Tonsilitis

Student name : M Zain Ramadhani

SRN : 1714201310015

Room : Pediatric Clinic

Health center/ Institution : Karang Mekar Health Care Center

A. Client Identity

Nama : An. M

Age : 12 years old

Sex : male

Addres : karang paci Rt. 006

Date of Entry : July 9th 2019

Date of Assessment : July 9th 2019

Patient next of skin : ismed yurni / clients father

B. Fokus Data

Subjective Data : clients father said his son got runny nose since 2 days

: client father said his son got sore throat since 2 days

: clients father said his son got cough since 1 day

: client father said his son cold

Objective Data :
 a. Inspection : The patients face looked sullen and not exited
b. Auscultation :
c. Percussion :
d. Palpation : The patients body feels warm

C. Additional Data

a. Vital Sign

- Temperature : 37,6 C

- Heigth : 133 cm

- weight : 26,9 kg

b. Other supporting results : (Lab, Ct scan/ Rontgen)

D. Analysis Data

No Data Etiologi Problem

1 Ds: client father said his Hipertermia Proses penyakit
son cold
Do :
Palpation : The patients
body feels warm
Vital sign :
T: 37,6 C
2 Do : client father said Nyeri akut Pembengkakan pada tonsil
his son got sore throat
since 2 days
Do : The patients face
looked sullen and not
exited
E. Rencana Keperawatan
No Diagnosa Tujuan
Keperawatan
1 Hipertermia Setelah dilakukan tindakan
keperawatan selama 1x 24 jam
hipertermi teratasi
Dengan kriteria hasil :
Suhu badan turun
2 Nyeri akut Setelah dilakukan tindakan
keperawatan selama 1x 24 jam
rasa nyeri berkurang
Dengan kriteria hasil :
Intervensi
1. Monitor tanda-tanda vital
2. Pantau suhu lingkungan
3. Berikan kompres hangat
4. Manajemen cairan
5. Kolaborasi pemberian
antipiretik
1. Monitor tanda-tanda vital
2. Manajemen nyeri
3. Pengaturan posisi
4. Pemberian analgesic