Nama : Yudha Fauza Wardana

NIM : P17320317060

Identity : Mr. S is 77 years old man. Hospital day #2 being treated by Chronic Obstructive
Pulmonary Disease (COPD).
In 24 hours the patient the treathment for patient are:
1. Infusion fluid therapy NACL 21 dpm
2. Monitor vital signs,
3. Medications : Hydralazine, Digoxin, Theo, Lasix, Pottasium supplement
4. Built in : OPA, Catherter, NGT, O2 Nasal canula 4 liters per minutes
PE Remarkable for :
1. VS : HR : 110, BP : 130/90, RR : 15, Temperature : 36,3 C, Pulse O2 : 85%
2. General : thin, cachetic appearance, alert and oriented
3. GCS : Stupor
4. Neuro : CN 11 – XII
5. Respiratory : Dyspnea on exertion, tachypnea at rest using accessory muscles to breath,
percussion : hyperresonance to all lobes. Ribe cage easily seen through chest wall
6. Cardiovascular : Heart sounds S1,S2,S3 gallop and systolic murmur, regular, NO JVP,
hepatojugular reflux
7. Abdoment : soft non-tender on palpation, bowel sounds in all quadrans
8. Musculoskeletal : weak movement, muscle wasting, patient rest in bed
9. Skin : poor skin turgor

Labs and Imaging remarkable for ;

1. Hematologi :
Hb: 10,0, Leuko : 9,800, Hema : 38,8 Trombosit : 252.000
Ph : 7,15, PaCO2 : 32, PaO2 : 74, HCO3 : 18
2. ECG, Rontgen, CT Chest, CT pulmonary angiography

Asessement :
1. Patient respiratory still dyspnea
2. VS : HR : 115, BP : 132/95, RR: 15, Temp : 36,5 C, Pulse : 80%
3. Urine bag : 100 cc

Nursing Diagnose :
1. Ineffective tissue perfusion
2. Ineffective breathing pattern
Nursing care plan :
1. Ineffective tissue perfusion
a. Check for optimal fluid balance
b. Note urine output
c. Maintain optimal cardiac output
d. Evaluate GCS
2. Ineffective breathing pattern
a. Observe for breathing patter
b. Monitor for diaphragmatic muscle weaknes chest muscle
c. Maintain a clear airway by encouraging patient

Collaboration plan :
a. Continous medications : Hydralazine, Digoxin, Theo, Lasix, Pottasium supplement
b. Provide respiratory medication and oxygen