INSTITUTE OF HEALTH SCIENCE SUAKA INSAN

Jln. H.Zafri Zam-zam no. 8 Banjarmasin

ASSIGNMENT OF INTENSIVE CARE UNIT ( ICU )

Student name : Incercersia Riakan Mangka, S.Kep

Semester / Level : Ten (X) / Profession Ners
Place of Practice : Saint Paul Hospital of Tuguegarao
Date of Review : Wednesday, July 04, 2018

CLIENT DATA

A. GENERAL DATA
1. Name Client Initials : Ny. G. FR
2. Age : 83 years old
3. Address : Antagan I, Tumauini, Isabela, Philippines
4. Religion : Catholic
5. Entrance Dates In Hospital : June 23, 2018
6. Med Record Number : 0109XXX
7. Medical Diagnosis : AMI ( Acute Miocard Infarction )
8. Ward : Medical Intensive Care Unit (MICU)

B. ASSESSMENT 13 DOMAIN NANDA

1. HEALTH PROMOTION
a. Public Health
- Reasons for admission to hospital :
The patient's family says "Mother complains of pain in the left chest and radiates
to the left arm" .
- Blood Pressure : 120 / 80mmHg
- Pulse : 76 X / Minutes
- Temperature : 36.2ºC
- Respiration : 28 X / Minutes
- SPO 2 : 98% using Nasal Kanul 2 liters per minutes

b. Past history (Illness, Accident, etc)

The patient's family says " In 2015 an accidental fall in the bath room resulted in a
femoral fracture so that in 2016 had to undergo surgery . And Mom suffering
from Diabetes Mellitus has been a long time as well as hypertension " .

c. Medical History
No Name of medicine / Dose Information
herbal medicine
1.
2.
3.
 The patient's family says that "It's always a routine to take medication for
Hypertension but do not remember the name of the drug your mother is taking "

d. Ability to Control Health

- What to Do When Sick
RGA Kelua patient says "Always routine health check mainly Diabetes and
Hypertension at the health clinic".
- Pattern Life ( Consumption / Alcohol / Sports, etc)
The patient's family says "It's good to eat meat, not to drink alcohol, and almost
never exercise just doing activities at home just like washing clothes, sweeping
houses, etc.)".

e. Socioeconomic Factors ( Income / Health Insurance , etc. )

The patient's family says "Mother has no income because she is not
working anymore so that she is living the life of Mother and Father as we are her
children, Mother has Health Insurance arranged by us".

f. Treatment Now
No Date in Medicine name Dose Gynecology Benefits
Doctor's
order
1 July 4, Hydrocortisone Adults: use 0.1- Hydrocortisone 1% Relieves mild
2018 2.5% cream on the inflammation in
affected area of the diet due to
dermatosis. eczema and
dermatitis, insect
bites
2 July 5, Fluimucil 1 tablet / day Acetylcysteine Dilute sputum in
2018 (preferably at respiratory
night). diseases where
there is a lot of
mucus or
phlegm
3 Levofloxacin 1 tablet or500 LEVOFLOXACIN 250 Acute maxillary
mg in a day mg sinusitis, chronic
Each film-coated tablet bronchitis with
containsLevofloxacin 250 acute bacterial
mg. exacerbations,
pneumonia, skin
LEVOFLOXACIN 500 infections and
mg uncomplicated
Each film-coated tablet skin structures,
containsLevofloxacin 500 urinary tract
mg . infections with
complications
 and acute
pyelonephritis.
4 Biogenic BIOGESIC tab Paracetamol BIOGESIC
taken 3 times daily tab used as
1-2 fever-lowering
tablets. BIOGESIC drugs and pain
tabs can be drunk relievers
before or after
meals.

2. NUTRITION
a. A ( Anthropometry ) includes BB, TB, LK, LD, LILA, IMT
1) BB usually: 57 kg, and BB now : 49 kg
2) TB : 154 cm
3) Abdominal Circumference : 80 cm
4) Head Circle : 53 cm
5) Chest size : 112 cm
6) Upper arm circumference : 18 cm
7) IMT : 49/1.54x1,54 = 20.6 (Normal weight18.5 -
22.9)

b. B ( Biochemical ) includes abnormal laboratory data :

- PH 7.51 (Up)
- PCO2 53.7 (Up)
- PO2 68 (Down)
- HCO3 42 (Up)
- tCO2 36.6 (Up)

c. C ( Clinical ) includes clinical signs of hair, skin turgor, lip mucosa,

conjunctival anemis / not :
Patient appears weak with the condition of hair looks dull and gray, skin turgor
looks dry, the mucosa of lips look dry and pale.

d. D ( Diet ) includes lust, type , frequency of food given during the hospital :
Patients are eager to eat by mouth with this type of food porridge , but the ability
to swallow is still not good so still eat through the NGT tube with the type of
food osterized feeding 1800 Kcal / day.

e. E ( Ene r gy ) includes the client's ability to engage in activity during the hospital :
Patients have not been able to perform the activity because it has not been allowed
to move that can accelerate the pacemaker.
 f. F ( Factor ) includes the causes of nutritional problems: ( Swallowing,
chewing , etc) :
Patients have problems chewing as well as swallowing so that nutrients can be
met through the NGT tube.

g. Assessment of Nutritional Status

Weight loss of 8 kg during illness but BMI in the normal range

h. Liquid Intake Pattern

Patients get fluid intake through a 30 cc NGT interval in one rinse after feeding
through NGT for fluid intake via parenteral DNSS of 44 ml / sec discharged
within 25 hours

i. In Fluid
Incoming fluids are orally 1680/24 hours and parenteral 1150/24 hours so the
total amount of fluid entering 2830 for 24 hours

j. Exit Liquid
The amount of urine out 3905/24 hours

k. Assessment of Liquid Status ( Liquid Balance )

I ntake liquid-Liquid Output = 2830-3905 = -1075

l. Abdominal Examination (System Elimination)

Inspection : Abdomen looks symmetrical
Auscultation : Noisy usu s normal 14 x / minute
Palpate : There is no tenderness in the abdomen
Percussion : Tympani's stomach percussion sound

3. ELIMINATION
a. Urinary System
1) Urine Discharge Pattern ( F recess, number, discomfort )
In catheter-attached patients to assist urine output with the amount of urine
output 3905 per 24 hours
2) History of Bladder Abnormalities
Not experiencing bladder abnormalities
3) Urine Pattern ( Number, color, viscosity, odor)
The amount of urine that is accommodated is 3905 per 24 hours, clear yellow
color, not thick, and characteristic of ammonia.
4) Bladder distention / Retention of Urine

b. Gastrointestinal System
1) Pattern Elimination
Patients CHAPTER 1 x / day with consistency soft and plucked
 2) Constipation and Causes of Constipation
Not constipated

c. System Integument
1) Leather (I ntegritas leather / hydration / turgor / color/ temperature)
Skin condition looks dry, not elastic, no tumors, skin color yellow langsat, body
temperature 36,6 º C

4. ACTIVITY / REST
a. Rest / Sleep
1) Bedtime :
- The patient's family says " P a da while still not in the hospital for
2 hours, 2 hours sleep and 5 nights sleep " .
- The patient's family says "While at the hospital the patient is sleeping for
only a short time".
2) Insomnia :
- The patient's family says " Mother does have trouble sleeping during home
and before illness " .
- The patient's family says "Mom is still having trouble sleeping, especially
especially at the hospital".
3) Per Express to Stimulate Sleep
- The patient's family says "Mothers usually try to lie down and close their
eyes until they fall asleep ."
- The patient's family says " While at the hospital s ama with when at
home before being treated"
-
b. Activity
1) Work : The patient is no longer doing the job activity
2) Exercise habit : Patients are rarely exercising since young
3) ADL
a) Eat : Assisted by nurses and families
b) Toileting : Assisted by nurses and families
c) Cleanliness : Assisted by nurses and families
d) Dress up : Assisted by nurses and families
4) ADL Help : Total dependency
5) Strength Muscle :

The degree scale of muscle strength is 5 (normal strength)

6) ROM : Active ROM and passive ROM can be performed by the patient
 7) Risk for Accident :
Patients are very high risk for injury because the elderly are very vulnerable
to fallen based on the incidence of accidents that fell in the bathroom in 2015
and also patients have heart problems

c. Cardio Response
1) Heart Disease : Patients have CHF (Congestive Heart Failure) since
early 2018
2) Edema Esktremitas : No edema of the extremities
3) Blood Pressure and Pulse
a) Lie down :
- TD: 130/80 mmHg
- Nadi: 89 x / min
b) Sit :
- TD: 130/80 mmHg
- pulse: 91 x / min
4) Jugular venous pressure :
There is no jugular vein suppression
5) Cardiac examination
a. Inspection : Ictus cordis is not visible
b. Palpate : Not a lump on the chest
c. Percussion : Dim, no ventricular hypertrophy
d. Auscultation : Pure S1-S2 heart sound

d. Pulmonary Response
1) Breathing System Disease :
Patients do not experience respiratory disease
2) Use of O 2 :
Patients used 2 liters per minute nasal cannula and SPO 2 : 99%
3) Breathing Ability :
The patient is able to breathe normally
4) Respiratory Disorders (Cough, Breath Sound, Sputum, Etc)
In the patient there is a sputum sounding Ronchi, sometimes coughing
5) Lung Examination
a. Inspection : Symmetrical chest, symmetrical chest
movement, no pull of intercostal muscle
b. Palpate : Tactile right fremitus equal to left
c. Percussion : Sonor whole airy lung
d. Auscultation : The sound of breath sounds ronchi due to the
accumulation of mucus in the airway

5. PERCEPTION / COGNITION
a. Orientation / Cognition
1) Education Level :
Senior Hight School
 2) Lack of Knowledge :
Patient
3) Knowledge About Diseases:
4) Orientation (Time, Place, People ) :
Patient is still able to remember time, place and person

b. Sensation / Perception
1) Heart Disease History :
The patient's family said "Patients have
CHF (Congestive Heart Failure) dal a m 1 last year".
2) Headache :
The patient's family says " Patients sometimes feel headache".
3) Use of Tools :
The patient's family says "Mother does not use hearing aids , sight, etc.".
4) Sensing :
The patient's family says "Mother is still able to hear, see, smell, taste , and taste
the food well".

c. Communication
1) Languages Used :
The patient's family said "At home pa da uses language Tagalog"
2) Difficulty in Communicating :
The patient's family said " It has been difficult to speak since before treatment"

6. SELF PERCEPTION
a. Self -Concept / Self-Esteem
1) Feelings of Anxiety / Fear :
The patient appears not anxious and uneasy but there is fear when the disease
recurs again
2) Feelings of Despair / Lost:
Patients do not feel discouraged or even lose
3) Desire To Injure :
Patients have no desire to harm themselves or others
4) Existence of Injury :
Patients have experienced an accident in the bathroom so that there is fracture of
the femur and undergo surgery in 2016

7. ROLE RELATIONSHIP
a. Relationship Role
1) Relationship Status : Married
2) The Nearest Person : Husbands and children and grandchildren
3) Conflict / Role Changes : No role change occurs
4) Lifestyle Changes : No lifestyle changes
 5) Interaction With Others : Still able to interact with others

8. SEXUALITY
a. Sexual Identity
1) Problems / Sexual Dysfunction : Not assessed
2) Menstrual Period : Not examined
3) The Family Planning Method Used : Not examined
4) Inspection BSE : Not examined
5) Papsmear Inspection : Not examined

9. COPING / STRESS TOLERANCE

a. Coping Response
1) Sense of / Fear / Anxiety :
The patient's family says "It does not feel sad but there is little fear and anxiety
if the same disease recurs again".
2) Tray to Overcome :
The patient's family says "Mother overcame it by telling us as a family about
what you feel".
3) Behaviors that Reveals Anxiety:
The patient's family says "I do not show that I'm worried".

10. LIFE PRINCIPLES

a. Trust value
1) Religious Activities Followed : Mass at church
The patient's family says "Mass Mother in Church
2) Ability to Participate :
The patient's family said "I want to take part in religious activities but I am not
too strong to walk because I have been in an accident and have been sickly".
3) Cultural Activities :
The patient's family says "Not following cultural activities ".
4) Problem Solving Abilities :
The patient's family said "Mother solved the problem by discussing with
family".

11. SAFETY / PROTECTION

a. Allergy :
Do not have food allergies or drugs
b. Autoimune Disease :
Has no autoimmune disease
c. Signs of Infection :
There was no sign of infection in the patient
d. Thermoregulation disorders :
There is no thermoregulation disorder
 e. Disorders / risks ( immobilization, falling, aspiration, peripheral neurovascular
dysfunction, hypertensive conditions, bleeding, hypoglycemia, disuse syndrome,
sedentary lifestyle ) :
Patients are highly at risk for falls, and patients have hypertension and lifestyle that
still likes to consume meat

12. COMFORT
a. Comfort / Pain
1) Provokes (painful ) : No pain
2) Quality ( how quality) : No pain
3) Regio (Place) : No pain
4) Scala (scale) : No pain
5) Time ( Time) : No pain

b. Other Uncomfortable Flavors : Nothing

c. Accompanying symptoms : Usually when pain accompanied by shortness

13. GROWTH / DEVELOPMENT

Growth and Development :
 C. DEVELOPMENT NOTES
General Condition
HOUR 7:00 8 am 9:00 10:00 11:00 12:00 1pm 2pm
TD 120/80 120/80 120/80 120/80 120/80 120/80 mmhg 130/80 130/80
mmHg mmHg mmHg mmHg mmHg mmHg mmHg
TTV PULSE 75 x / min 85 x / min 80 x / min 77 x / min 90 x / m enit 82 x / min 89 x / min 72 x / min
RR 14 x / min 18 x / min 24 x / min 17 x / min 14 x / min 20 x / min 22 x / min 18 x / min
TEMPERATURE 3 6 , 5ºC 3 6 , 6 ºC 35, 8 ºC 35, 9 ºC 3 6 2 ºC 35, 8 ºC 3 6 2 ºC 3 6 , 5ºC
EYE 4 4 4 4 4 4 4 4
(Spontaneous) (Spontaneous) (Spontaneous) (Spontaneous) (Spontaneous) (Spontaneous) (Spontaneous) (Spontaneous)
MOTORIK 6 6 6 6 6 6 6 6
(Obey orders) (Obey orders) (Obey orders) (Obey orders) (Obey orders) (Obey orders) (Obey orders) (Comply with
GCS the
Command)
VERBAL 5 5 5 5 5 5 5 5
(Oriented) (Oriented) (Oriented) (Oriented) (Oriented) (Oriented) (Oriented) (Oriented)
D. LABORATORY DATA

Date & Time

Checking type Check up result Unit Interpretation
23/6 23/6 24/5 25/6 26/6 29/9 30/6 2/7 3/7
WBC 17.54
HGB 10.4
HCT 34
Seg 0.63
Lympho 0.35
Mono 0.02
PLT Cnt 186
RBS 17.039
BUN 3.56
Crea 91 75
Na 133 136 124 125
K 4.26 2.03 3.44 2.49
CKMB 45.26
Trop 1 (Qualitative) Negative Positive
pH 7.11 7.49 7.46 7.52 7.49
PCO 2 26.6 30.2 35.5 38.6 39
PO 2 76 176 84 109 77
HCO 3 8.1 23 24.6 31.1 29.2
HCO 2 8 207 22.4 28.4 26.6
BE -20.7 0.7 1.4 3.7
SO 2 89.7% 99.7% 96.5 % 48.7 % 96.2%
5.7
HBAIC
59
SGPT
0.60 0.70
Magnesium
1.11
PTPA (INR)
71.9
(ACT)
13.1
(TME)
7.10
FBS
3.27
K
0.60
Mg
 Checking type Check up
Unit
Date & Time result
05/07/2018 PH 7.51 pH
05:14 Am PCO 2 53.7 mmHg
PO 2 68 mmHg
HCO 3 42 mEq / L
tCO 2 36.6 mEq / L
BE 16 mEq / L
SO 2 9 7 .5% %

E. SUPPORTING INVESTIGATION
1. ECG Check
ST Elevation
 DATA ANALYSIS

No Data Etiology Nursing Issues

1. Subjective data: Myocardial The
The patient's family said "Mother still infarction ineffectiveness of
coughs up phlegm and can not airway clearance is
remove the sputum" Cardiac associated with
contractility excess mucus,
Data Objective: decreases retained secretion
1. Auscultation of breath
Decreased cardiac
sounded Ronchi
output and
2. Patients seem to want to decreased
cough but have trouble O2 saturation
removing secretions
3. Nebulisasi using Combivent Sputum
accumulation in
the airway

Ronchi breath
sound
2. Subjective data: Myocardial Activity
The patient's family says "Mothers infarction intolerance is
are encouraged by doctors for plenty related to the
of rest". Cardiac imbalance between
contractility supply and oxygen
Data Objective: decreases demand
1. Bedrest patients in bed
according to doctor's Decreased cardiac
recommendation output and
decreased
2. TTV
O2 saturation
a. Blood
pressure 120/80mmHg
b. Nadi 76 x / Minutes Supply
c. Temperature 36.2ºC disruptions
d. Respiration 28x / Minute O 2 into the body
e. SPO 2 98% using Nasal
Kanul 2 liters per minute Weakness