Nama : Intan sari

Nim : 4003190107
D3 keperawatan b

KEDIRI BAPTIST HOSPITAL HEALTH SCIENCE COLLEGE

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 : kristen
Address : Sumberejo, Ngasem-Kediri
Occupation :-
Date of Admission : -
Date of Assessment : September 23, 2014
Blood Group : Not Assessed
Medical Diagnosis : typoid
2. Chief Complaint
Patient said that he fever since three days ago liquid chapter nausea, vomiting
and pain stomach scale 4 .
3. History of Present Illness
Patient said that he with complaint the agency still fever, nausea and vomiting.
Stomach pain and liquid chapter patient brought to the Installation of Kediri
Baptist Hospital to get nursing care.
4. History of Past Illness
Patient said that he had no history of hereditary diseases. Recently, she had
complaint of abdominal tenderness and pain when passing water.
5. History of Family Illness
 Patient said that her family had no hereditary and infectious diseases such as
hypertension, Diabetes Mellitus, and TBC

Genogram

I Information :

or = Die = Patient

= Male = marriage relationship

= Female = descendant relationship

= Staying at home

6. History of Psycho-Social and Spiritual

Psycho-social : Patient can interact well with family mambers and

history nurses in hospital, patient speaks Javaness and
Indonesian
Spiritual history The patient was a kristen,

7. Activity Daily Living (Eat, Rest/Sleep, Elimination, Activity, Personal

Hygiene, and Sexual)

No Activity Daily In the house In the Hospital

Living (ADL)
1. Fulfillment Of Eat / Drink Eat / Drink
 Nutrition And Quantity : - Quantity :
Fluid Need Type : - Type :
1) Rice : 1 times/day 5) Rice :
2) Side dishes : 6) Side dishes :
3) Vegetable : 7) Vegetable :
4) Drinking : ± 1600 8) Drinking :
cc/day Abstinence :
Abstinence : - Difficulty eating /
Difficulty eating / drinking :
drinking : - Efforts to overcome
Efforts to overcome difficulties :
difficulties : -
2. Elimination Urinating :2 -3 times/day Urinating :
Quantity : - Quantity :
Defecate : 3-4 times/day Defecate :
Consistency : Not mushy Consistency : .
not slimy liquid Problems and how to
Problems and how to overcome :
overcome : -
3. Rest/Sleep In the afternoon : ± 2 In the noon :
hours In the afternoon :
In the evening : - hour In the night :
In the night : 7-8 hours Sleep disturbances :
Sleep disturbances : - Use of sleep medication
Use of sleep medication : :
-
4. Personal Hygiene Frequency of bathing : 2 Frequency of bathing :
times/day Hair washing
Hair washing frequency : frequency :
3 times/week Frequency of tooth
Frequency of tooth brushing :
brushing : 2 times/day Nail circumstances :
Nail circumstances : Change clothes :
clean
Change clothes : 2
times/day after bathing

5. Other Activity 1) Routine Activity : 1) Routine Activity :

Patient as learning 2) Activity in leisure
and school. time :
Everyday, her
activity is watching
and playing
2) Activity in leisure
time : Patient said
that she fill the
leisure time with
watching TV and
come together with
her family.

8. Condition / Appearance / General impression of the patient :

a. Patient looks dry lips and fever.
 b. Patient looks pale and weak.
c. Patients seem grimaced in pain in the stomach.
d. Patient's general condition is good, awareness is composmentys.

9. Vital Sign :
0
a. Temperature : 38 C
b. Heart Rate : 80 x/menit
c. Blood Pressure : 120/70 mmHg
d. Respiratory Rate : 20 x/menit
e. Weigth / Heigth : 40 kg, .................... cm.

10. Physical Examination

a. Head and Neck examination

Inspection : Head of the symmetrical attern, a little grey hair color, hair
looks lusterless.
Palpation : No assesment.
b. Integumen dan nail Examination
Inspection : Skin color caussacian, there’s no change color on the nails.
Palpation : Akral warm, the nail seemed quited clean
c. Mammae dan Axilla Examination (if necessary)
No Assesment
d. Sternum/Thorax Examination
Inspection of thorax : The form of thorax normla, the chest wall left and
right of the same, no abnormality on thorax.
Lung : No Assesment
e. Heart Examination
No assesmnet
f. Abdomen Examination
Inspection : No found the existence of the former surgery, the stomach
looked strained.
Palpation : The patient to experience the press at the lower of the
abdomen, pain scale 6.
g. Sex and surrounding areas Examination (if necessary)
Genetalys : No assesment
Dubur : No Assesment
h. Musculosceletal Examination
MMT : 5 5 Explanation:5=Can hold gravity, prisoners maximum.
 5 5
i. Neurology Examination
Awareness : Composmentys
GCS : E=4, V=5, M=6
Explanation : 4 = The response to open eyes spontaneously.
5 = Orientation good
6 = Follow orders well
j. Mental status Examination
1) Patient can recognize herself
2) The patient not having disorientation with the environment, people, and
time.
3) Patient can communicate well with the family and all the nurse.

11. Laboratory Result

Date : No assesment
No Examination Result Normal Value Interpretation of
result
1.
2.
3.
4.
5.
12. Implementation/Therapy
1. Ampisilin 3 x 1 tablet
2. Kloram fenlkol 250 mg 3x1
3. Kontrimoksasol 2x2 tablet
4. Paracetamol 500 mg PRN (tablet)
13. Client/Family expectations with respect to the disease
Patient said that she wanted to recovery from his illness and could do the job /
activity as usual day.

Student’s Signature

Eka faridatul
 DATA ANALYSIS
Patient’s Name : Mr. H
Age : 18 yers old
Register Number : 581902
Subjective Data Problem Etiologi
Objective Data

Subjective Data : Comfortable disorders Salmonela thyposa

Patient said that stomach pain
pain with a scale of 4. Digistive tract
Objective Data :
1. Patient looks weak. Absorbed by the smal
2. Patients seem intestine
grimaced in pain.
3. Patient appears Bacteria in the systemic
holding his stomach blood flow
in the left lower
quadrant. Liver
4. Pain scale 4
Hematomegali
Nutrion less than body
requirements Pain palpability

Subjective Data : Comfortable disorders pain

Patient said that he
nausea an vomiting.
Objective Data :
1. debilitated patients the lymph nodes of the small
2. mucosal dry lips intestine
3. Pale
4. hot body, bowel 6 x / plaque peyeri in the terminal
min ileum
5. dry turgor
6. since three days ago ulcers
defecate liquid
nausea
vomiting

lack of nutrients the

body needs

LIST OF NURSING DIAGNOSIS

Patient’s Name : Mr. H

Age : 18 yers old
Register Number : 581902
No DATE NURSING DIAGNOSIS SIGNATURE
APPEAR
1. 23 september Comfortable disorders pain
2014 associated with inflammatory
bowel which is characterized by
abdominal pain patients say the
pain scale 4, the patient appears
weak, grimacing painfully.

Nutrition less than body

23 september requirements related to the nausea
2. 2014 and vomiting that is characterized
by saying nausea and vomiting,
debilitated patients, mucosal dry
lips, pale, hot body, bowel 6x/
minute, turgor dry, since three days
ago defecate liquid.

NURSING ACTIONS

Patient’s Name : Mr. H

Age : 18 yers old
Register Number : 581902
N DATE NURSING ACTIONS DATE OF SIGNATURE
o APPEAR RESOLVED
1. 23 1. Observation of vital
september signs
2014 Blood pressure :120/70
MmHg
Temperature : 38º C
Pulse : 80 x/ minute
Breath : 20x/minute
2. Teaches deep breathing
relaxation techniques
and distractions.
3. Provide a safe and
comfortable
environment
4. Collaboration with
physicians in the
delivery of analgesic
drugs.

2. 23 1. Give to eat little but

september often, the food is fine.
2014 For example porridge,
rice baby.
2. Provide oral hygiene
before eating.
3. Presscribe PO before
meals to prevent nausea
and vomiting.
4. Collaborate with
nutritionsist on
nutrition purchases
speader light soft fiber
diet.

PROGRESS NOTES

Patient’s Name : Mr. H

Age : 18 yers old
Register Number : 581902
No No HOUR EVALUATION SIGNATURE
DX
1. 1 18.00 S: patients say stomach still ached
with scale 3.
O: - patients appear weak
- Tenderness in the left lower
qudrant.
- Grimacing painfully.
A: the issue is resolved in part
P: 1-5 continued intervention in the
patients home outpatient return

S: Patients say they nausea and

vomiting.
.
O: - Debilatated patients
- Mucosa dry lips.
2. 2 18.00 - Body heat
- Bowel 6x/minure
- Turgor dry
- 3 liquid bowel movement.
A: problem has not been resolved
P: 1-5 continued intervention in the
patients home outpatient return