NURSING CARE AT Mr.T WITH MEDIC DIAGNOSE HEPATITIS AT ROOM CEMPAKA REGIONAL HOSPITAL CILEGON A.Study 1. Identity a.

Client Name Age Sex Religion Education !ccu"ation Address Status o$ material %ate enter to os"ital %ate o$ learning No. cm %iagnose &. .nder /riter Name Age Sex Religion Education !ccu"ation Address Relations i"

:Mr.T : 26 years old : Male : Moslem : Senior ig sc ool : Teac er : Eart Sudiang #ermai : Single : %esem&er 21t ' 2(12 : !cto&er 22t ' 2(12 : )*+,2 : -e"atitis :Mr.R : +6 years old : Male : Moslem : Senior ig sc ool : Em"loyee : Eart Sudiang #ermai : 0at er

2. Client he lth hi!t"ry a. Es"ecial sig t. Client. Com"lained "ain in t e u""er rig t a&doment. #. Pre!ent he lth hi!t"ry !n desem&er 21t '2(12'Client a$ter consuming alco olic &e1erages' t e client 1omiting'anorexsia and com"lained "ain in t e u""er rig t a&doment'"ain in t e a&doment $elt to increase i$ client a lot o$ mo1ement' "ain in a&doment scale ). ( : no "ain 1 : t ere "ain in a&doment

2 ) * +

: a little more "ain : agoni2ing : se1ere "ain controlled : se1ere "ain not controlled

Client also com"lained n u!e $. P !t He lth Hi!t"ry Client told t at e ne1er ex"osed HEPATITIS % d. & 'ily He lth Hi!t"ry Client told in t at e $amily' no one ad e"atitis 3 (. Phy!i$ l a. 4enerality Client $ace loo5ed "ale' $ace ex"ression /ince a/areness conm"os mentis )it l !i*n 3lood "ressure : 12(67( mm-g Res"iratory rate : 2) times $or a minutes -ealt rate : 7( times $or a Tem"erature : ),( C minutes

C. Re1ie/ o$ system Re!+ir t"ry !y!te' Symmetrical nose $orm't ere isn8t magni$ication o$ adenoid'&reat ing 1oice 1esicular /it $re9uency o$ &reat e 2) times $or a minute. He rt nd ,en"u! !y!te' Symmetrical &est $orm' t ere isn8t lesion' "ain in a&doment de"ress' / en do t e auscultation eard &y 1oice o$ lu" : S1 an S2; /it r yt m o$ regular. G !tr"inte!tin l !y!te' Symmetrical est $orm' dam" li" mucosa' teet seen rat er dirty' 1isi&le and rose colored tongue' mo1ement o$ $ree tongue t ere are no stomatitis' t ere are no tonsillitis client can8t $eel &elo1ed'"ositi1e "u5ing re$lect' a&doment is not symmetrical t ere is enlargement o$ t e e"ar' t ere are "ain in t e u""er rig t a&doment de"ress. Eyes sig t system Le-t eye <cteri5 sclera'anemia con=uncti1a'gro/t eyelas and eye&ro/ $latten'"u"il o$ meiosis moment gi1en &y excidement /it lig t &y touc /it cotton s"iral at cornea.

 Ri*ht eye <cteri5 sclera' anemia con=uncti1a'gro/t eyelas and eye&ro/ $latten'"u"il o$ meiosis moment gi1en &y excidement /it lig t &y touc /it cotton s"iral at cornea E r! '"uth nd t l.in* !y!te' Mout can ma5e a mo1e $reely' tongue loo5 a little dirty' symmetrical ear $orm' t ere are no edema at "inned' t ere are no cerument' t ere are no dry &lood at &ot and "inna o$ canali2e external auditor' client can orient to time' "lace' "eo"le. Client can communication /it nurse' "ro1en o$ client can ans/er / at is as5ed &y nurse. Intre*u'ent !y!te' 4ood us5 tugor can return lees t an 1 second' us5 do not eyanosis. Urin ry !y!te' %o not &e attac ed &y cat eter do/er. Mu!$ul"!.elet l !y!te' o Ta" extremity Is attac ed &y 5nac5 in$use 2( dro"6minute at le$t extremity $luent strem elastic us5 turgor "ositi1e "atella re$lect strengt o$ muscle *. o 3ottom extremity T ere are no odem t ere no lesion elastic us5 turgor' "ositi1e "atella re$lect strengt o$ muscle *. o Endocrine system T ere are no magni$ication o$ gland o$ tiroid. o Ner1ous system Ner1ous ol$actory :I; Client can sell eucaly"tus oil smell Ner1ous o"tics :II; Client can see &etter' client can road nurse name &adge' &etter in distance > 1 M /it out using s"ectacles. Ner1ous o5ulomatorius :III;

Ta5ing a &at Cut is nail @as ing air Teet &rus

o 2 times $or a day o 1 times $or a /ee5 o !nes $or a day o 2 times $or a day

e. P!y$h" !"$iety d t Client loo5 /ea5en and a dirty' client seen =um"y' $ace ex"ression /ince' client tell "ain in t e u""er rig t a&doment' client tell to /is 9uic5ly recor1er. -. Reli*i"n d t Client a moslem' client $eel sure t at t e disease o$ /ill recor1er.

*. Su++"rt d t
-emoglo&in S4!6S4#T Al&umin : 1( g6dl : *(6*? : )'+ g6dl

N " 1

Di--erent d t S% Client tell 1omiting Anorexsia Nausea S% Client com"laint #ain in t e u""er rig t a&doment. Scale "ain in a&doment. <imited mo1ement

Eti"l"*y Inade9uete inta5e

Pr"#le' Nutrition

#ain

Nur!e di *n"!e 1. Nutrition to t e situation anorexsia' gastrointestinal "ro&lem. S% !% Client loo5 /ea5en Client loo5 nausea Client tell anorexsia'nausea and 1omiting.

1. #ain in t e u""er rig t a&doment to in$lammation "rocces mar5ed &y : S% com"laint in u""er rig t a&doment !% Scale "ain in a&doment is )

NO . 1

Nur!e Di *n"!e Nutrition relate to t e t e anorexsia' gastrointestinal "ro&lem. S% Client tell anorexsia and 1omiting. !% Client loo5 /ea5en Client loo5 nausea

T r*et A$ter conducted Action &y treatment during t/o e9uals t/enty $our our Ex"ected &y /it criteria : AIncreased a""etite clients say AClient does not loo5 nausea. A$ter conducted Action &y treatment during t/o e9uals t/enty $our our Ex"ected &y /it criteria : Aclient say t e "ain disa""eared

Inter,enti"n A#ro1ide $ood little and o$ten according to t e diet. AColla&oration o$ nurse and doctor

R ti"n l AMinimi2ing anorexsia and nausea in connection /it uremic status. A to eliminate nausea6 1omiting and oral inta5e can increase.

#ain in t e u""er rig t a&doment to in$lammation "rocces mar5ed &y : S% Client com"laint in u""er rig t a&doment !% Scale "ain in a&doment is )

Study6note status o$ neurologist regulary and com"are /it 1alue o$ 4CS

Studying t e existence o$ tendency at le1el a/areness o$ Intra cranial "ressure and use$ul in determining extension 'location.

NURSING CARE AT Mr. T WITH MEDIC DIAGNOSE HEPATITIS AT ROOM CEMPAKA REGIONAL HOSPITAL CILEGON

Disusun oleh:

RIZQI HAMZAH FANSHURY NIM.3011041104

PROGRAM STUDI DIII KEPERAWATAN SEKOLAH TINGGI ILMU KESEHATAN FALETEHAN SERANG-BANTEN 2 !2

D ily $ti,ity
N". A$ti,ity At h"'e At h"!+it l

 1 Nutrient : a. Eat &. %rin5

0re9uency : ) times $or eac day Rice'$is '1egeta&les and $ruits #ortion : 1 "ortion $inis ed 0re9uency : *A6 glass eac day Mineral /ater'tea

0re9uency : ) times $or eac day Rice'$is '1egeta&les and $ruits #ortion : C "ortion not $inis ed 0re9uency : +A6 glass eac day Mineral /ater

Elimination a. %e$ecate

0re9uency : 1A2 times $or eac day Consistency: $la&&y Colour: 3ro/n Smell: ty"ical 0re9uency: +A6 times $or day Colour : Bello/ clean

0re9uency : 1 times $or eac day Consistency: $la&&y Colour: 3ro/n Smell: ty"ical 0re9uency: )A* times $or day Colour : %ra5 clean

&. Ta5e a "ee