SECTION I
INTRODUCTION
1.1
Purpose
of The Report
This
report is to describe how to implement the Nursing Care of the Client ; Mr. “S”
with Medical Diagnose of Pulmonal Tuberculosis at The 2B Ward of the Siti Hajar
Islam Hospital in Sidoarjo.
1.2
Scope
and Limitation
a. The
scope of this report covers the nursing care of client in the Siti Hajar Islam
Hospital in Sidoarjo.
b. The
limitation of this report covers the nursing care of the client Mr. “S” with
Medical Diagnose of Pulmonal Tuberculosis at The 2B Ward of the Siti Hajar
Islam Hospital in Sidoarjo.
1.3
Procedure
of Gathering The Data
The data of this
nursing care report was taken from the result of examination form of nursing
data (anamneses) and other medical records.
1.4
Organization
of The Report
Section
I. Deals with Purpose of The Report, Scope and Limitation, Procedure of
Gathering The Data, and Organization of The Report.
Section
II. Content the review of The Literature, it deals with Definition, Ethyology,
Phatophysiology, Nursing Diagnose, Intervension, and Rationalization.
Section
III. . Content the examination Form The Nursing Data that deals with Identity
of Client, Nursing Data, Daily Activity, Physichosocial Data, Phisical
Diagnose, Supporting Data, Theraphy and Managing System, and Problem
Classification.
Section
IV. Deals with Data Analysis, Nursing Diagnose, Nursing Care Plan, Nursing
Action, Nursing Records, and Evaluation.
Section
V. deals with conclusion and suggestion.
SECTION II
REVIEW OF LITERATURE
2.1
Definition
Tuberculosis is a disease caused by
bacteria Mycobacterum Tuberculosis. This disease seems to invade other organs
and is transmitted from person, if treatment with this disease can be cured
completely.
2.2
Etiology
One bacterial cause of tuberculosis is
Tuberculosis Mycobacterum. A type of bacteria that are rod-shaped with a length
of 1-4 mm and a thickness 0-3-0.6 mm. germs mostly consist of fatty acids
(lipids). Lipids are made more resistant germs live on the air is cold and dry
because germs are in the dormant nature. Besides these bacteria are aerobic so
it enjoys a high O2 network, in this case the area apikat lungs.
2.3
Classification
a. Pulmonary TB
-
Direct
smear microscopy / culture (+), supporting TB thoracic abnormalities, clinical
symptoms according TB.
-
Direct
microscopic smear / culture (-), but the x-ray abnormalities and corresponding
TB clinics and member improvement on the initial treatment of tuberculosis.
b. Pulmonary TB suspects
-
Sputum
smear (-), yet another sign of positive pulmonary TB suspects should be
treated.
-
Sputum
smear (=), another sign of pulmonary tuberculosis suspects no doubt need to be
treated.
c. Former TB
There is a history of past TB in
patients with / without treatment / description of normal or abnormal rondge
stable therapy on the photo and serial sputum smear (-), this group does not need to be treated.
2.4
Physiological Anatomy
a. Nasal (nose) = mucus membranes of
nasal cavity coated as a very rich vein and continued with sinus mucus membrane
that has holes into the nasal cavity.
b. Paranasal sinus: an open area on the
skull that have fotalis sinus, etmoidalis, spenoidalis, and maxillary sinus.
Their function are helping to warm and humidification, lighten bone weight the
skull and set the sound the human voice with a resonance.
c. Pharynx: muscular tube that runs
from the base of the skull until junction with the esophagus.
d. Larynx: located in front of the
lowest part of the pharynx that separates Columna nertebra, walk up to a height
of fering servikelrs vertebrae and into the trachea in it.
e. Trachea: windpipe about length 9 cm,
the trachea is composed of 16-20 incomplete circle the ring of cartilage that
tied together by a network of fibrous tissue besides making muscle tissue.
f. Bronchus: Right primary bronchus is
shorter, thicker, and straighter than the left primary bronchus because the
aortic arch swung down the trachea to the right each branch primary bronchus 9-12
times to form secondary and tertiary bronchi with a diameter gets smaller, when
the tube narrows , replace cartilage rods subsequently form a ring of cartilage
bronchioles, terminal bronchioles, respiratory bronchioles, and elvecoli dultus
alvcolar.
g. Alveoli: where gas exchange sinus
and respiratory bronchioles consists of, which sometimes have small air pockets
in the walls, alvecolus lining the thoracic cavity is separated by a wall
called khon pore.
h. Lungs: the pyramid-shaped organ like
a sponge and air-filled cavities located in the right toraks. There are three
lobes and the left lung two lobes of the right lung lobe is superior, medial
and inferior lobe of the left lung is superior and inferior. This is covered by
the pleura parietal pleura and visceral pleura.
2.5 Pathophysiologis
2.6
Clinical
Manifestation
a.
Fever:
subfebris,
but sometimes
reaches
40-41
º
C
intermittent
b. Cough:
occurs because
there is
irritation
of the bronchi
to remove
inflammation
of production,
starting from
dry cough
up
purulent
cough,
coughing
up
blood
condition
c.
Tightness:
when
is advanced
where
up to half
of lung
inflammatory
infiltration
d. Chest
pain; these
rare,
pain
occurs when
the infiltration
was
up to the
pleura
causing
pleuritis
e. Malaise:
found
in the form of
anorexia,
decreased
appetite,
loss weight,
headache, muscle pain, night sweats
2.7
Treatment
a. Giving
drugs
TB
treatment is done
in 2 phases;
·
The initial phase
of intensive
activities
for
damage the population bakterisid
rapidly dividing
bacteria
·
Advanced
phase,
through
sterilization
of germs
on
the short-term
treatment or bacteriostatic
activity
on
conventional treatment.
OAT (anti-TB) that is normally used Isoniazid, rofampisin, pyrazinamide, and streptomycin and ethambutol. In addition to OAT can be given medication broncodilator
b. Physiotherapy
and
Rehabilator
c. Regular
consultations
2.8
Nursing
Care Plan Concept
2.8.1 ASSESSMENT
A. Client
Identity
Includes name, age,
address, sex, religion, education, occupation, nationality, date of hospital admission,
registration number and medical diagosa
B. History
Of Nursing
·
The main complaint: shortness of breath
·
disease history first: once the old
cough and does not heal, but it never went disorganized and did not recover
·
history of family illness: is there a
family who suffer like this?
C. Physical
examination
·
Eyes:
conjunctival pallor, icterus, pupil isokor, symmetric
·
Skin: peripheral
cyanosis, decreased turgor, edema.
·
Mouth: lips moist mucosa, stomatitis, enlarged tonsils
·
Nose: There
nostril breathing or not
·
Neckline:
enlargement of the jugular veins, difficulty swallowing, enlargement of the
thyroid gland
·
Chest:
retraction of accessory muscles, movement of the right chest and left
asymmetric, no abnormal breath sounds like a wheezing or crackles, or ronchi.
And a pigeon chest deformity such, there is dullness to percussion on the state
of advanced atrophy, intercostal retraction and fibrosis. There
hipersonor if there is sufficient cavity.
D. Supporting
inspection
·
Sputum culture
·
Zeitel nelson
·
Chest X-ray
·
Tissue culture
·
Blood
·
Bronchografi
2.8.2 DIAGNOSTICS
NURSING
1)
airway clearance Ineffective related to
viscous secretions or blood, weakness efforts bad cough, tracheal or pharyngeal
edema.
2)
impaired gas exchange associated with a
decrease in the effective surface lung, alveolar capillary membrane damage, a
strong secret, bronchial edema.
3)
impaired
nutritional needs associated with increased production of sputum or cough,
dyspnea or anorexia
4)
high risk of infection associated with
inadequate primary defenses, decreased in cilia movement, stasis of secretions
5)
lack
of knowledge about treatment and prevention of conditions related to lack of
information
2.8.3 INTERVENTION
a. airway
clearance Ineffective related to viscous secretions or blood, weakness efforts
bad cough, tracheal or pharyngeal edema.
Objective: Airway
hygiene
Criteria Result: no
extra noise on breathing, sputum can familie.
Intervention:
1. Explain
clients about to cough effectively and illness
2. Teach
clients about effective cough
3. Clean the secret of the mouth and trachea: suction as needed
4. Maintain
at least 2500 cc of fluid entry per day
5. Auscultation of the lungs before and after effective cough
6. Collaboration
with other medical teams.
b. impaired gas exchange associated with a
decrease in the effective surface lung, alveolar capillary membrane damage,
which ental secret, bronchial edema.
Objectives: Effective
gas exchange
Criteria Results:
Effective respiratory frequency, normal TTV
Intervention:
1. Approach
to the patient and the patient's family
2. Observation
of respiratory function, record respiratory rate, dyspnoea or change your vital
signs.
3. Give
Fowler position or semifowler
4. Increase
bed rest in patients
5. Give
oxygenation
6. Collaboration
with other medical teams.
c. Impaired
nutritional needs associated with increased production of sputum or cough,
dyspnea, or anorexia
Objective: Adequate
nutritional needs
Expected outcomes:
increased appetite, weight gain.
Intervention:
1. Discuss
the causes of anorexia, dyspnea, and nausea.
2. Explain the importance of nutrition for the body
3. Instruct
the client to take a break before eating.
4. Encourage
clients to eat a little but often
5. Give
food to suit your taste and conditions
6. Give
oral hygiene
7. Observations
weight
8. Collaboration
with other medical teams.
2.8.4 IMPLEMENTATION
From the results of
interventions that have been made and implemented or carried out in accordance
with the patient. Implementation is the processing and realization of the plan
of action that includes several parts, namely, validation, nursing plans,
provide nursing care, data collection and implementation of this can happen if
the client has a desire to participate in it. All nursing actions are recorded
in a format specified by the institution
2.8.5 EVALUATION
However,
evaluation is an integral part in every process of nursing. Evaluation is a systematic
comparison of the nursing plan and problem clients with the stated goals made
in a sustainable way by involving the client and the health care team. Through
evaluation allows nurses to monitor omissions that occurred during the study,
data analysis, diagnosis, intervention and implementation. And evaluation is an
integral part in each of the nursing process.
REFERENCES
Sloane,
ethel. 2003. Anatomi dan Fisiologi.
Jakarta: ECG
Doengos,
Marilynn E. 1999. Rencana Asuhan
Keperawatan. Jakarta: ECG
Potter
and Parry. 2006. Fundamental Keperawatan.
Jakarta: Media Aesculapius
Soeparman.
1990. Ilmu Penyakit Dalam. Jakarta:
Balai Penerbit FKUI
SECTION III
EXAMINATION FORM OF
NURSING DATA
No. Registration : 256629
Ward : II - A
Enter Hospital Date : 2
January 2013
Anamnesa Data : 5
January 2013
Medical Diagnose :
Pulmonal Tuberculosis
3.1
IDENTITY
a. Patient
Identity
Name : Tn. S
Address : Cemandi RT 6 / RW 2 Sedati –
Sidoarjo
Sex : Male
Age : 68 years old
Religion : Moslem
Nasionality : Java / Indonesia
Education : Junior High School
Work : Farmer
b. Responsibility
Name : Tn. A
Address
: Cemandi RT 6 / RW 2 Sedati – Sidoarjo
Sex : Male
Age
: 66 years old
Religion : Moslem
Nasionality : Java / Indonesia
Education : Senoir High School
Work : Private
Relation with client: Brother
3.2
HISTORY
OF CLIENT HEALTH
a. Main
Complain
Patients
say shortness of
breath
b. Present
History of Disease
Patients
say do not know exactly the cause of the pain, but
after returning to farm on January 1, 2013 the
patient felt shortness of breath until it can be
anything with a cough, body
pain, heat, no pain.
Considered more severe, the
patient was taken to the hospital
on January 2, 2013 at 10:55
c. Previous
History of Disease
The patient
said had been
treated at area hospitals with the same disease at 5 years ago.
d. Family
History of Disease
Patients
told not to have
family members who suffer from diseases like this and
no infectious diseases or decreased.
3.3
DAILY
ACTIVITY
|
No.
|
Daily Activity
|
At Home
|
At Hospital
|
|
1
|
Nutrition
|
Eat 3 – 4
x /day, menu : rice, fish, vegetable
Drinks
quality : 2000 – 2500 cc / day
|
Eat 2 – 3
x /day, menu : smooth rice, fish, vegetable
Drinks
quality : 2000 – 2500 cc / day
|
|
2
|
Elimination
|
Defecation:
1 x / day, Urination : 3 – 5x / day,
|
Defecation:
1 x / day, Urination : 3 – 5x / day,
|
|
3
|
Rest and
Sleep
|
Normal,
sleep from 22.00 – 04.00 WIB
|
Difficult
to sleep because the patient felt shortness of breath , sleep
from 19.00 – 05.00 WIB
|
|
4
|
Physical
activity
|
Going to
the farm
|
Just lied
on the bed
|
|
5
|
Personal
Hygiene
|
Taking a
bath 2 x/day, brushing teeth 2 x/day, shampoo 3x/weeks
|
Taking a
bath by his family just once, brushing teeth 1x/day, client not yet wash his
hair
|
|
6
|
Dependence
|
Coffe :
1x/day
Cigarette
: 2 – 3 cigarettes
|
nothing
|
3.4
PHYSCOSOSIAL
DATA
a.
Emosional Status
Emotions
patient is stable
b. Self Concept
·
Body Image :
The patient
said that he was ill and needed treatment in hospital
·
Self Ideal :
Patients
want to get a speedy recovery
·
Self Esteem :
Patients
treated well told by doctors and nurses
·
Self Performance :
Patients
feel his body limp, and lay sick all weak
·
Self Identity :
The patient
a 68-year-old patriarch
addressed in the village Cemandi RT 6 / RW 2 Sedati - Sidoarjo
·
Role : Activity
as the farmer
c. Social
Interaction
Patients
daily use Javanese
and Indonesian. Patients with good family relationships. Patients also cooperative
with nurses and doctors.
d. Spiritual
Patient is a muslim and
realize that this disease is a trial from Allah.
3.5
PHYSICAL
CHECK UP
1.
General Condition Weak
2.
Conscious
Composmentis with GCS 4 – 5 – 6
3.
Vital Sign
Blood
presure : 150 / 100 mmHg Temperature
: 36,4°C
Pulse : 88 x
/ minutes Respiration
Rate: 28 x / minutes
4.
Head
• Hair: clean, black and gray, no
lesions, no dandruff
• Face: symmetrical shape, no edema or injury
• Eyes: Isokor, symmetrical, no jaundice, conjunctival pink
• Nose: clean, symmetrical right and left, no polyps, no nostril breathing
• Ears: a little dirty, symmetrical right and left, both auditory function
• Mouth: symmetrical, mucosal dry lips, no thrush
·
Neck: There is no enlargement of the thyroid gland, no
enlargement of the jugular vein, no swallowing dysfunction
5.
Chest and Thorax
•
Inspection: pegeon chest shape, no lumps
• Palpation: no tenderness,
no lumps
• Percussion: resonant
to both lungs, heart sounds
deaf
• Auscultation: heart
sounds S1, S2 single, no additional sound
in the lungs
6.
Abdomen
•
Inspection: belly shape symmetrical, no lesions
• Auscultation: bowel
sounds 12x / min
• Palpation: no tenderness,
no enlargement of the liver
• Percussion: timpani
sound
7.
Extremity
·
Above:
symmetrical, no lesions, no edema, no tenderness, left hand attached infusion
·
Bottom:
symmetrical, no lesions, no edema, no tenderness
8.
Genetalia
Not attached catheter
3.6
SUPPORTING
DATA
|
NO
|
EXAMINATION
|
RESULTS
|
NORMAL VALUE
|
|
1
|
WBC
|
12,2
|
LK:13-18 PR:11,5-16,5
|
|
2
|
RBC
|
3,94
|
LK:4,5-5,5 PR: 4,0-6,0
|
|
3
|
WBC
|
4,41
|
4,0-11,0
|
|
4
|
PLT
|
149
|
150-400
|
|
5
|
SGOT
|
32
|
LK:0-40 PR:0-35
|
|
6
|
SGPT
|
24
|
LK:0-40 PR:0-35
|
3.7
THERAPY
AND MANAGING SYSTEM
a. Infuse : RL 14
drops/mnt
b. drug : drip aminophilin 1 amp/ kolf
Futaxon 2x1 1 g / IV drip PZ 100 cc
Pepsol 1x1 1 vial / IV
Codein 3x1 1 x tab / PO
Rimstar 3x1 1 x tab / PO
Combiven 3x1 1 amp
3.8
GROUPING
OF DATA
a. Subjective
Data
Patients say shortness of breath, cough,
body pain, heat, sleep soundly
b. Objective
Data
General condition was less, wearing a
nasal cannula, pigeon chest, composmentis awareness, mucosal dry lips.
= 
Vital sign 
BP: 150/100 mmHG T: 36,4 
RR: 28 x/mnt HR:
88
x/mnt
SECTION IV
IMPLEMENTATION AND
DISCUSSION
DATA
ANALYSIS
Name : Tn.S Room:
II-A
Age :
68 tahun No.
Reg: 256629
|
NO
|
DATE
|
GROUPING
OF DATA
|
ETIOLOGY
|
PROBLEM
|
|
1
|
05-01-13
|
1. DS:
The patient says shortness of breath, can not sleep, his body felt hot.
2. DO: General condition was less, pigeon chest,
awareness composmentis, wearing a nasal cannula.
=
VS  BP: 150/100 HR: 88 x/mnt
RR:
28 x/mnt T: 36,4
|
Damage to the
alveolar capillary membrane
|
Impaired gas exchange
|
|
2
|
05-01-13
|
1. DS:
The patient says cough, body pain and could not sleep all.
2. DO: General condition was less, mucosal dry
lips, awareness komposmentis,
VS BP: 150/100 HR: 88 x/mnt
RR: 28 x/mnt T: 36,4
|
Irritation of the
bronchi
|
Impaired sense of
comfort (cough)
|
NURSING DIAGNOSIS
Name : Tn.S Room
: II-A
Age :
68 tahun No.
Reg: 256629
|
NO
|
DATE
|
NURSING DIAGNOSIS
|
|
1
|
05-01-2013
|
Impaired gas exchange
related to alveolar capillary membrane damage, characterized by:
1. DS:
The patient says shortness of breath, can not sleep, his body felt hot.
2. DO: General condition was less, awareness composmentis,
pigeon chest, wearing a nasal cannula.
=
VS BP:
150/100
RR: 28 x/mnt
T: 36,4
HR: 88 x/mnt
|
|
2
|
05-01-2013
|
Impaired sense of
comfort (cough) related to Irritation of the bronchi, characterized by:
1. DS:
The patient says cough, body pain and could not sleep all.
2. DO:
General condition was less, awareness
komposmentis, mucosal dry lips
VS BP:
150/100
RR: 28 x/mnt
T: 36,4
HR: 88 x/mnt
|
NURSING INTERVENTIONS
|
Name
: Tn. S
|
Room : II-A
|
|
Age : 68 tahun
|
No.
Reg : 256629
|
|
No
|
Nursing Diagnose
|
Purpose
|
Interventions
|
Rational
|
|
1.
|
Impaired
gas exchange
|
-
Long term
Within
2 x 24 hours gas exchange becomes effective with the following criteria:
1. Shortness missing
2. Normal
respiration (12-20 x/minute)
-
Short term
Within
1 x 24 hours shortness reduced by the following criteria:
1. . Breathe easily.
2. Sleep well.
|
1. Approach the patient and his
family.
2. Give semi-Fowler position.
3. Give O2 via nasal cannula.
4. Give motivation to improve total
bedrest.
5. Observations vital sign.
6. Collaboration (corresponding
therapeutic advice).
|
1. Establish trust with patients.
2. Easing respiratory function.
3. Meet the needs of O2.
4. To decrease the severity of
symptoms.
5. Indicate the patient's progress.
6. Increase quality healthcare.
|
|
2.
|
Impaired
sense of comfort (cough)
|
-
Long term
Within 2 x 24 hour cough subsides with the following criteria:
1. Sigh of relief.
2. Sleep well.
Within
1 x 24 hours cough is reduced by the following criteria:
1. Normal
TTV:
Blood Preasure:
140/90 mmHg
Respirations:
12-20 x/menit
Temperature:
365 -375
Heart Rate:
60-100 x/menit
|
1. Approach the patient and his
family.
2. Give semi-Fowler position.
3. Teach clients challenged the
method effective cough.
4. Observations Vital Sign.
5. Collaboration (giving nebulizer)
|
1. Establish trust with patients.
2. Easing respiratory function.
3. Effective cough is very tiring.
4. Shows the development of health.
5. Respiratory loosen phlegm or thin.
|
IMPLEMENTATION
|
Name : Tn. S
|
Room : II-A
|
|
Age : 68 tahun
|
No.
Reg : 256629
|
|
No
|
Date
|
Implementation
|
Respons
|
TTD
|
|
1.
|
05-01-2013
|
1.
Approaching the patient and family.
2.
Giving semi-Fowler position.
3.
O2 via nasal cannula Member.
-
O2 à 4 L / min via nasal cannula.
4.
Provide motivation to improve bedrest.
-
Shortness of breath is a sense of weight as one of the reasons is that a
lot of strenuous activity or with adequate rest can reduce the need for O2.
5.
Observing TTV.
-
BP: 150/100 mmHg
-
HR: 88 x / min
-
Temperature: 36,4
-
Respiration: 28 x / min
6.
Collaboration (appropriate therapeutic advice)
-
Infusion: RL 14 drops/mnt
-
Medication:
·
Drip Aminophilin 1 amp/ kolf
·
Futaxon 1 g / IV drip PZ 100 cc
·
Pepzol 1 vial / IV
·
Codeine 1 x tab / PO
·
Rimstar 1 x tab / PO
·
Combiven 1 amp
|
Patients
received
Patients
cooperative
Patients
comfortable
Patients
received
Patients
cooperative
Patients
cooperative
|
|
|
2.
|
05-01-2013
|
1. Approaching
patients and their families.
2. Provide
semi-Fowler position.
3. Teach
patients about effective methods of coughing.
-
Breath deeply and slowly when
sitting as upright as possible, diaphragmatic breathing (abdominal
breathing), hold the breath for 3-5 seconds and then remove it through the
mouth as much as possible, do it in a second breath, hold and cough from the
chest with a short and strong.
4. Observing
vital sign
-
BP: 150/100 mmHg
-
HR: 88 x / min
-
Temperature: 36,4
-
Respiration: 28 x / min
5. Collaboration
(giving nebulizer)
-
Combiven 1 amp.
|
Patients received
Patiens comfortable
Patients cooperative
Patients cooperative
Patients cooperative
|
|
EVALUATION
|
Name : Tn. S
|
Room : II-A
|
|
Age : 68 tahun
|
No.
Reg : 256629
|
|
No.
|
Date
|
Evaluation
|
|
1.
|
05-01-2013
|
S: the patient says
it still feels tightness, coughing decreases, body sumer, His body was starting to feel better,
sometimes only just awakened from sleep.
O: general condition
enough, awareness composmentis, pegeon chest,wearing a nasal cannula, mucous
lips moist.
Vital Sign à BP: 150/100 mmHg
HR: 88 x / min
T : 36,4
Rr: 24 x / min
A: - Impaired gas
exchange related to membrane damage Alveolar capillaries are partially
resolved.
- Impaired sense of
comfort (cough) related to irritation
of the bronchi partially resolved.
P:
Intervention continued.
- Give semi-Fowler position.
- Give O2 via nasal cannula.
- Give nebulizer action.
|
SECTION V
CONCLUSION AND
SUGGESTION
5.1
CONCLUSION
Tuberculosis
is a disease caused by bacteria Mycogacterum Tuberculosis. This disease seems
to invade other organs and is transmitted from person, if treatment with this
disease can be cured completely.
The
clinical manifestation is fever,
cough,
tightness, chest
pain, malaise
5.2
SUGGESTION
As a nurse we must be
care with patient tuberculosis, because problem of patient with tuberculosis is
respiratory, so is vital sign.
