NURSING CARE IN CHILD “A” WITH RESPIRATORY SYSTEM

DISORDERS IN MEDICAL DIAGNOSES OF ACUTE RESPIRATORY

INFECTION IN THE CHILDREN'S INPATIENT INSTALLATION ROOM
AUGUST 18-19, 2018

A. ASSESSMENT
Assessment date : August 19, 2018
Assessment time : 10.00 a.m.
Date of entry : Agust 18, 2018
Entry time : 10.00 p.m.
Room : Child care room
No. RM : 120931

1. Client Identity
a. Patient
Name : An. “A”
Age : 6 years old
Gender : female
Religion : Islam
Tribe / Nation : Sasak / Indonesia
Education : Primary school
Status : Student
Address : Ampenan
Medical diagnoses : ISPA

b. Person in charge
Name : Ny. “D”
Age : 25 years old
Occupation : Teacher
Address : Ampenan
Relationships with client : Parents
2. Medical History
a. Main complaint
Coughing
b. Complaints when reviewed
The family said her child had flu, fever, nausea and frequent tightness
c. History of nursing now
Patients were taken to the Emergency Department of Mataram City Hospital
on August 18, 2018 at 10pm with complaints of cough and flu for a week with
fever. After the examination, An. “A” is taken to the child care room.
d. Formerly nursing history
The family said that her child had been ill like this, namely cough and flu
for three days but was not taken to the hospital.
e. Family health history
The family said that there was no history of ARI, only ordinary illnesses
such as coughing, flu, fever and no other hereditary diseases.

3. Biological, psychological, social, spiritual patterns according to Gordon

a. Respiration pattern
 Before getting sick
Patients can breathe normally without respiratory aids
 When sick
he patient breathes with nasal cannula
b. Nutrient pattern
 Before getting sick
The patient said that he ate 3 times a day with a portion of rice with side
dishes and drank 6-7 glasses of water
 When sick
Patients only spend half the portion of food provided from the hospital and
nausea vomiting when eating. drink 5 glasses of water per day
c. Elimination pattern
 Before getting sick
 Patients say normal defecation 1 time a day with solid consistency, yellow
color, urinate 4-5 x / day with clear yellow color
 When sick
Patients say that they defecate 1 time a day with soft consistency, brownish
yellow color, typical of fese. Urination 4 - 7 times a day with cloudy yellow
like tea.
d. Exercise and activity pattern
 Before getting sick
Patients can carry out activities and activities without the help of others
 When sick
Patients feel weak and must be helped to do activities
e. Sleep rest pattern
 Before getting sick
Patients can sleep 7-8 hours / day without interruption rarely take a nap
 When sick
The patient said that he could not sleep all night and also the afternoon
could not sleep

4. Physical Examination
a. General examination
1) The general state : Weak
2) Awareness : Composmentis
3) Blood pressure : 100/65 mmHg
4) Respiration rate : 35x/menit
5) Pulse : 115x/menit
6) Temperature : 38,3oC
b. Head to toes
1) Head
a) Inspection : Symmetrical head shape, thick black hair color, not dirty
scalp
b) Palpation : No tenderness, no swelling
 2) Eyes
a) Inspection : Symmetrical eye shape, non anemic conjunctiva, white
sclera, pupils shrink when given light stimulation.
b) Palpation : No tenderness
3) Nose
a) Inspection : Symmetrical nose shape, the client can smell eucalyptus.
b) Palpation : No tenderness
4) Mouth
a) Inspection : Symmetrical mouth, dry lips, no stomatitis.
b) Palpation : No tenderness
5) Thorax
a) Inspection : Symmetrical chest shape, additional sound (stridor) while
sleeping.
b) Palpation : No tenderness
c) Auskultation : Additional sound stridor
6) Abdomen
a) Inspection : Symmetrical abdomen, no wounds
b) Palpation : No tenderness
c) Auskultation : Intestinal noise 12x/menit
7) Extremites
a) Up
 Inspection : Acral warm, no swelling, attached Lactate Ringer infusion
16 drops per minute on the right hand
 Palpation : No tenderness
b) Down
 Inspection : There are no wounds, no swelling
 Palpation : No tenderness

5. Results of Laboratory tests

a. Drug therapy
Pamol syrup 3x1 sdm
 Coparcetin syrup 3x1 sdm
Amoxcillin 3x0,5 tab
RL 16 tts/mnt
Dedsametason 3x0,5 tab

B. NURSING DIAGNOSES
1. Data analysis
Data
DS :
The family said her child had
flu, fever, nausea and
frequent tightness
Etiology Problem
Invation of germs Ineffectiveness of
airway clearance
Inflammation in the
respiratory tract

DO :
a) Additional sound Germs release
(stridor) while endotoxins
sleeping.
b) The patient looks
weak
Stimulate the body to
c) Lips look dry
d) Vital sign : release pyrogens by
 BP : 100/65 mmHg leukocytes
 RR : 35x/menit
 P : 115x/menit
Hypothalamus to the
 T :38,3oC
thermoregulator part

Body temperature
increases

Stimulates the body’s

defense mechanism
against the presence of
microorganism
 Increases the production
of basilic mucus cells
along the respiratory tract

Stacking of mucus
secretions in the airway

Airway obstruction

Ineffectiveness of
airway clearance

2. Diagnoses formula
Ineffectiveness of airway clearance associated with airway obstruction marked by
the family said her child had flu, fever, nausea and frequent tightness, additional
sound (stridor) while sleeping, the patient looks weak, lips look dry, BP : 100/65
mmHg, RR : 35x/menit, P : 119x/menit, T : 38,3oC.

C. NURSING INTERVENTION
Days / Objectives and
Dx Intervention Rational
Date results creteria
Sunday, 1 After nursing 1. Assess vital signs 1. To know the
19 action for 1x24 patient's progress
August hours, it is and to determine
2018
expected that the next therapy
ineffective airway
clearance can be 2. Auscultation of 2. To find out if
resolved by the additional breath there are
results criteria: sounds additional breath
a. Demonstrating sounds
an effective
cough and clean 3. Position the semi- 3. Increase secretion
breath sounds, fowler patient movement to the
no cyanosis and big airway to be
 dyspneu (able expelled
to secrete
sputum, able to 4. Monitor the 4. to find out
breathe easily, patient's oxygen oxygen levels in
no pursed lips). status the blood
b. Show a patent
airway (the 5. Collaboration of 5. Relieve lung
client does not 3lpm nasal cannula work to meet
feel suffocated, O2 therapy oxygen needs and
breathing meet oxygen
rhythm, needs in the
respiratory body.
frequency in the
normal range,
no abnormal
breath sounds)
c. Able to identify
and prevent
factors that can
inhibit the
airway.

D. NURSING IMPLEMENTATION
Days /
Time Dx Implementation Response results Paraf
Date
Sunday, 11.30 1 1. Assess vital signs 1. BP : 100/65 mmHg
19 p.m. RR : 105x/menit
August P : 35x/menit
2018 T :38,3oC

2. Auscultation of 2. There are still

additional breath additional breath
sounds sounds (stridor)

3. Set the position 3. Patients say they

patient of the semi- are comfortable
fowler with the position
given by the nurse
E. NURSING EVALUATION
Days /
Time Dx Progress note Paraf
Date
Sunday, 05.00 1 S : The patient said he was still coughing,
19 p.m. short of breath
August Patient say they are comfortable with the
2018
position given

O : The patient is still coughing

BP : 100/80mmHg
RR : 20x/menit
P : 100x/menit
T : 36,5oC

A : The problem is partially resolved

P : Intervention continued