Nama : Siti Sopiah

Nim : 4003190050
D3 Keperawatan B

NURSING REPORT HYPERTERMIA

A. Assessment
1. Identify
Name : An. F
Age : 12 years old
Gender : Male
Adress : Kuin selatan
Religion : Islam
Tribes : Jawa

2. The identity of the person responsible

Name : Ny. E
Age : 33 Years old
Gender : Female
Address : Kuin selatan
Work : IRT
Relationship with patients : Biological mother

1. Assessment

A . General circumstances

Fever
B. Current medical history
The patient came to the islamic hospital delivered by his family on Desember 2, 2019 with
complaints of heat for the past 2 days before entering the hospital
C. Past medical history
The client’s mother said that her child had never been treated in a hospital with the same
complaint, namely fever, the client was not allergic to drugs
D. Family health history
The client’s mother said that in her family no one had the same disease as the patient.
E. Assessment of the patient’s basic needs
- Activities and training
Before getting sick : the client’s daily activities are school and also playing
like other children his age
When sick : the client said he could not do other activities such as school
and aoso playing, the client seemed to be lying weak on the bed
- Rest and sleep
Before getting sick : the client sleeps 9 hours a night and takes a nap 2
hours
 When sick : the client says sleep for 7 hours a night because the client
often wakes up at night while sleeping.
- Comfort and pain
The client’s mother says her child often cries when the fever is high
- Nutrition
Before getting sick the patient’s diet was good but when in the hospital
the patient had no appetite, the portion spent was only ½ portion
provided by the hospital
- Liquids and electrolytes
The patient’s mother said that when he was sick the patient’s drinking
pattern was good, elastic skin turgor
- Oxygenation
The patient’s mother said her child did not have a history of shortness of
breath
- Elimination
The patient’s mother said that before the illness and when the BAK was
reviewed the client was still good and normal
- Elimination of bowed
The client’s elimination said before being sick and while at BAB’s hospital
the client was still good 1x a day every morning, yellowish brown and
distinctive smell
- Sensory, perception, and cognitive
- The client’s mother said her child did not have a disturbance in the
sensory system, perception, and also cognitive.

2. Physical examination
- General circumstances
When a physical examination is obtained the vital sign results
Blood pressure : 100/70 mmHg
Pulse : 97x/minute
Body temperature : 38,7°C
Rate repiration : 26x/minute
- Head
Mesocepal head shape, clean black hair, conjunctival eye condition is not anemic,
aninkteric sclera, absent nose or abscess nose and no polyp enlargement, the ear
appears to be cerumen, symmetrical, no stomatitis, no cavities, yellow teeth, the
situation looks dirty
- Neck
No enlargement of the thyroid gland
- Chest
Inspection : Symetris, no chest retraction
Palpation : palpable vocal virration of fermitus
Percussion : sonor
Auskultation : vesicular no additional btreath sounds
- Heart
 Inspection : not visible ictus cordis
Palpation : palpate ictus cordis
Percussion : dim
Auskultation : S1, S2 regular
- Abdomen
Inspektion : there is no edema or injury
Auskultation : bowel sound 20 x/minute
Palpation : no tenderness
Percussion : timpani
- Ekstermities
Upper extremity : attached infusion RL 10 tts/minute, skin feels warm
Lower extremity : there is no edema or injury, skin feels warm
3. Supporting investigation
Laboratorium

4. program
- Pamol oral 6 ¾ x tab if it’s hot
- Rl 10 tts/minute

5. Data analysis
 Data :
Ds : The client’s mother said his child was fever from 2 days ago
Do :
Skin feels warm
Blood pressure : 100/70 mmHg
Pulse : 97x/minute
Rate respiration : 26x/minute
Body temperature : 38,7°C

 Problem

Hypertermia

 Etiology
Infection process