NURSING REPORT HYPERTERMIA

Name : Siti.Aisyah Al- Munawarah

Semester / class : 5A

NPM : 1614201110054

A. Assessment
1. Identity
Name : An.F
Age : 12 years old
Gender : Male
Address : Kuin Selatan
Religion : Islam
Tribes : Jawa

2. The identity of the person responsible

Name : Ny. E
Age : 33 years old
Gender : Female
Address : Kuin selatan
Work : IRT
Relationship with patients: Biological mother

I. Assessment
A. General circumtances
Fever.
B. Current medical history
The patient came to the Islamic Hospital delivered by his family on December 2,
2018 with complaints of heat for the past 2 days before entering the hospital.

C. Past medical history

 The client's mother said that her child had never been treated in a hospital with the
same complaint, namely fever, the client was not allergic to drugs.
D. Family health history
The client's mother said that in her family no one had the same disease as the
patient.

E. Assessment of the patient's basic needs

1. Activities and training

Before getting sick: the client's daily activities are school and also playing like
other children his age.
When sick: the client said he could not do other activities such as school and
also playing, the client seemed to be lying weak on the bed.
2. Rest and sleep
Before getting sick: the client sleeps for ± 9 hours a night and takes a nap ± 2
hours.
When sick: the client says sleep for ± 7 hours a night because the client often
wakes up at night while sleeping.
3. Comfort and pain
The client's mother says her child often cries when the fever is high.
4. Nutrition
Before getting sick the patient's diet was good but when in the hospital the
patient had no appetite, the portion spent was only ½ portion provided by the
hospital.
5. Liquids and electrolytes
The patient's mother said that when he was sick the patient's drinking pattern
was good, elastic skin turgor.
6. Oxygenation
The patient's mother said her child did not have a history of shortness of breath.
7. Elimination
The patient's mother said that before the illness and when the BAK was
reviewed the client was still good and normal.
8. Elimination of bowed
 The client's elimination said before being sick and while at BAB's hospital the
client was still good 1x a day every morning, yellowish brown and distinctive
smell.
9. Sensory, perception, and cognitive
The client's mother said her child did not have a disturbance in the sensory
system, perception, and also cognitive.

E. Physical examination
1. General circumtances
When a physical examination is obtained the vital sign results
Blood Pressure : 100 / 70 mmHg Body temperature: 38, 7ºC
Pulse : 97 x/minute Rate repiration : 26 x/minute
Weigh : 27 kg

2. Head
Mesocepal head shape, clean black hair, conjunctival eye condition is not
anemic, aninkteric sclera, absent nose or abscess nose and no polyp
enlargement, the ear appears to be cerumen, symmetrical, no stomatitis, no
cavities, yellow teeth, the situation looks dirty.

3. Neck
No enlargement of the thyroid gland.

4. Chest
Inspection : symetris, no chest retraction
Palpation : palpable vocal vibration of fermitus
Percussion : sonor
Auskultation : vesicular no additional btreath sounds

Heart
Inspection : not visible Ictus Cordis
Palpation : palpate Ictus Cordis
Percussion : dim
Auskultation : S1, S2 regular
 Abdomen
Inspektion : there is no edema or injury
Auskultation : bowel sound 20x/ minute
Palpation : no tenderness
Percussion : timpani

Ekstermities
Upper extermity : attached Infusion RL 10 tts / minute, skin feels warm.
Lower extermity: there is no edema or injury, skin feels warm.

F. Supporting investigation
Laboratorium

G. Therapy program
- Pamol Oral 6 ¾ x tab if it’s hot.
- RL 10 tts/ minute.

II. Data analysis

No. Data Problem Etiology
1 DS : The client’s mother said his Hypertermia Infection process
child was fever from 2 days ago.

DO :
- Skin feels warm
- Blood pressure :
100 / 70 mmHg
- Pulse : 97 x/menit
- Rate respiration :
26 x/menit
- Weight : 27 kg
- Body temperature :
38, 7ºC
 III. Nursing diagnoses
Nursing Nursing care plan
Diagnoses Outcomes Intervention (NIC) Rational
(NOC)
Hypertemia 1.Body 1.Monitor body 1.Know the progress of
related to temperature in temperature as often as patient’s general condition
desease the normal posible. 2.knowing change of vital
range. 2.Monitor Blood pressure, sign patients.
2.Pulse, & Rate Pulse, & Rate respiration. 3.Prevent dehydration.
respiration in the 3.Increase fluid intake. 4.Minimize heat production.
normal range. 4.Teach patients to 5.Accelerate the decrease in
3.There is no prevent heat fatigue. heat production.
change in skin 5.Do tapid water sponge
color & no
dizziness

IV. Implementation
No Day/ date Time Nursing Implementation Evaluation of Nurses’
diagnoses action s sign
1. Thursday/ 08.00 Hypertemia 1.Monitoring body Evaluation day 1
03.12.18 related to temperature as 1.Vital sign
desesase often as possible. decreased.
2.Monitoring 2.Less fluid
Blood pressure, intake.
Pulse, & Rate 3.Body
respiration. tempeature is
3.Increasing fluid still increasing
intake.
4.Teaching Evaluation day 2
patients to prevent 1.Vital sign is in
heat fatigue. a state.
 5.Doing tapid 2.Moderate fluid
water sponge. intake.
3.Body
temperature in
the normal
range.

Evaluation day 3
1.Vital sign in
the normal
range.
2.Fluid intake
fulfilled.
3.Body
temperature in
the normal
range.

V. Evaluation
No Day/date Time Nursing diagnoses Evaluation
1. Thursday/ 08.30 Hypertermia Day 1
13.12.18 related to decrease S : the patient said he had a fever
O : the patient looks to be lying weekly
on the bed, palpate skin feels warm, T=
38,7ºC.
A : the problem has not been resolved.
P : action plan 1,2,3,.... continue.

Day 2
S: the patient said he felt no fever
anymore.
O : the patient looks to be healthy,
T=37,0ºC
A : the problem half resolved.
P: action plan 1,2,3,.... continue

Day 3
S : the patient said he felt no fever
anymore.
O : the patient looks healthy.
A : the problem is resolved.
P : action plan 1,2,3,.... be stop.