REPORT TBC

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.