RESUME

NURSING DIAGNOSIS WITH ATRIUM SEPTAL DEFECT (ASD)

ON CHILD. K IN ELANG 1 WARD
RSUP dr. KARIADI SEMARANG

Arranged by:
NUR CHAFIDHOH AULIYA RACHMANY
P1337420617031

BACHELOR OF APPLIED SCIENCE OF NURSING

HEALTH POLYTECHNIC OF HEALTH MINISTRY OF SEMARANG
2019
 NURSING DIAGNOSIS WITH ATRIUM SEPTAL DEFECT (ASD)
ON CHILD. K IN ELANG 1 WARD

Name of Student : Nur Chafidhoh

NIM : P1337420617031
Date : Thursday, May 8th 2019

I. ASSESSMENT
A. Biodata
1. Client’s Biodata
Name : Kid. K
Age : 6 y.o, 0 month, 22 days
Address : Pegiringan RT 10 RW 05 Pemalang
Education :-
Occupation :-
Religion : Moslem
Entrace Date : 8th Mei 2019
Medical Diagnose : ASD
Register Number : C469416

B. Main Complaint

C. Nursing History
1. Present Nursing History
Client came to RSUP dr. Kariadi on 8th May 2019 from ICCU to Elang 1 ward
to get Cardio-Surgery. Client get ASD sign since 4 months old. Client was born
when her mother was 32 y.o, aterm pregnancy, the weight of birth 2500 gram.
Vital sign
HR : 110x/mnt
RR : 22x/mnt
T : 36,4℃
Therapy :
D10% + Na + K 8 cc/hr (intravena)
Meropenem 250 mg/8 hr (intravena)
OMZ 15 mg/12 hr (intravena)
Paracetamol 250 mg/8 hr (intravena)
Nursing Intervention

Date Nursing Diagnose Purposes Intervention

Risk of infecton r/t within 1x24 hours 1. Observe vital sign

post op surgery it is expected that 2. Observe sign of infection
incision there is no 3. Instruct the family to report
infection sign with if there is any sign of
the results criteria: infection
1. There is no
4. Maintain asepsis for
infection sign (
dressing changes or wound
tumor, lubor,
care
dolor, color,
functio laesa)
2. Normal vital
sign
3. No fever
Implementation
Implemetation Patient’s respond