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1. PENGKAJIAN
a) Biodata klien
Nama : An. Y
Umur : 4 tahun
Jenis kelamin : Laki – laki
Alamat :Bandungrejo ,Ngablak, Magelang
Pekerjaan : Pelajar
Agama : Islam
Status : Belum Menikah
Tanggal masuk : 12 Maret 2013
No RM : 22.1204.08
Bangsal : Melati
Medical diagnosis:
b) Riwayat Kesehatan
Keluhan utama : klien mengeluh nyeri kepala berdenyut.
Riwayat Penyakit sekarang : Menurut keluarga Sejak 1 minggu yang lalu klien sering
menangis karena nyeri kepala yang berdenyut hebat, tubuh terasa panas/demam, dan kaku pada
kuduk. Klien belum diperiksakan ke dokter. Sejak kemarin disertai mual ,muntah bahkan
kejang, hingga klien dibawa oleh keluarganya ke Rumah Sakit ini.
Riwayat Penyakit Dahulu : Menurut keluarganya Klien belum pernah mempunyai
penyakit TBC tetapi klien pernah menderita influenza. Klien juga pernah jatuh dari tempat tidur
setinggi 1M, tetapi tanpa trauma serius.
Riwayat penyakit keluarga : Keluarga mengatakan dalam keluarganya tidak ada yang
menderita penyakit seperti ini
d. PEMERIKSAAN FISIK
1. Keadaan umum : lemas
2. Kesadaran : Composmentis
3. Tanda – tanda vital :
Kepala : I: Keadaan rambut dan hygiene kepala baik,Warna rambut hitam ,Tidak mudah rontok,
Kebersihan rambut bersih.
P:Tidak teraba adanya massa yang abnormal, Tidak ada nyeri tekan.
Muka : I : Muka simetris kiri dan kanan,Bentuk wajah lonjong, Ekspresi wajah murung, tampak
kesakitan dan gelisah, mukosa bibir kering
Mata : I : Tidak ada oedema dan tanda-tanda radang. Sklera tidak ikterik, reflek pupil normal,
konjungtiva anemis.
Hidung : I :Bentuk hidung simetris kiri dan kanan,Tidak ada sekret pada hidung, Tidak ada sumbatan pada
hidung,adanya halusinasi penciuman.
Gula darah
- Glukosa ad random : 169 mg/dl ( 140 mg/dl)
Faal Hati
- SGOT : 55 U/L (L < 37 P < 31 U/L)
Faal Ginjal
- Serum Creatinin : 1,52 mg/dl (L : 0,9 – 1,5 P : 0,7 – 1,3)
Elektrolit
- Natrium : 154 mmol/l (135 – 145 mmol/l)
- Kalium : 4,08 mmol/l (3,5 – 5,5 mmol/l)
- Clorida : 114 ( 97 – 113 ).
2. ANALISA DATA
Nama inisial klien : An.Y Dx medis : Meningitis
No.RekamMedis : 22.1204.08 Bangsal : Melati
NO Tanggal dan jam Data subjektif Data objektif
pengkajian
1 23 maret 2013 Klien mengatakan nyeri Klien tampak
15.39 kepala yang berdenyut hebat meringis kesakitan
P : Nyeri karena adanya dan menangis karena
infeksi virus pada selaput nyeri,.
otaknya
R ::nyeri kepala
Q :terasa berdenyut-denyut
S : skala nyeri 5
T :nyeri setiap saat,
2 23 maret 2013 Klien mengatakan tidak ada Klien tampak lemas
15.45 nafsu makan,merasa mual dan pucat
dan muntah saat melihat Berat badan turun 1
makanan. Klien juga merasa kg selama 3 hari.
nyeri ditenggorokan.
3 23 maret 2013 Klien mengatakan badan Kulit kemerahan,
16.00 panas, demam,merasa tidak turgor kulit jelek,akral
nyaman,kaadang terjadi teraba hangat
kejang S : 40̊̊̊c
3. DIAGNOSA KEPERAWATAN
Nama inisial klien : An.Y Dx medis : Meningitis
No.RekamMedis : 22.1204.08 Bangsal : Melati
NO TGL SYMPTOM ETIOL PROB DIAGNO
& OGI LEM SA
JAM
1 23 Ds:Klien mengatakan nyeri Agen Nyeri Nyeri akut
maret kepala yang berdenyut hebat cedera akut berhubung
2013 P : Nyeri karena adanya infeksi biologis an dengan
15.39 virus pada selaput otaknya agen
R ::nyeri kepala cedera
Q :terasa berdenyut-denyut biologis
S : skala nyeri 5
T :nyeri setiap saat,
Do:Klien tampak meringis
kesakitan dan menangis karena
nyeri,
23 DS:Klien mengatakan tidak ada Ketidak Ketidak Ketidaksei
maret nafsu makan,merasa mual dan mampua seimba mbangan
2013 muntah saat melihat makanan. n ngan nutrisi
15.45 Klien juga merasa nyeri menging nutrisi kurang
ditenggorokan esti kurang dari
DO:Klien tampak lemas dan makanan dari kebutuhan
pucat kebutuh tubuh b/d
Berat badan turun 1 kg selama 3 an ketidakma
hari tubuh mpuan
menginges
ti
makanan
23 DS:Klien mengatakan badan dehidrasi Hiperte Hipertermi
maret panas, demam,merasa tidak rmi b/d
2013 nyaman dehidrasi
16.00 DO:Kulit kemerahan, turgor
kulit jelek,akral teraba hangat.
S : 40̊̊̊c
ASSASMENT OF GASTRITIS
B. IDENTITY
1. Client Biodata
Name : An. Y
Gender : Male
Age : 4 years old
Religion : Islam
Tribe / nation : Indonesia
Status Marital : Un married
Address : Hajimena
2. Person in charge
Name : Tn. P
Age : 31 years old
Gender : Male
Religion : Islam
Occupation : Farmers
Relationship with client : Father
Address : Hajimena
3. Medical diagnosis
Meningitis
C. CHIEF COMPLAINT
D. CLIENT HISTORY
1. History of Present Illnes
Since 1 week ago clients often cry because the headache is throbbing great, the body feels
hot / fever, and stiff on the nape. The client has not been seen to the doctor. Since
yesterday accompanied by nausea, vomiting and even seizures, until the client brought by
his family to this hospital.
2. Past History`
According to his family Clients have never had tuberculosis but clients have had influenza.
Clients also once fell from the bed as high as 1M, but without serious trauma.
E. DAILY ACTIVTIES
7. Nutrition
The family said before sick the client ate 3 times a day with the amount of 1 portion every meal
with the type of rice, vegetables and side dishes. Drink 6-7 glasses a day. But during the illness
clients do not have an appetite because they feel nauseated when they see food, even to vomit.
Clients lose weight by 1kg for 3 days.
8. Elimination
When not feeling the pain as now, clients urinate 5-6 times daily with clear yellow and smooth,
defecate 1 times a day with consistency soft. But when you feel the pain of urinary clients 5-6
times a day with clear yellow color. Client defecate 3 times consistency of liquid, slimy without
blood..
9. . Activity/rest
Before the client's illness always play with his friends, sleeping at night is also on time, but
during illness the clients are just at home resting, and always sleeping late because clients often
cry because of headaches and discomfort due to illness.
10. Coping/stress tolerance
When feeling sick clients always tell the mother and father. Clients are also only bought
medicine stalls when feeling sick..
11. Comfort
Clients always feel headache and body feels so hot that clients often cry because of
feelings of discomfort in the body. The client also looks uneasy.
12. Growth/Development
The client is still in its infancy but the client has no growth problems. Weight loss
decreased 1 kg for 3 days.
F. PHYSICAL EXAMINATION
1. Awareness
CM (Composmentis)
2. Vital sign
Bp : 90/70 mmHg
T : 37 ° C
Pulse : 100 times / min
RR : 28 times / min
3. Head
Scalp
I: State of hair and good head hygiene, Color black hair, Not easy to fall out, Clean hair
hygiene.
P: No palpable abnormal mass, No tenderness..
Face
I: Front left and right symmetry, Oval face shape, Facial expression moody, looks pain
and anxiety
P: Not felt abnormal mass, No tenderness..
Eyes: I: No edema and signs of inflammation. The sclera is not jaundiced, normal pupil
reflexes, conjunctival anemis.
Nose: I: Right and left symmetrical nose shape, No nasal secretions, No nasal blockage,
presence of olfactory hallucinations.
P: There is no tenderness in the nose
Ears: I: ears look clean no serumen
Mouth
dry lips mukosa
4. Neck
I: no enlargement of the thyroid gland, no injuries or surgery
P: not palpable hyperthyroidism
5. Chest and Thorak
I: chest symmetrical and also invisible ictus cordis
P: palpable ictus cordis in the 5th rib (intercosta 5-6)
P: no heart enlargement
A: sounds of heart lup - duk, regular
6. Abdomen
I: left and right symmetric abdomen
A: bowel sound has decreased 10x / min
P: the sound of the abdomen is dim
P: tenderness in the abdomen.
7. Extremities
upper extremities : RL 60 tpm micro infusion attached to the left arm
lower extremities : client has limited movement in lower extremities
8. Skin
warm skin and reddish look, dry skin and less elastic, poor skin turgor
9. Genetalia
No catheter installed.
G. SUPPORTING EXAMINATION
Complete Blood Date: March 13, 2018.
Blood sugar
- Glucose ad random: 169 mg / dl (<140 mg / dl)
liver faal
- SGOT: 55 U / L (L <37 P <31 U / L)
Kidney Faal
- Serum Creatinin: 1.52 mg / dl (L: 0.9 - 1.5 P: 0.7 - 1.3)
Electrolyte
- Sodium: 154 mmol / l (135 - 145 mmol / l)
- Potassium: 4.08 mmol / l (3.5 - 5.5 mmol / l)
- Clorida: 114 (97 - 113).
H. DATA ANALYSIS
Objective data :
1. Clients seem to grimace
in pain and cry because
of pain
2. The client pain scale 7
of the scale (0-10)
Subjective data : Psychological Nutritional deficit
1. The client says there is factors
no appetit
2. The cliant feeling
nauseated and
vomiting at the sight of
food.
Objective data :
1. Clients Weight loss of 1
kg for 3 days
2. Mr. "S" looks weak
and not energized
Objective data :
1. Reddish skin, bad skin
turgor, akral felt warm.
2. Temperature: 40֯c
I. NURSING DIAGNOSIS
1. Acute pain associated with Physiological injury agents
2. Nutritional deficit associated with psychological factor
3. Hyperthermic associated with dehydration