NURSING CARE FOR Mrs.

Y WITH THERMOREGULATION
DISORDER: HYPERTERMIA IN THE SHOFA ROOM OF THE
HOSPITAL PKU MUHAMMADIYAH CEPU
Supporting Lecturer : English Team

Arranged By :

Name : Uji Maulana Hadi

Grade : 2A
NIM : (P1337420417057)

POLTEKKES KEMENKES SEMARANG

PRODI DIII KEPERAWATAN BLORA

2018

CHAPTER II
 CASE REVIEW

Student Name : Uji Maulana Hadi

Place of Practice : Shofa Room PKU Muhammadiyah Cepu Hospital
Practice Date : November 5, 2018. 01:15 p.m

I. ASSESSMENT
1. Biodata
a. Patient Identity
Name : Mrs. Y
Age / Date Of Birth :15 years old / August 22, 2003
Work :-
Education : Vocational High School
Gender : Female
Religion : Islam
Address : Karanganyar Rt05/Rw08 Randublatung, Blora
Date of Hospital Admission : November 5, 2018 at 12.00 a.m
Date of Review : November 5, 2018 at 01.00 p.m
Registration Number : 135688
Medical Diagnosis : DHF

b. Identity of the Person In Charge

Name : Mrs. D
Age : 45 years old
Work : Entrepreneur
Address : Karanganyar Rt05/Rw08 Randublatung, Blora
Relationship With Patients : Mother

2. Main Complaint
The patient complained that her body felt hot since five days ago,
accompanied by nausea, vomiting and dizziness a day ago

3. Current History
The patient came to the emergency room at PKU Muhammadiyah Cepu
hospital on November 5th 2018 at 12.00 WIB with her body complaints feeling hot
since five days ago. The patient said nausea vomiting after eating a day ago. The
patient also said his head was dizzy when used to stand too long. From the results
 of the examination in the emergency room obtained data, vital signs of the patient
are :
Blood Pressure : 90/60 mmHg, Pulse : 120 x/minute, Respiratory Rate : 20
x/minute, Temperature : 400C, Weight : 48 kg. Therapies obtained include ringer
lactat infusion 20 drops/minute, injection of Ranitidine 2x1 (1 amp/2ml),
Parachetamol tablets 3x1 (500 mg). The patient is taken to the shofa room (room
number 1) at 12.30 p.m with the condition attached to the Ringer Lactat infusion
20 drops/minute, in the left hand. From the results of the examination obtained
data, the patient's vital signs are : Blood Pressure : 97/55 mmHg, Pulse :
122x/minute, Respiratory Rate : 20 x/minute, Temperature : 40,50C.

4. Past Medical History

The patient said he did not have a history of decreased disease such as asthma,
militus diabetes, tuberculosis, hypertension, heart disease and others.

5. Family Health History

The patient's mother said there was no family member who had a history of
decline, such as asthma, tuberculosis, diabetes mellitus, hypertension, heart
disease, etc.
6. Physical Examination
a. General condition of the patient : Weak
b. Level of awareness : Composmentis, GCS: 15, E4V5M6
c. Height : 154 cm
Weight : 48 kg
d. Vital Signs are
Blood Pressure : 97/55 mmHg
Pulse : 122 x/minute
Respiratory Rate : 20 x/minute
Temperature : 40,50C
e. Head
Shape : Mesochepal
f. Eye : The conjunctiva is not anemic, isocorous pupil, the sclera is
not jaundiced, and do not use assistive devices.
g. Nose : no polyps, no secret
h. Ears : There is no hearing loss, there is no cerumen.
i. Mouth : Pale lips, dry lips mucosa, clean teeth.
j. Neck : No enlargement of the thyroid gland.
k. Thorax : I = The shape of the chest is symmetrical, the frequency of
breathing is regular and there are no injuries.
P = No lumps, tympanic.
P = No tenderness
A= Normal sound S1 S2 heart.
l. Abdomen
 Shape : Symmetrical
Peristalsis : 10 times per minute
Percussion : Thympani
Palpation : No tenderness
m. Extremities
 Upper limb : left hand attached ringer lactat infusion 20
drops per minute, no swelling, nails of the left hand thumb long.
 Lower extremity : no swelling, no lesions, good skin turgor.

7. Assessment of Functional Patterns According to Gordon

1. Patterns of Perception - Health Management
The patient said that he had high blood pressure for the first time up to five
days and don’t know how to handle it.
2. Nutrition - Metabolic Pattern
a. Before illness : the patient says he eats 2 to 3 times a day, menu that
patient like include vegetable soup and rice. The patient said he had no
history of food allergies. The patient says he drinks 200 cc of water a day.
b. During illness : The patient says he eats 3 times a day with the hospital
menu and only consume half a portion.

3. Elimination Pattern
1. Defecation Elimination
a. Before illness : The patient defecate twice a day with the consistency
of soft stool, yellow stool colour.
b. During illness : The patient says he defecate once a day with
consistency of soft stool, black colour and frequency of feces around
200 cc.
2. Urine Elimination
a. Before illness : the patient says urinating 5 to 6 times a day with the
colour of yellow urine, urine frequency 1500 cc a day
b. During illness : the patient says urinating 3 to 4 times a day with the
colour of yellow urine, urine frequency 1000 cc a day
4. Activity Training Pattern
a. Before illness : The patient said before being sick, he could carry out
daily activities independently
 b. During illness : The patient said during illness, when he was going to
the bathroom, he was told by his mother.
5. Perceptual Pattern
a. Perceptual sensory : the patient says dizziness in the head when he
wants to get up from the bedroom, his body is hot since 5 days ago
accompanied by a little nausea and vomiting.
b. Cognitive perceptual : the patient says already know what dengue
High Fever is, because there are many people who suffer from the same
disease in the area where they live. however, both patient and families do
not know how to treat and prevent Dengue High Fever.
6. Sleep Rest Pattern
a. Before illness: the patient says his sleep is always sound, with a frequency
of sleep 8 hours a day.
b. During illness: the patient says his sleep is disturbed and often wakes up
when he feels his body is hot, the patient says he has just slept for 2 hours,
then wakes up.
7. Self-Concept Pattern - Self Perception
The patient said he was anxious about him, especially with his current illness.

8. Role-Relationship Pattern
The patient said the relationship with his family was fine and there were no
obstacles or problems.
9. Reproductive Patterns
Patients are female and there are no problems with their reproductive health.
10. Coping-Mechanism Pattern
The patient still spends a lot of time resting and the family supports every
nursing action given.
11. Pattern of Values-Beliefs
The patient said he was Muslim and prayed 5 times.
8. Therapy
a. Asering infusion 20 drops / minute
b. Injection of Ranitidine 2x1 (1 amp/2ml) : Intravenously
c. Amoxillin (3x1) : Oral
d. Aviter (1x1) : Oral
 e. Immunos plus (2x1) : Oral
f. Paracetamol Tablet (3x1) : Oral
g. Ulsafas Syrup (3x1) : Oral
h. Methylpresmisolon (3x16mg) : Oral
i. Kalnex (3x1) : Oral
9. Supporting Investigation
a. Laboratory Examination
Results of laboratory tests on November 5, 2018
REFERENCE
HEMATOLOGY RESULTS UNIT METHOD
VALUE
Hemoglobin 13,8 12 – 14 g/dl Colorymetric
Hematocrit 39,4 37 – 43 % Analyzer
Leukocytes 2,03 4 – 10 103/ul Impedance
Platelets 79 150 – 400 103/ul Impedance
Erythrocytes 78 81 – 99 fl Analyzer
MCV 27 28 – 33 Pg Analyzer
MCH 35 32 – 36 g/dl Analyzer
MCHC 5,02 3,5 – 4,5 106/ul Impedance

Results of laboratory tests on November 6, 2018

REFERENCE
HEMATOLOGY RESULTS UNIT METHOD
VALUE
Hemoglobin 13,7 12 – 14 g/dl Colorymetric
Hematocrit 38 37 – 43 % Analyzer
Leukocytes 1,7 4 – 10 103/ul Impedance
Platelets 54 150 – 400 103/ul Impedance
Erythrocytes 4,85 81 – 99 fl Analyzer
MCV 78 28 – 33 Pg Analyzer
MCH 28 32 – 36 g/dl Analyzer
MCHC 36 3,5 – 4,5 106/ul Impedance

DATA ANALYSIS
No. Date Data Cause Problem
1. November Subjective Data : process of hypertermia
5, 2018 The patient complained that her body disease or
felt hot since five days ago. infection

Objective Data :
  Vital Signs are
Blood Pressure: 97/55 mmHg
Pulse : 122x/minute
Respiratory Rate: 20 x/minute
Temperature : 40,50C

2 Subjective Data : Nutritional

The patient says nausea and vomiting. imbalance is
less than the
Objective Data : body's
The patient's condition is weak needs

II. NURSING DIAGNOSES

1. Hypertermia associated with the process of virus infection is characterized by the
patient saying his body is hot since five days ago, the general condition is weak,
the patient's vital signs : Blood Pressure : 97/55 mmHg, Pulse : 122x/minute,
Respiratory Rate : 20 x/minute, Temperature : 40,50C
2. Lack of nutritional imbalance from the body needs to be connected with
nutritional intake that is not strongly connected with nausea and vomiting.