermia
the client said the body
temperature felt hot and
feverish 1 week ago
objective data :
temperature: 38.30C, the
client's skin looks red and
feels hot when palpated
2 Subjective data : Biological injury agent Acute pain
The client said he felt pain in
his head which he had been
feeling for a week
P: the client said the pain had
appeared since he had
meningitis and the pain
increases if he moves his
head too much
 Q: the quality of the client's
pain is sharp as if being
stabbed
R: pain is felt in the frontal
area of the head
S: pain scale 8 (1-10)
T: pain appears suddenly with
a duration of 30 seconds
Objective data :
The client appears to be in
pain. When speaking, the
client often closes his eyes to
reduce pain, Krenig's sign (+)
 nursing diagnoses
1. Hyperthermia related to increased metabolic rate
2. Acute pain related to biological injury agent
C. Nursing Intervention

No Nursing Goals and outcome criteria Intervention

diagnosis
1 Hyperthermia After nursing actions for 1. Monitor the client's body
related to 3x24 hours, it is expected temperature and skin color
increased that the patient's 2. Warm compresses on the
metabolic rate hyperthermia will be patient's groin and axilla
resolved with the following 3. Increase air circulation using a
criteria: fan
1. Body temperature within 4. Instruct the client to drink
normal range plenty of water
2. Pulse within normal 5. Collaboration with the medical
range team in administering anti-pyretic
3. Skin color is not reddish drugs
4. Skin does not feel warm
2 Acute pain After nursing actions for 1. Comprehensive assessment of
related to 3x24 hours the client's pain pain including location,
biological injury level decreased with the characteristics, duration,
agent following criteria: frequency, quality and
1. The client can control the precipitation factors
pain 2. Observe nonverbal reactions to
2. Clients are able to apply discomfort
relaxation techniques 3. Control the environment that
independently can affect pain such as room
3. Nonverbal client shows temperature, lighting and noise
pain 4. Teach about non-
4. Pain scale decreased pharmacological techniques to
reduce pain such as using deep
breathing techniques or guided
imaginary
5. Apply a cold compress on the
painful area
6. Collaboration with the medical
team in administering analgesic
drugs
7. Evaluate the effectiveness of
pain control
D. Nursing Implementation and Evaluation
Days/ No implementation
Date dx
Wednesday/ 1 1. Monitor the patient's body
4-08-2021 temperature and the client's
skin color
2. Doing a warm compress on the
groin and axilla
3. Increase air circulation using a
fan
4. Encourage clients to drink lots
of water
5. Collaborating with the medical
team in the provision of
antipyretic drugs
wednesday/ 2 1. Assess pain comprehensively
4-08-2021 including location, characteristics,
duration, frequency, quality and
precipitation factors
2. Observing nonverbal reactions
to discomfort
3. Teach non-pharmacological
techniques to reduce pain such as
using deep breathing techniques
4. Controlling the environment
that can affect pain
5. Doing a cold compress on the
part that is experiencing pain
6. Collaborate with the medical
team in administering analgesic
drugs
7. Evaluate the effectiveness of
pain control
Days/ No implementation
date dx
thursday 1 1. Monitor the patient's body
/ temperature and the client's skin
5-08- color
evaluation
S: the client says his body
temperature is still high
O: The temperature is 38.5 C.
The skin looks reddish and feels
hot
A: the client's nursing problem
has not been resolved
P: the intervention is continued
S:
P: Mr.A said the pain since he
had meningitis and the pain
increases if he moves his head
too much
Q: the pain is like being stabbed
R: pain is felt in the frontal area
of the head
S: pain scale 8(1-10)\
T; pain appears suddenly with a
duration of approximately 30
seconds
O :The client looks to be in pain
A: the client's nursing problem
has not been resolved
P: the intervention is continued
evaluation
S: the client says his body
temperature is still high
O: The temperature is 37,8 C.
2021 2. Doing a warm compress on the The skin still looks reddish and
groin and axilla feels hot
3. Increase air circulation using a A: the client's nursing problem
fan has not been resolved
4. Encourage clients to drink lots P: the intervention is continued
of water
5. Collaborating with the medical
team in the provision of
antipyretic drugs
thursday 2 1. Assess pain comprehensively S:
/ including location, characteristics, P:Mr.A said the pain comes
5-08- duration, frequency, quality and when he moves his head too
2021 precipitation factors much
2. Observing nonverbal reactions to Q: the pain is like being stabbed
discomfort R: pain is felt in the frontal area
3. Teach non-pharmacological of the head
techniques to reduce pain such as S: pain scale 6(1-10)\
using deep breathing techniques T; pain appears suddenly with a
4. Collaborating with the medical duration of approximately 15
team in administering analgesic seconds
drugs O : The client is seen holding his
5. Evaluate the effectiveness of head while speaking
pain control A: the client's nursing problem
has not been resolved
P: the intervention is continued
Days/ No implementation evaluation
date dx
friday/ 1 1. Monitor the patient's body S: the client says that the body
6-08- temperature and the client's skin temperature has started to drop
2021 color O: Temperature 36.50 C
2. Encourage clients to drink lots of A: the client's nursing problem is
water resolved
P: the intervention is stopped

thursday 2 1. Assess pain comprehensively S: the client says he still feels

/ including location, characteristics,
6-08- duration, frequency, quality and
2021 precipitation factors
2. Collaborating with the medical
team in administering analgesic
drugs
3. Evaluate the effectiveness of
pain control
pain in his head, but at night the
client can sleep well
O: pain scale 5
A: problem partially resolved
P: intervention continues
1. Assess pain comprehensively
2. Collaboration with the medical
team in administering analgesic
drugs
3. Evaluate the effectiveness of
pain control