NAMA : CELIA KRISTIANA PUTRI

NIM : 01.2.22.00805

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
November 2022, Medical Record number 1096970, with a medical diagnosis of typhoid fever.
The patient was brought to Private Hospital on November 10th 2022 by his wife,Mrs. L at
10.00 a.m. Nursing assessments were conducted on November 10th , 2022 at 11.00 a.m.
The 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 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 38.9oC, 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.
The 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, write the nursing
diagnose, prioritize it from high to low priority.
Write this assignment in Ms. Word. The deadline for submission of assignments at 08.00 a.m on
29thNovember 2022
Note : If the desired data is not in the case study, consider the data as normal.
-- Good Luck --
 Data Etiology Nursing Problem

Subjective Data : Infection produced primarily Hyperthermia

The Patient said that He had a fever that by Salmonella enterica serotype typhi
appeared during the day and gradually in the digestive tract
normalized towards the evening for 5
days
Objective Data : Inflammation
 The general condition of the
patient is weak, and pale
 The level of consciousness is Endotoxin
compos mentis
 Hot acral.
Vital Signs : Hyperthermia
 Blood pressure = 120/80 mmHg,
 Pulse = 80 x/minute, weak
 Temperature = 38.9oC, in axilla
 Respiration Rate = 15 x/minute,
 SpO2 = 99%, room air

Subjective Data : Infection produced primarily Imbalanced nutrition:

The patient complains of abdominal by Salmonella enterica serotype typhi less than body
discomfort, nausea, bloating and lacked in the digestive tract requirements
appetite
Objective Data :
 The general condition of the Inflammation
patient is weak and pale
 The patient eat 3 times per day
only ¼ portion of meals Dry oral mucosa and oral thrush
 The patient drinks approximately
six glasses (250cc / glass) per
day with warm water or hot tea Nausea, Anorexia/Less Intake
 In the upper extremity of left
hand was attached 0.9% 14 drops
per minute NaCl infusion Imbalanced nutrition: less than body
 The patient's mouth was found to requirements
be dry oral mucosa and oral
thrush, tenderness in epigastrium
area
Vital Signs :
 Blood pressure = 120/80 mmHg,
 Pulse = 80 x/minute, weak
 Temperature = 38.9oC, in axilla
 Respiration Rate = 15 x/minute,
 SpO2 = 99%, room air

Subjective Data : Infection produced primarily Activity Intolerance

The patient said that feels limp and does by Salmonella enterica serotype typhi
not have the energy to do activities
Objective Data :
 The general condition of the Inflammation in the digestive tract
patient is weak and pale
 The patient's activities are
assisted by family and nurses Nausea, Anorexsia, Less Intake
Vital Signs :
 Blood pressure = 120/80 mmHg,
 Pulse = 80 x/minute, weak Mandatory bed rest
 Temperature = 38.9oC, in axilla
 Respiration Rate = 15 x/minute, Activity Intolerance
 SpO2 = 99%, room air

Nursing Diagnose:
1) Hyperthermia related to underlying infectious process by Salmonella Typhi as evidenced by
temperature 38.9oC.
2) Imbalanced nutrition: less than body requirements related to less intake as evidenced by nausea
and lacked appetite.
3) Activity Intolerance related to mandatory bed rest as evidenced by weakness