1

CHAPTER 2
NURSING CARE

Student name : Novia Fergina

NIM : 2017.C.09a.0857
Practice room : Space Aster
Date Practice : 11 April 2019
Date & Time Assessment : 2 April 2019, 14:30 pm

3.1 ASSESSMENT
3.1.1 IDENTITY OF PATIENTS
Name : Tn.A
Age : 70 yrs
Gender : Man
Tribes : Dayak
Religion : Christian Protestant
Work : Private
Education : SD
Marital status : Married
Address : Jl.B. Koetin
date MRS : March 29, 2019, 19:25 pm
Medical diagnosis : Aplastic anemia

3.1.2 HISTORY OF HEALTH / CARE

1. Main complaint :
Clients say right upper abdominal pain accompanied by fever.
P = Non-traumatic puncture Q = Stabbed R = Stomach (no spread)
S = Medium (4) T = <30 minutes
2. hospital sheet now:
Clients said on March 29, 2019, client Chapter black, black vomit, and the
limp body could not stand up later at 19:15 pm was taken to hospital
clients Dr.Doris Sylvanus Palangkaraya arrived in the ER at 19:25. In the
given client IGD Inf.NaCl 0.9% 15 500 ml 15 TPM, injection omeprazole,
 2

kalnex injection, and injection lansoprazole. Furthermore, clients brought

to the room next Aster for hospitalization and for intensive treatment
3. Disease Previous history (history of the disease and surgical history)
Clients said there was no pain and never operation
4. The Family Disease History
Clients say no history of hereditary disease.

Genogram FAMILY:

INFORMATION:
= Male
= Women
= Death
= Family ties
= Married
= Stay at home
= Patients

3.1.3 Physical examination

1. circumstances general:
 3

Clients look sick moderate, semi-Fowler's position, awareness compos

mentis, installed drip infusion of NaCl Adona 1 ampoule 15 TPM in the
hands of the right hand
2. Mental Status
a. level of Consciousness : compos mentis
b. Facial expressions : Quiet, no restless
d. How to lay down / move : Supine
e. speak : clear
f. Mood : Calm
g. Appearance : Pretty neat
h. Cognitive function:
 Orientation time : Clients can distinguish between
morning, afternoon, and evening
 Orientation People : Clients can recognize health workers,
nurses, and family
 Orientation Points : Client acknowledges being in hospital
i. Hallucinations: None
j. The thought process: No
k. Insight: Good
m. Defense mechanism: Adaptive
n. other complaint : There is no

3. Vital Signs
a. Temperature / T : 38, 1 0C  axilla  rectal  oral
b. Nadi / HR : 105 x / mt
c. Breathing / RR : 20 x / tm
d. Blood Pressure / BP : 140/60 mm Hg

4. Breathing (Breathing)
Chest shape : Symmetrical
Smoking habit : There is no
 4

Cough : There is no
 coughing up blood : There is no
 sputum : There is no
 cyanosis : There is no
 Chest pain : There is no
 Dyspnea chest pain  Orthopnea  Others: None
 Out of breath  When inspiration  When activity  During a break
Type Breathing :  Chest  Stomach  Chest and Abdomen
 Kusmaul  Cheyne-Stokes  Biot
 Others: None
Breathing rhythm :  Regular  Irregular
breath Sounds :  vesicular  Bronchovesikuler
 bronchial  tracheal
Additional Breath Sounds :  wheezing  dry Rochi
 Ronchi wet  Others: None

Other complaint : There is no

Nursing issues : There is no

5. cardiovascular (Bleeding)
 Chest pain  leg cramps  Pale
 Dizziness / syncope  clubing finger  cyanosis
Headache  palpitations  fainting
 Capillary refill time  > 2 seconds  <2 seconds
 edema:  Face  upper extremities
 anasarca  lower extremities
 ascites
 Ictus cordis  visible  Not visible
Jugular Veins  not Increase  increase
Heart Sounds  Normal, S2> S1: Lub-Dub
 There abnormalities
Other complaint: There is no
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Nursing issues: Ineffective peripheral tissue perfusion

6. persyarafan (Brain)
GCS value: E :4
V: 5
M: 6
Total Value GCS : 15
Awareness:  compos Menthis  Somnolent  delirium
 Apathetic  Soporus  Coma
pupil :  Isokor  anisokor
 mydriasis  meiosis
Light reflexes:  Right  Positive  Negative
 Left  Positive  Negative
 Pain, Location: none
 vertigo  agitated  aphasia  pins and needles
 Confused  dysarthria  convulsions  tremor
 pelo
Cranial Nerve Test:
Cranial nerve I Patients can distinguish odors
Cranial nerves II Patients can see clearly
Cranial nerve III Patients can open the eyelids
Cranial nerve IV : The patient can move his eyes
Cranial nerve V Patients can open his mouth
Cranial nerve VI : The patient can move his eyes to the left
and to the right
Cranial nerve VII Patients can smile
Cranial nerve VIII Patients capable of responding when called
Cranial nerve IX : The patient can swallow
Cranial nerve X Patients may show reflex
Cranial nerve XI Patients can move the shoulder
Cranial nerve XII Patients can be stuck out his tongue
Test Coordination:
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Upper extremities : Finger to finger Positive 

Negative
Finger to nose  Positive  Negative
Lower extremities : Jempul heel to toe  Positive Negative
Body Stability Test :  Positive  Negative
Reflex:
Biceps :  Right Scale: +1  Left Scale: +2
triceps :  Right Scale: +1  Left Scale: +2
brachioradialis :
patellar :  Right Scale: +1  Left Scale: +2
Achilles :  Right Scale: +1  Left Scale: +2
Babinski :  Right Scale: +1  Left Scale: +2
Other reflex : There is no
complaints Lainya : There is no
Nursing Issues:There is no

7. Elimination of Uri (Bladder)

Urine production : 1000 ml 2-3x / day
Color : Yellow
Smell : Typical ammonia
 No problem / smooth  drips  Inkotinen
 oliguri  painful  retention
 polyuria  Hot  hematuri
 Dysuri  Nocturi
 catheter  Cystostomi
Other complaint : There is no
Nursing issues: There is no

8. Elimination Alvi (Bowel)

Mouth and pharynx
Lip : Dry
Tooth : There were dated (lower molars)
Gum : No Inflammation
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Tongue : Moist
mucous : Moist
tonsils : No Inflammation
rectum : No lesion / disorder
Hemorrhoids: None
CHAPTER : 1x / day Color: YellowConsistency: Soft
 No problem  Diarrhea  Constipation  bloating
 bloody stool  melena  Purgative  Lavement
Noisy Intestine: 6x / minute
Press pain: right upper belly
Bumps: None
Other complaint : There is no
Nursing issues: Acute pain

9. Bones - Muscles - Integumentary (Bone)

 The ability of motion  Free  Limited
 Parese, location : There is no
 Paralise, location : There is no
 Hemiparese, location : There is no
 Crackles, location : There is no
 painful , location : There is no
 Stiffness, location : There is no
 Flaccidity, location : There is no
 Spasticity, location : There is no
 Muscle size:  Symmetrical
 Atrophy  hypertrophy
 contractures  malposition
Muscle Strength Test:  Upper extremity 1111 5555

 Lower extremities 1111 5555

 Bone deformity, location : There is no
 Inflammation, location : There is no
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 Injury, location : There is no

 Fractures, location : There is no
Spine:  Normal  scoliosis
 kyphosis  lordosis

10. The skins Hair

history of allergy  Drug : There is no
 Food : There is no
 Cosmetics : There is no
 more : There is no
skin temperature Warm  Hot  Cold
Skin color  Normal  Cyanosis / blue  Jaundice / yellow
 White / pale  Dark brown / hyperpigmentasi
turgor  Well  Enough  Less
Texture  Smooth  Rude
lesions  Macula, location : There is no
 Pustules, location : There is no
 Nodules, location : There is no
 Vesicles, location : There is no
 Papules, location : There is no
 Ulcer, location : There is no
scarring : There is no
Hair texture : Not visible closed head wound dressings
Distribution Hair: Black evenly
nail shape :  Symmetrical  irregularity
 clubbing  Others: None
Nursing issues: There is no

11. Sensing System

a. Eyes / Vision
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visual function :  diminish  hazy

 ganda  Blind / dark
Eyeball movement :  normal move  silent
 Moving spontaneous / nystagmus
vision : Eyes Right (VOD): 6/6
Left eye (VOS): 6/6
sclera :  Normal / white  Yellow / icterus  Red / hyphema
Konjunctiva :  Pink  Pale / anemic
cornea :  Clear  cloudy
AIDS :  Eyeglasses  Contact lens 
more
painful : There is no
Other complaint : There is no
b. Ears / Hearing: Normal
Hearing function:  diminish  buzz  Deaf
c. Nose / Smell : Normal
Form :  Symmetrical  Asymmetric
 lesions : There is no
 patency : There is no
 obstruction : There is no
 Tenderness sinus: None
 Transluminasi : There is no
Nasal cavity: Color: No secretion Integrity :-
Nasal septum:  Deviation  Perforation  Bleeding
Secretion, color None secretion
 polyp  Right  Left  Right and left
Nursing issues: Peripheral perfusion ineffective

12. The neck and lymph glands

Mass  Yes  Not
Scar tissue  Yes  Not
Lymph nodes  palpable  impalpable
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Thyroid gland  palpable  impalpable

mobility Neck  Free  Limited

Nursing Issues: There is no problem of nursing

13. Reproductive System

a. Male reproductive
Redness, Location: Not examined
Itching, Location: Not examined
Gland Penis: Not examined
Maetus Urethra: Not examined
Discharge, color: Not examined
Srotum: Not examined
Hernia: Not examined
Abnormalities: Not examined
Another complaint: Not reviewed.

3.1 4 PATTERN FUNCTIONS OF HEALTH

1. Perception on Health and Disease:
Clients say that it is a healthy body does not feel pain conditions / disorders. And
pain is a feeling where the body does not feel comfortable and if ill should seek
treatment
2. Nutrition and Metabolism
TB : 153 cm IMT: BB: TB2 (M) =
46: 2.3409 = 19.65 (Normal)
BB now : 46 kg
Before BB sick : 48 kg
Diet:
 ordinary  Liquid  strain  Soft
Special Diets:
 low salt  low calorie  TKTP
 Low fat  low purine  Others: None
 Nausea
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 Vomiting ............ times / day

difficulty swallowing  Yes  Not
thirst
Other complaints: There is no
Everyday Diet after Pain before Pain
Frequency / day 3x1 3x1
Portion Less well (½ servings) Good (1 serving)
Appetite Not good Well
type of Food Rice, vegetables, side Rice, vegetables, and
dishes, and fruit side dishes
Beverage type Water Water

The number of drinks / ± 1,500 cc ± 2000 cc

cc / 24 hours
Eating habit Morning afternoon Morning afternoon
Evening Evening
Complaints / problems Lack of appetite Good appetite

Nursing Issues: Risk deficit nutrsi

3. The pattern of rest and sleep:

Clients seem to sleep soundly and comfortably.
Night sleep pattern: 10-11 hours (After illness)
9-10 hours (before pain)
Pattern nap: 1-2 hours (After illness)
1 hour (before pain)
Nursing issues: No Issues Nursing
4. Cognitive:
Clients and family already know the disease after being given an explanation of
doctors and other medical personnel.
Nursing issues: No Issues Nursing
5. The concept of self (self-image, ideal self, identity, self-esteem, role):
picture of yourself : Clients always like everything on him
ideal self : The client wished a speedy recovery
Personal identity : Clients say I was a father
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Pride : Client tidak embarrassment to the current situation

The role of self : Clients tell me a husband
Nursing issues: No Issues Nursing
6. Daily Activities
Before ill clients can move independently, but after sick most client activity
assisted by the family.
Nursing issues: No Issues Nursing
7. Koping-Tolerance to stress
Clients said that when he was there was a problem, he always told the family.
Nursing issues: No Issues Nursing
8. Value Patterns Confidence
Clients believe in their own religion.
Nursing issues: No Issues Nursing

3.1.5 SOCIAL - SPIRITUAL

1. Ability to communicate
Verbally, the patient can communicate well.
2. Colloquially
Dayak language
3. Relationships with family
Good and harmonious.
4. Relationships with friends / health care workers / others
Well. Clients can work with nurses in the delivery of nursing actions.
Relationships with friends and others also good.
5. People mean / nearby
Wives, children and families.
6. The habit of using spare time:
Clients say the habit of using his free time with family
7. Activity worship:
Clients say when sick less routine of worship
SUPPORTING DATA 3.1.6 (radiological, LABORATO RIUM, ENABLING MORE)

Results of laboratory tests March 30, 2019

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No. Parameter Result Unit Ref. Range

1. WBC 6.69 x 10 ^ 3 / uL 4:00 to 10:00

2. RBC 2.91 x 106 / uL 4:00 to 5:50
3. HGB 8.7 g / dL 12.0 to 16.0
4. PLT 72 x 103 / uL 150- 400

Laboratory Examination Results March 17, 2019

No. Parameter result Unit The normal
value
1. glucose when 142 mg / dl <200

2. creatinine 0.84 mg / dl 0.7 to 1.5

3. Hbs Ag (-) / negative (-) negative

1.3.7 MEDICAL MANAGEMENT

No. Name of drug / fluid Dose Route Indication

1. The infusion of NaCl 500 ml intraveno In lieu of body fluid

0.9% 15 TPM us

2. Adona 3 x 50 intraveno To cope with the condition

mg us of bleeding due to a
decrease in capillary
resistance capillary
permeability
3. injection 2 x 30 intraveno To cope with the disease by
lansoprazole mg us excess stomach acid
production

4. injection Kalnex 3 x 500 intraveno Reduced bleeding injury

mg us

5. Po Sucralfat 3x1 oral To treat the condition

increased production of
gastric acid
6. transfusion PRC 2 kolf intraveno Oxygen carrier (such as
transfusion TC 6 kolf us erythrocytes
To meet the needs of red
blood cells because of
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thrombocytopenia

7. PCT 500 mg Reduce fever, relieve

oral headaches, toothache and
other minor aches

Palangkaraya, 2 April 2019

College student,

Novia Fergina

Table 3.2 data analysis

DATA ANALYSIS
SUBJECTIVE AND
OBJECTIVE DATA POSSIBLE CAUSE PROBLEM
DATA
1. DS: Client says pain Excessive destruction of acute pain
accompanied by swelling erythrocytes
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back of his hand section

DO: - Punggun left hand The hemoglobin level drops
was swollen (edema)
- Face pale clients
Pengahantar cell Komparten
- Temperature of hot skin oxygen / nutrients to cells
- fast pulsed Nadi lacking
Laboratory Results:
WBC: 4.95 x 10 ^ 3 / uL
Peripheral perfusion
RBC: 2.84 x 10 ^ 6 / Ul ineffective
HGB: 8.7 g / dl
PLT: 72 x 10 ^ 3 / uL

2. DS: Client says lack of

appetite The risk of nutritional
Increases gastric activity
DO: The client appears deficits
not want to eat
- The food seemed not Increased gastric acid
spent (½ servings)
- Dry lips
Stomach muscle contraction
- Client appears to extend
Po Sucralfat 3 x 1
BB before the illness: 48 Nauseous vomit
kg

BB after illness: 45 kg
BMI: normal 19.65
Inadequate intake

The risk of nutritional

 16

deficits
3. DS: Clients say the
upper right abdominal acute pain
Edema and inflammation
pain
P: Non trauma
Q: Stabbed and needles Release of chemical
R: Stomach (no spread) mediators

S: 4 (medium)
T: <30 minutes Stimulates pain receptors

Increased gastric acid

acute pain
4. DS: The client says it is
a fever Hipertermi
DO: Clients looks fever inflammation

TTV:
Temperature: 38.1 ° C The accumulation of
BP: 140/60 mmHg monocytes, macrophages, T
RR: 20 x / min helper cells and fibroblasts

N: 105 x / min

The release of endogenous

pyrogens (cytokines)

interleukin -1
interleukin -6

Stimulating the vagus nerve

 17

The signal reaches the

central nervous system

Prostaglandin formation of
brain

Stimulates the
hypothalamus increases the
temperature reference point

Increased basal temperature

Hipertermi

PRIORITY ISSUES
1. Peripheral perfusion is not effectively connected with hemoglobin levels fall
marked with the back of the left hand swelling (edema)
2. The risk of nutritional deficits associated with inadequate intake
3. Acute pain associated with increased gastric acid characterized by a client of
said upper right abdominal pain
4. Hipertermi associated with increased basal temperature
18

Nursing Interventions 3.3
Patient Name: Tn.A
Rawat space: Aster (A-7)
Nursing diagnoses Objectives (outcomes)
1.Perfusi ineffective After nursing measures 3 x 7 hours is
peripheral associated expected to back the effective
with hemoglobin levels peripheral perfusion with outcomes
fall 1. The upper limb is no longer edema
2. The normal pulse rate 60-100 x /
min
3. The conjunctiva is not anemic
4. The normal hemoglobin level From
12.0 to 16.0 g / dL
5. Capillary refill time <2 seconds
19
Nursing Plan
Intervention Rational
1. Observe general conditions and TTV 1. By observing the general condition and
2. Evaluation of peripheral edema and vital signs can mengtahui general
pulse condition and vital signs
- Protect the upper limb edema section 2. Provide information about the network
of injury and help keadekutan intervention needs
- Monitor the time and capillary 3. To increase the levels of hemoglobin
instability to the conjunctiva
- Check the results of laboratory
hemoglobin
3. Provide information to clients and
families to report in case of bleeding
4. Collaboration of PRC transfusions
and blood TC to meet the needs of
clients
1. Knowing the client's intake and output

2. The risk of After a 7-hour nursing actions 3x
nutritional deficits expected client's nutritional needs are
associated with met with the expected outcomes: 1.
inadequate intake Increasing client appetite
2. Intake and normal output
After nursing measures 3 x 7 hours of
acute pain is reduced by the expected
3. Acute pain associated outcomes:
with stomach acid to 1. The client reported no pain
rise anymore
2. The client looks rilexs
3. TTV stable
After the act of nursing for 3 x 7 hours
4. Hipertermi associated is expected to return to normal body
1. Observation intake and output
2. Encourage clients to eat little but
often
- Encourage clients to eat while warm
3. Provide information to clients to eat
nutritious food in order to meet the
nutritional needs
4. Collaboration with nutritionists to
increase the BB
1. Observe general conditions and TTV
2. Adjust the position of the clients as
comfortable as possible semi-Fowler
3. Teach relaxation and distraction
techniques
4. Collaboration with physicians in
providing analgesic to relieve pain
1. Observe general conditions and TTV
20
2. In order for the nutritional needs are
met
3. Eat while warm may reduce nausea
4. Increase in BB
1. Knowing the general state stability and
TTV
2. Adjust the position as comfortable as
possible may reduce pain dirasakaan
3. Provision of analgesics can handle the
pain
1. By observing the general condition and
vital signs can determine the general

with increased basal temperature client with a criterion of
temperature the results:
1. The client does not complain of
fever / increase in body temperature
2. Normal body temperature:
36,3- 37.7 oC
2. Provide warm water compresses to
the client
- Encourage clients to drink plenty of
water at least 1000 cc (1 liter) in 1 day
3. Provide information to clients or
families to report if there is an increase
in body temperature
4. Collaboration with the doctor for
giving antipyretic
21
condition and body temperature,
especially TTV client
2. Giving a warm compress is able to
dilate blood vessels, which will accelerate
the transfer of heat from the body to the
skin
- Increased body temperature increases
evaporation so it needs to be balanced
with a high fluid intake.
3. Provision of antipyretics transform and
accelerate the healing process and quickly
lower demam.Pemberian pertumbuha
inhibiting antibiotics and the infection
process.

3.4 Implementation and Evaluation of Nursing
IMPLEMENTATION AND EVALUATION OF NURSING
Patient Name: Tn.A
Rawat space: Aster (A-7)
ate Clock Implementation
il 2, 2019 Implementation of the day Tuesday, April 2nd,
2019 at 16:50 pm
1. Observe general conditions and TTV
Peripheral - General appearance: Clients look sick moderate,
Effective semi-Fowler's position, installed drip infusion of
NaCl Adona 1 amp the hands of the right hand
Implementation of the day Tuesday, April 2nd,
2019 at 16:10
2. Evaluate peripheral edema and pulse
- Back hand edema began to decrease with depth
assessment of the degree 1 to 2 mm and a back 3
seconds
- pulse 95 x / minute
Protect the upper limb edema from injury
- The back hand edema protected from injury
Monitor the time and capillary instability to the
conjunctiva
- Capillary normal time <2 seconds, conjunctival
still looked anemic
Check the results of laboratory hemoglobin
- Results of laboratory hemoglobin: 9.2 g / dL
Implementation of the day Tuesday, April 2,
2019, at 16:50 pm
3. Provide information to clients and families to
22
Sign
Evaluation (SOAP)
na
Evaluation of the day Wednesday, April 3, 2019,
15:00 pm
S = Clients say no more dizziness, weakness
O: General appearance: The client looks sick
moderate, semi-Fowler's position, installed drip Novia
infusion of NaCl Adona 1 amp 15 TPM in right
hand
- Back hand edema decreases with depth
assessment of the degree 1 to 2 mm and a back 3
seconds
- The back hand edema protected from injury
- Capillary normal time <2 seconds
- The conjunctiva is still looked anemic
Novia
- Results of laboratory hemoglobin: 9.2 g / Dl
- Clients and families seemed cooperative
- Provision of transfusion PRC = 2 kolf
- Giving transfusions TC = 6 kolf
TTV
BP: 140/60 mmHg RR: 20 x / min
N: 95 x / min S: 36.5 ° C
A: The issue is resolved in part Novia
Q: Continue interventions
1. Observe general conditions and TTV
2. Evaluation of peripheral edema and pulse
- Protect the upper limb edema section of injury

report in case of bleeding
- Clients and families seemed cooperative
Implementation of the day Tuesday, April 2 at
16:55 pm
4. Collaborate PRC transfusion and blood TC to
meet the needs of clients
- Giving transfusions PRC = 2 kolf
- Giving transfusions TC = 6 kolf
il 2, 2019 Implementation of the day Tuesday, April 2,
2019, at 17:16 pm
tritional 1. Observe client intake and output
- Intake and normal output
Intake = 1500 ml
Output = 2000 cc
Implementation of the Tuesday, April 2, 2019, at
17:18 pm
Implementation of the day Tuesday, April 2,
2019, at 17:20 pm
2. Encourage clients to eat little but often
- The client seemed so little but often
Advise clients to eat while warm
- The client looks eat while warm
Implementation of the day Tuesday, April 2,
2019, at 17:25 pm
3. Inform the client to eat nutritious food in order
to meet the nutritional needs
- The client seemed cooperative
23
- Check the results of laboratory hemoglobin
3. Provide information to clients and families to
report in case of bleeding
4. Collaboration of PRC transfusions and blood
TC to meet the needs of clients
Evaluation of the day Wednesday, March 3, 2019,
at 16:00 pm
S: Client says his appetite began to exist and
increase
O: Intake and normal ouput
- Intake = 1,500 cc Novia
- Output = 2000 cc
- Clients seem to eat little but often
- The client looks eat while warm
- The client seemed cooperative
- Granting Appetite TKTP diet started there
A: The issue is resolved in part
Q: Continue interventions
1. Observe the general circumstances and TTV
2. Encourage clients to eat little but often
- Encourage clients to eat while warm
3. Provide information to clients to eat nutritious
food in order to meet the nutritional needs
4. Collaboration with a nutritionist to improve BB
Novia

Implementation of the day Tuesday, April 2,
2019, at 17. 28 pm
4. Collaborate with a nutritionist to improve BB
- Provision of diet TKTP
Implementation of the day Tuesday, April 2,
2019, at 17.35 pm
April 3, 2019 1. Observe general conditions and TTV
- General appearance: The client looks ill being,
the client looks relaxed semi-Fowler's position,
Acute Pain installed drip infusion of NaCl Adona 1 amp 15
TPM in right hand
- TTV
BP: 140/60 mmHg RR: 20 x / min
N: 95 x / min S: 36.5 ° C
Implementation of the day Tuesday, April 2nd,
2019 at 17:37 pm
2. Adjust the position of the client as comfortable
as possible semi-Fowler
- The client lies with semi-Fowler's position
Implementation of the day Tuesday, April 2nd,
2019 at 17:40 pm
3. Teach relaxation and distraction techniques
- Client practicing relaxation techniques and
distractions
Implementation of the day Tuesday, April 2nd,
2019 at 17:45 am
4. Collaborate with physicians in providing
analgesic to relieve pain
- The client is given the injection lansoprazole 30
24
Evaluation of the day Wednesday, April 3, 2019,
17:00 pm
S: The client said reduced pain
O: - General appearance: The client looks ill
being, the client looks relaxed semi-Fowler's
position, installed drip infusion of NaCl Adona 1
amp 15 TPM in right hand
- TTV
BP: 140/60 mmHg RR: 20 x / min
N: 95 x / min S: 36.5 ° C
- The client lies with semi-Fowler's position
- Client practicing relaxation techniques and
distractions
- The client is given the injection lansoprazole 30
mg 2x
A: The issue is resolved in part
Q: Continue interventions
1. Observe general conditions and TTV
2. Adjust the position of the clients as comfortable
as possible semi-Fowler
3. Teach relaxation and distraction techniques
4. Collaboration with physicians in providing
analgesic to relieve pain

mg 2x
Implementation of the day Tuesday, April 2,
il 2, 2019 2019, 17:50 pm
1. Observe general conditions and TTV
- General appearance: Clients look sick moderate,
semi-Fowler's position, installed drip infusion of
NaCl Adona 1 amp 15 TPM in right hand
- TTV
pertermi BP: 140/60 mmHg RR: 20 x / min
N: 95 x / min S: 36.5 ° C
Implementation of the day Tuesday, April 2,
2019, at 17:05 pm
2. Provide warm water compresses to the client
- Clients compressed warm water
Advise clients to drink plenty of water at least
1000 cc (1 liter) in 1 day
- Clients seem to drink water as much as 1000 cc
in 1 day
Implementation of the day Tuesday, April 2,
2019, at 17:15 pm
3. Inform the client or family to report seeing an
increase in body temperature
- Clients and family cooperative
Implementation of the day Tuesday, April 2,
2019, at 17:18 pm
4. Collaborate with the doctor for giving
antipyretic
- The client is given the oral drug PCT 500 mg
25
Evaluation of the day Wednesday, April 3, 2019,
18:00 pm
S: The client says no more fever
O: - General appearance: Clients look sick
moderate, semi-Fowler's position, installed drip
infusion of NaCl Adona 1 amp 15 TPM in right
hand
- TTV
BP: 140/60 mmHg RR: 20 x / min
N: 95 x / min S: 36.5 ° C
- Clients compressed warm water
- Clients seem to drink water as much as 1000 cc
in 1 day
- Clients and family cooperative
- The client is given the oral drug PCT 500 mg
A: The issue is resolved in part
Q: Continue interventions
1. Observe general conditions and TTV
2. Provide warm water compresses to the client
- Encourage clients to drink plenty of water at
least 1000 cc (1 liter) in 1 day
3. Provide information to clients or families to
report if there is an increase in body temperature
4. Collaboration with the doctor for giving
antipyretic
 26

BIBLIOGRAPHY

Bakhshi.2009. Aplastic Anemia.http://www.emedicine.com, Accessed on: March 1st, 2019

Devotees. 2006. Clinical Hematology Brief. EGC: Jakarta
Carpenito, Lynda Juall.2009. Applications of Nursing Diagnosis Clinical Practice Edition 9. In Jakarta:
EGC
Specialist Doctors Association of Indonesia. 2007. Internal medicine textbook. FKUI: Jakarta.
Price, Sylvia. 2005. pathophysiologic: Concept Clinical disease processes. Jakarta: EGC