NURSING CARE FOR MR.
T
WITH THE INEFFECTIVENESS OF THE CLEARANCE OF THE
AIRWAY IN PATIENTS OBS DYSPNEA EL SUSP TUBERCULOSIS (TBC)
AT SHOFA ROOM 10 PKU MUHAMMADIYAH CEPU HOSPITAL
LECTURE BY : ENGLISH AND TEAM
COMPILED BY :
NAME : HIDAYATUL UMI ROHMAH
NIM : P1337420417051
CLASS : II A
HEALTH POLYTECHNIC OF SEMARANG
DIPLOMA III NURSING OF BLORA
2018/2019
NURSING CARE FOR MR. T
WITH THE INEFFECTIVENESS OF THE CLEARANCE OF THE
AIRWAY IN PATIENTS OBS DYSPNEA EL SUSP TUBERCULOSIS (TBC)
AT SHOFA ROOM 10 RS PKU MUHAMMADIYAH CEPU HOSPITL
Student name : Hidayatul Umi Rohmah
Place practice : Shofa Room 10 PKU Muhammadiyah Cepu Hospital
Date practice : November 8th ,2018
I. ASSESMENT
1. IDENTITY
a) Patient Identity
Name : Tn.T
Age / Date of birth : 60 Years old, November 19th, 1960
Occupation : Welder
Education : Elementary school
Gender : Male
Religion : Moslem
Mental Status : Composmentis
Adress : Nglengkir village, Bogorejo
Date of assesment : November 8th ,2018 (15.30 pm)
Registration number : 135841
Medical Diagnosis : Obs Dyspnea el susp tuberculosis
b) Responsible Identity:
Name : Ny. M
Age : 58 Years old
Occupation : Housewife
Adress : Nglengkir village, Bogorejo
Relationship with clients : Wife
2. The Main Complains
Patient said shortness of breath for one week
3. Current Medical History
Tn.T (64 years old) came to the emergency room RS PKU Muhammadiyah Cepu on the
date November 08, 2018 18.30 pm. The patient came with complaints of sshortness of
breath for one week. For one week the patient is ot brought to the hospital because it is
too crowded not too severe and comes and goes so just in berilan medical for the
pharmacy. But today the shortness of breath is getting worse so his family brought the
patient to the hospital. Patients say nausea, decreased appetite and abdominal senep. The
patient looked limp and breathing seemed choked a trembling voice. From the results of
the examination of the mark's vital signs, blood pressure 97/65, pulse 70 times per
minute, temperature 36, breathing 34 times per minute. From the agency emergency
department the patient received oxygen therapy 3 liters, the infusion of assering 20 drops
per minute, injection ranitidine 2 x 1 ampoule.
4. Past Medical History
Patients said was once in the home hospital with a complaint claustrophobic. Patients said
never in a surgery. Patients said have smoking.
5. Family Health History
The families of patients said that there is a cousin male who have a history of shortness of
breath and exposed tuberkulosis.
6. Physical Examination
General examination
General state : Weak
Level of conscious : Consciousness GCS: E4V5M6
Body Height : 165 cm
Body Weight before getting sick : 62 kg
Body Weight during the illness : 58 kg
Vital signs : Blood Pressure = 97/63 mmHG
Pulse = 78x/s
RR = 22x/s
Temperature = 36oC
Examination Head To Toe
a. Head
Shape of head : Mesochepal
Hair :The Greasy
Skin Head : Clean
b. Eyes
The shapness sight: Decrease
Inflamation : Haven’t
Sklera : Haven’t Ikterik
Konjungtiva : Anemis
Pupil : Normal
c. Nose
Polip : No
Secret : No
The olfactory function : Normal
d. Ear
Serumen : Yes
The hearing function : Decrease
e. Mouth
Edge : Pale, dry
Tooth : Easy shaky
Tongue : Dirty
The speak function : Normal
The labeling function : Normal
f. Neck
Difficult to swallow : No
g. Thorax
Inspection : Simetris
Palpation : No
Perkution : No
h. Heart
Inspektion : Ictus cardis
Palpation : Pulmonalis located in ICS 3 left sinista
Auscultation : Normal
i. Pulmo
Inspection : Simetris
Palpation : Fremikus +
Perkution : Sonor
Auskultation : Vaskular
j. Muskoloskeletal
Muscle strength : Decrease
Muscle tonus : Good
Hinge climsy : No
Atropi : No
ROM : Normal
Pain : No
Skin : Wrinkled
Refleks : Normal
k. Abdomen
Inspection : Simetris
Auskultation : Bowel 20x/s
Palpation : There is pain press
Perkution : Timpani sound
7. Assessment Of Gordon Functional Pattern
a. Pattern of perception
Patients said if there are pasie sick or there are family members who are sick
immediately give the drug from the chemist if not healed then immediately in bring to
the hospital. My family members always care and pay attention when there is a
family of the hospital.
b. The pattern of nutrients.
Before getting sick : the patient is said the day to eat more or less three times a day,
the portion of the meal is, the patient home to eat with rice, side dish, fruit and
vegetable. The patient said to drink approximately 5 to 8 times per day which
includes water, tea, milk. The weight of the patient before hospital 62 kg.
During the illness : the patient is said the day to eat 3 times a day with a menu from
the hospital. The portion that's why only half of the plate and to drink 3 to 6 glasses
per day. Weight used submarines hospital 58 kg.
c. The Pattern of elimination
Before getting sick : the patient said bowel movement one time with a soft
consistency, nau distinctive, yellow color and did not bleed. The patient told to urinate
as much as approximately 6 times with a limpid color, a distinctive smell and there is
no interference during urination.
During the illness : patients told not defecate submarine in the hospital . The patient
told to urinate as much as approximately 3 times with limpid color, a distinctive smell
and is not attached to the catheter.
d. Patterns of rest and sleep
Before getting sick: the patient is said to sleep approximately eight hours at night and
2 hours during the day.
For pain : the patient says insomnia submarine hospital because of shortness of breath
and chest pain. The patient only sleep less than 4 hours.
e. A pattern of activity and exercise
Before getting sick
Self care ability 0 1 2 3 4
Eat Drink V
Take a bath V
Toileting V
Get dressed V
Mobilization in bed V
Move V
Ambulation ROM V
Steatment : 0 = Self, 1= Toll, 2= Assisted people, 3= People and tolls, 4= Depending
on the total
For pain
Self care ability 0 1 2 3 4
Eat Drink V
Take a bath V
Toileting V
Get dressed V
Mobilization in bed V
Move V
Ambulation ROM v
Steatment : 0 = Self, 1= Toll, 2= Assisted people, 3= People and tolls, 4= Depending
on the total
f. Pattern cognitive perceptual.
Patients say vision is still better and can distinguish colors. Patients say can
memdengarkan well. Patients also do not use hearing aids. The patient says can
distinguish the taste. The patient says can still smell the smells. Patients say can feel
when given a stimuli example in a pinch or on conjecture.
g. Patterns of self-perception
The patient said no minder with the disease patients are said to recover quickly.
Role : before the patient's pain as a parent and the help the economy is his son.
h. Patterns of sexuality and reproduction
Before getting sick: the patient is said to have two sons and one daughter.
During the illness : the patient said sselama sick children come and take turns to guard
her and care for her.
i. Self-Identity : the patient can recognize yourself.
j. The Pattern of role relationships
Before getting sick: the patient says the head of the household in the search for a living
usually in stone by his son and the work itself.
For pain : the patient says can only be bedridden, the role minimal.
k. Patterns of values and conviction
Before getting sick: the patient says always worship at home or in the mosque.
During the illness : the patient is lying in a hospital prayer was in bed.
8. Therapy
a. Infusion Assering 20 TPM
b. O2 3 liter
c. Inj Ranitidin 2x1gr IV
d. Oat FDC 1x3
e. Salbutamol 3 x 25
f. Curcuma 3 x1
g. Codein 3 x 20
h. Onoiwa 3 x1
9. Diagnostic Examination
Laboratorium
Examination Outcome Normal Unit
Hematologi
Hemoglobin 11,6 14 – 16
g/dl
Hemotokrit 34,4 40 – 48 %
Leukosit 5,4 4 – 10 103/πl
Trombosit 179 150 – 400 103/πl
Eritrosit 4,42 3,5 – 4,5 106/ πl
MCH 27,4 28 – 33 Pg
MCHC 33,7 32 – 36 g/dl
MCV 81,1 84 – 94 fL
Blood Chemistry
Glucosa 117 <180
Mg/dl
Hepatitis Negative Negative
HbsAg
10. Data Analysis
No DATA FOCUS ETIOLOGI PROBLEM
1. DS: The ineffectiveness Bronchospasm
-Patient said shortness of breath of the clearance of Capillary
for one week the airway associated
DO:
-During breathing seemed
chocked a trembling voice,
- The patient loked limp,
- Attached oxygen to 3 liters,
- Vital sign,
Blood pressure 97/63 mmhg,
Pulse 70 x/minutes,
Temperature 36,9 o c,
RR 34 x/minutes.
2. DS:
- Patient say nausea The Imbalance intake Imbalance nutrition
- Pasient say stomach pain of nutrients less than body
- Patient appetite requirements
DO:
- The patient loked limp,
- Weight Before getting sick: 62
kg
-Weight during the illness : 58 kg
II. NURSING DIAGNOSE
1. The ineffectiveness of the clearance of the airway associated with bronchospasm
capillary is charaterized by patient said shortness of breath for one week,during breathing
seemed chocked a trembling voice, the patient loked limp, attached Oxygen to 3 liters,
Vital sign, blood pressure 97/63 mmHg, pulse 70 x/minutes, temperature 36,9 o C, RR 34
x/minutes.
2. The Imbalance intake of nutrients associated with Imbalance nutrition less than body
requirements charaterized by Patient say nausea,pasient say stomach pain, patient
appetite, the patient loked limp, weight Before getting sick: 62 kg, weight during the
illness : 58 kg
