Name : Amalina Nur Fadhilah

NIM : P1337420217061

Nursing Care for Typhoid Fever Clients

Case Reports

Simple Assessment

A. Data Collection
1. Client Identity

Name : Mr.N

Gender :Male

Age : 25 years

Address : Mutiara Baru, RT 02 RW 11, kec Bojong Gede

Job : Private employee

Marital status: Not married

Religion : Islam

Hospital entry date: April 2, 2019

Date of Assessment: April 3, 2019

Medical Diagnosis: Thypoid Fever

2. Person in Charge Identity

Name : Mr.Y

Gender : Male

Age : 61 years

Occupation : Trader
 Address : Mutiara Baru, RT 02 RW 11, kec Bojong Gede

Relationship with clients: Father

3. Main Complaints

The client says fever

4. Health History
a. Medical History Now

Before the client was treated at the hospital the client said he had a fever, had not
defecated for 2 days, no appetite, for 4 days and had been dealt with stalls and the
client's condition There was no change. On April 2, 2014 the client's family took
the client to the Cibinong Hospital Hospital with the same complaints at home,
after the doctor's observation suggested that the client be treated at this hospital in
the flamboyant room of the internal medicine department.

b. Past Medical History

When it was conducted a study the client said he had not experienced this disease
before, usually only a normal fever and recovered after being given the drug stall
dank lien also said he had never been treated at the hospital before

c. Family Health History

The client said that his mother had had typhoid disease and was treated in a
medical center hospital for 3 days in 2012. The client's grandfather died due to
accident and head injury.

d. Psychosocial History

The client said he was worried and anxious about his illness, the client could
socialize well with other family and friends. Clients can also respond to medical
teams namely nurses and doctors.

e. Spiritual History
 Clients of the Islamic religion, before entering the client's hospital obeyed
praying diligently five full time, at the client's hospital rarely pray. Clients always
pray for a speedy recovery.

f. Everyday Patterns

No Habit pattern At home In Hospital

¤ Nutritional
1 pattern side dishes and vegetables - Team rice
- Eat - 3 times a day 1 full portion - 3 times a day, only 6
- eating type tablespoons or ½
- - frequency servings are used up.

Drink Water
Type Drinking - Water, tea and coffee - Approximately 3
- Frequency Approximately 1 liter glasses of aqua 1 cup
of 220 ml aqua

2 Elimination pattern mushy - Can't chapter

- BAB - yellow with a characteristic - Can't chapter
- Consistency odor - During the hospital
- color - 1x every day never chapter
- frequency
- BAK - Clear yellow Clear yellow
- color - 6x a day - 3 times a day
- frequency - Approximately 850cc - More or less 425
- volume

3 Activity pattern - Work - while in the hospital

the client just rests
and lies on the bed
4 Sleep rest patterns - Clients sleep from 9:00 to - Clients sleep from
- Night 5:00 23.00 to 05.00
 - Afternoon - Clients never take a nap - Clients take naps 2
to 3 hours per day

5 Personal hygiene - 2x a day - 1x a day

patterns - 2x 1 week - Not yet
Bathing - 1x 1 week - Not yet
Shampooing
Nail clippers

g. Physical examination
1. General situation: moderate
2. Awareness: composmetis (CM) when reviewed by the client's GCS
 Motor Response: 6 (follow orders)
 Speak Response: 5 (good orientation)
 Eye Response: 4 (spontaneously open eyes)
Total score: 15 (normal)
3. Vital sign
 Blood Pressure: 130/90 mmHg
 Pulse: 110 x / minute
 Respiration: 22 x / minute
 Temperature: 38, oC
4. Anthropometric examination
 BB before entering hospital: 67 kg
 Weight during assessment: 64 kg
 TB: 165 cm
 Ideal BB: (TB - 100) x 90%

= (165 - 100) x 90%

= 65 x

= 58.5 kg
5. Head to toe examination
a. Chief
 Inspection: symmetrical head shape, the color of black hair looks
clean, no visible cuts or bumps
 Palpation: not palpable tenderness, or lumps
6. Face
 Inspection: face looks pale. Face without redness oval face shape,
brown skin color, there is no scarring, clean skin, not oily and jagged
 Palpation: no tenderness or lumps
7. Eyes
 Inspection: symmetrical eye shape, anemic conjunctiva, colored sclera
 Palpation: not palpable tenderness or bumps, and the pressure of both
eyes the same
 Function: the eyes are still functioning properly can see and can read
in a long distance to close range
8. Nose
 Inspection: the shape of the nose is symmetrical, looks clean, there is
no scret and there are no bumps or sores
 Palpation: not palpable looking for presses or bumps
 Function: the sense of smell still functions properly without any
interference. Clients can distinguish between the smell of perfume and
the smell of wind oil.
9. Ears
 Inspection: the symmetrical shape of the ear looks clean and does not
look as serious as around the ear
 Palpation: no palpable pain or lumps
 Function: ear can still function properly can hear normally without the
help of a tool.

10. Mouth
  Inspection: mouth looks clean, teeth complete with yellowish brass color,
tongue looks clean with pink.
 Function: good tasting, clients can feel a variety of tastes, and there are no
distractions.
11. Neck
 Inspection: neck looks clean skin turgor is not visible swelling in the neck
area.
 Palpation: no palpable pain or lumps. And there is no swelling in the area
around the neck.
12. Thorax / back
 Inspection: symmetrical form of the thorax, when breathing the
development of the right and left lungs the same, normal respiration 22x /
minute
 Palpation: vocal fremitussama pressure, no tenderness in the chest.
 Percussion: there is a hyper sonor sound
 Auscultation: bronchovesicular client breath sounds (inspiration equals
expiration) no additional sounds
13. Abdomen
 Inspection: the client's stomach looks bloated, umbilicus is not prominent
and is in the middle, visible mass in the lower abdomen and abdominal
dysentery (bloating)
 Auscultation: audible client bowel sounds with a frequency of 9x / minute
 Palpation: palpable stool mass in the lower abdomen of the left quadrant.
 Percussion: when you tap, you hear a tympani sound
14. Upper extremity
 Inspection: both hands can be moved but the left hand is not disturbed
because of the RL infusion, looks sweaty
 Palpation: no tenderness, lumps
15. Lower extremities
 Inspection: both feet can be moved normally without the aid of any tools
  Palpation: no tenderness, lumps
 Function: the lower extremity is still functioning properly, there is no
interference with walking, squatting, or running.
16. Genetalia
 There are no complaints or problems in the genetal area,
17. Supporting examination
a. Urine examination
Laboratory Results April 3, 2019

Type of hecks Results Units

I.Urine
* Urine routine
-Colour Yellow Yellow
- Turbidity Clear Clear
-PH 7,0 4,7-7,0
-Glukosa (-) neg (-) neg
-Protein (-) neg (-) neg
-Billirubin (-) neg (-) neg
-Urobilin Normal Normal
-Blood (-) neg (-) neg
-leucocytes (-) neg (-) neg
-Nitrite (-) neg (-) neg
-keton (-) neg (-) neg
-spesific gravity (-) neg (-)neg
* Sendimen 1,010 1.000-1.030
-Eritrosit 1 0-1
-Leukosit 2 1-3
-Eoitel 2 <6
 b. Blood Checking
Laboratory Results on April 3, 2019

Type of hecks Results Units

1. Haematologi
-Hb 10,9* 12.6
-Leuco 6,55 4,5 – 10,5
-Diff count
-Basofil 0 0–1
-Fasinofil 0* 1–3
-Batang 0* 2–6
-Segmen 55 50 – 70
-Limfosit 44* 20 – 40
-Monosit 1* 2–8
-Hematokrit 33* 36 – 48
-Trombosit 212 150 – 400

2. Blood Chemistry
-SGPT 18 <36
-SGOT 19 <35
-Glucose moment 91,4 70-110
3.Immunulogi seralogi
-Widal test
-H
-AH 1/160* 1/80
-O 1//160* 1/80
-AO 1/80 1/80
1/80 1/80

c. Digital testing
Done to detect the presence of antibodies against salmonella typhi bacteria.
In the widal test an agglutination reaction occurs between the salmonella
tupi bacterial antigen and the salmonella antibody which has been turned
off and treated in the laboratory. Widal test is intended to determine the
presence of agglutinin in the serum of patients with typhoid fever suspects.