KEDIRI BAPTIST HOSPITAL HEALTH SCIENCE COLLEGE

UNDERGRADUATE NURSING STUDY PROGRAM

MEDICAL-SURGICAL NURSING DOCUMENTATION

NURSING CARE TO PATIENT WITH TYPOID

IN OUT-PATIENT INSTALLATION OF KEDIRI BAPTIST HOSPITAL

1. Personal Data
Name : Mr. H Register Number: 581902
Age : 18 years old
Sex : Male
Religion : kristen
Address : Sumberejo, Ngasem-Kediri
Occupation :-
Date of Admission : -
Date of Assessment : September 23, 2014
Blood Group : Not Assessed
Medical Diagnosis : typoid
2. Chief Complaint
Patient said that he fever since three days ago liquid chapter nausea, vomiting
and pain stomach scale 4 .
3. History of Present
Illness
Patient said that he with complaint the agency still fever, nausea and vomiting.
Stomach pain and liquid chapter patient brought to the Installation of Kediri
Baptist Hospital to get nursing care.
4. History of Past Illness
Patient said that he had no history of hereditary diseases. Recently, she had
complaint of abdominal tenderness and pain when passing water.
5. History of Family Illness
Patient said that her family had no hereditary and infectious diseases such as
hypertension, Diabetes Mellitus, and TBC

Genogram
 I Information :

or = Die = Patient

= Male = marriage relationship

= Female = descendant relationship

= Staying at home

6. History of Psycho-Social and Spiritual

Psycho- : Patient can interact well with family mambers and

social nurses in hospital, patient speaks Javaness and
history Indonesian
Spiritual The patient was a kristen,
history

7. Activity Daily Living (Eat, Rest/Sleep, Elimination, Activity, Personal

Hygiene, and Sexual)

No Activity Daily In the house In the Hospital

Living
(ADL)
1. Fulfillment Of Eat / Drink Eat / Drink
Nutrition Quantity : - Quantity :
And Fluid Type : - Type :
Need 1) Rice : 1 times/day 5) Rice :
2) Side dishes : 6) Side dishes :
3) Vegetable : 7) Vegetable :
4) Drinking : ± 1600 8) Drinking :
cc/day Abstinence :
Abstinence : - Difficulty eating /
Difficulty eating / drinking :
drinking : - Efforts to overcome
Efforts to overcome difficulties :
difficulties : -
2. Elimination Urinating :2 -3 Urinating :
Quantity :
times/day
Defecate :
 Quantity : - Consistency : .
Defecate : 3-4 Problems and how to
times/day overcome :
Consistency : Not
mushy not slimy
liquid
Problems and how to
overcome : -
3. Rest/Sleep In the afternoon : ± 2 In the noon :
In the afternoon :
hours
In the night :
In the evening : -
Sleep disturbances :
hour Use of sleep medication
In the night : 7-8
:
hours
Sleep disturbances :
-
Use of sleep
medication : -
4. Personal Hygiene Frequency of bathing : 2 Frequency of bathing :
Hair washing
times/day
Hair washing frequency : frequency :
Frequency of tooth
3 times/week
Frequency of tooth brushing :
Nail circumstances :
brushing : 2 times/day
Change clothes :
Nail circumstances :
clean
Change clothes : 2
times/day after bathing

5. Other Activity 1) Routine Activity : 1) Routine Activity :

2) Activity in leisure
Patient as learning
time :
and school.
Everyday, her
activity is watching
and playing
2) Activity in leisure
time : Patient said
that she fill the
leisure time with
watching TV and
come together with
her family.
8. Condition / Appearance / General impression of the patient :
a. Patient looks dry lips and fever.
b. Patient looks pale and weak.
c. Patients seem grimaced in pain in the stomach.
d. Patient's general condition is good, awareness is composmentys.

9. Vital Sign :
0
a. Temperature : 38 C
b. Heart Rate : 80 x/menit
c. Blood Pressure : 120/70 mmHg
d. Respiratory Rate : 20 x/menit
e. Weigth / Heigth : 40 kg,......................cm.

10. Physical Examination

a. Head and Neck examination

Inspection : Head of the symmetrical attern, a little grey hair color, hair
looks lusterless.
Palpation : No assesment.
b. Integumen dan nail Examination
Inspection : Skin color caussacian, there’s no change color on the nails.
Palpation : Akral warm, the nail seemed quited clean
c. Mammae dan Axilla Examination (if necessary)
No Assesment
d. Sternum/Thorax Examination
Inspection of thorax : The form of thorax normla, the chest wall left and
right of the same, no abnormality on thorax.
Lung : No Assesment
e. Heart Examination
No assesmnet
f. Abdomen Examination
Inspection : No found the existence of the former surgery, the stomach
looked strained.
Palpation : The patient to experience the press at the lower of the
abdomen, pain scale 6.
g. Sex and surrounding areas Examination (if necessary)
Genetalys : No assesment
Dubur : No Assesment
h. Musculosceletal Examination
MMT : 5 5 Explanation:5=Can hold gravity, prisoners
maximum. 5 5
i. Neurology Examination
Awareness : Composmentys
GCS : E=4, V=5, M=6
Explanation : 4 = The response to open eyes spontaneously.
 5 = Orientation good
6 = Follow orders well
j. Mental status Examination
1) Patient can recognize herself
2) The patient not having disorientation with the environment, people, and
time.
3) Patient can communicate well with the family and all the nurse.

11.Laboratory Result
Date : No assesment
No Examination Result Normal Value Interpretation
of result
1.
2.
3.
4.
5.
12. Implementation/Therapy
1. Ampisilin 3 x 1 tablet
2. Kloram fenlkol 250 mg 3x1
3. Kontrimoksasol 2x2 tablet
4. Paracetamol 500 mg PRN (tablet)
13. Client/Family expectations with respect to the disease
Patient said that she wanted to recovery from his illness and could do the job /
activity as usual day.

Student’s Signature

Eka faridatul

DATA ANALYSIS
Patient’s Name : Mr. H
Age : 18 yers old
Register Number 581902
 Subjective Data Problem Etiologi
Objective Data

Subjective Data : Comfortable disorders Salmonela thyposa

Patient said that stomach pain
pain with a scale of 4. Digistive tract
Objective Data :
1. Patient looks weak. Absorbed by the smal
2. Patients seem intestine
grimaced in pain.
3. Patient appears Bacteria in the
holding his stomach systemic blood
in the left lower flow
quadrant.
4. Pain scale 4 Liver

Nutrion less than body Hematomegali

requirements
Pain palpability
Subjective Data :
Patient said that he Comfortable disorders
nausea an vomiting. pain
Objective Data :
1. debilitated
patients
2. mucosal dry lips the lymph nodes of
3. Pale the small
4. hot body, bowel 6 intestine
x / min
5. dry turgor plaque peyeri in
6. since three days the terminal
ago defecate ileum
liquid

ulcers

nausea
vomiting
 lack of nutrients
the body needs

LIST OF NURSING DIAGNOSIS

Patient’s Name : Mr. H

Age : 18 yers old
Register Number 581902
No DATE NURSING DIAGNOSIS SIGNATUR
APPE E
AR
1. 23 Comfortable disorders pain
septem associated with
ber inflammatory bowel which
2014 is characterized by
abdominal pain patients say
the pain scale 4, the patient
appears weak, grimacing
painfully.

2.

23
septem Nutrition less than body

ber requirements related to the

2014 nausea and vomiting that is

characterized by saying
nausea and vomiting,
debilitated patients,
mucosal dry lips, pale, hot
body, bowel 6x/ minute,
turgor dry, since three days
 ago defecate liquid.

NURSING ACTIONS

Patient’s Name : Mr. H

Age : 18 yers old
Register Number 581902
No DATE NURSING DATE SIGNAT
AP ACTIONS OF URE
PE RESO
LVED
AR
1. 23 1. Observation of vital
sep signs
Blood pressure :120/70
tem
MmHg
ber
Temperature : 38º
201 C Pulse : 80 x/
minute Breath :
4
20x/minute
2. Teaches deep breathing
relaxation techniques
and distractions.
3. Provide a safe and
comfortable
environment
4. Collaboration with
physicians in the
2.
delivery of analgesic
 drugs.

1. Give to eat little but

23
often, the food is fine.
sep
For example porridge,
tem
rice baby.
ber 2. Provide oral hygiene
201 before eating.
3. Presscribe PO before
4
meals to prevent nausea
and vomiting.
4. Collaborate with
nutritionsist on
nutrition purchases
speader light soft
fiber diet.

PROGRESS NOTES

Patient’s Name : Mr. H

Age : 18 yers old
Register Number 581902
No No HO EVALUATION SIGNAT
D U URE
X R

1. 1 18.0 S: patients say stomach still ached

0 with scale 3.
O: - patients appear weak
- Tenderness in the left lower
qudrant.
- Grimacing painfully.
A: the issue is resolved in part
P: 1-5 continued intervention in the

patients home outpatient return

2. 2
S: Patients say they nausea and
18.0 vomiting.
.
0
O: - Debilatated patients
- Mucosa dry lips.
- Body heat
- Bowel 6x/minure
- Turgor dry
- 3 liquid bowel movement.
A: problem has not been resolved
P: 1-5 continued intervention in the
patients home outpatient return