ASSESSMENT OF BASIC AND FOCUS DATA

Assessment Taken by date : 09 August 2020 Hours: 14.30

Date of entry : 09 August 2020 Reg: 004164xx
Room No. : HCU Teratai
Diagnostic Entry : TB lymphadenitis

I. IDENTITY
1. Name : Mr. M
2. Age : 20 years
3. Gender : Male
4. Religion : Islam
5. Tribes : Java
6. Language : Indonesia
7. Education : High school
8. Profession : Student
9. Address / No. Tel : Pasuruan
10. Person in charge : Parents

II. HISTORY BEFORE SICKING

1. Previous serious illnesses:
Tuberculosis
2. Medicines commonly consumed:
Anti TB Drugs (OAT)
3. Treatment habits:
Check at the puskesmas
4. Drug / food allergies:
There is no
5. Tools used:
There is no

III. THE HISTORY OF THE DISEASE NOW

1. Main complaint:
Decreased consciousness and breathlessness
 2. Sick start date:
8 August 2020
3. Process of illness:
The patient came to the ER with complaints of decreased consciousness and a lump in
the left neck since 2 months.

Suddenly  Gradually
Trigger factor:
Tuberculosis
4. Efforts that have been made:
Giving Oxygen
5. Vital sign:
S: 37.2 oC
N: 88 x / minute
RR: 24 x / minute on a ventilator
121
T: Mm / Hg
82

IV. HISTORY OF FAMILY HEALTH

1. Diseases that have been suffered by family members:
There is no
2. Diseases that are being suffered by family members:
There is no

V. ASSESSMENT SYSTEM
1. Respiratory System (B1 = Breathing)
Subjective data:
not studied
Objective Data:
 Spontaneous breathing with O2 NRBM 8 Lpm
 Thick yellow discharge
 Ronchi's breath sound +
 RR 26x / Meint
 SPO2 100%
2. Cardiovascular System (B2 = Blood)
Subjective data:
Not assessed
Objective Data:
 HR: 88 x / minute
121
 TD: Mm / Hg
82
 Attached to the NS 14 Tpm infusion
 Akral warm
 CRT <2 seconds

3. Neurological System (B3 = Brain)

Subjective data:
Not assessed
Objective Data:
 GCS: 3, 1, 5

4. Urinary System (B4: Bladder)

Subjective data:
Not assessed
Objective Data:
 Attached a catheter
 Yellowish urine
 Urine production 50cc / hour

5. Digestive System (B5: Bowel)

Subjective data:
Not assessed
Objective Data:
 NGT attached
 CHAPTER brownish liquid
 50 kg body weight
 6. Musculoskleletal System (B6: Bone)
Subjective data:
Not assessed
Objective Data:
 Head up position 300
 The wound on the left neck

7. Other related systems (Endocrine System. Reproduction, Immunology, etc.)

-

8. Break pattern:
Unconscious

9. Personal hygienic patterns:

Total care assisted by nurses

VI. PSYCHOSIAL
1. Social / Interaction:
The patient is unconscious
2. Self concept:
Not assessed
3. Spiritual:
The client's worship activities are disrupted

VII.MEDICAL ACTION AND MEDICINES PROVIDED

1. Attached ns 14 tpm infusion
2. Suction
3. NGT attached
4. Installed DC
5. Pulmicort Nebul / 8 hours
6. Drug injection: Moxifloxacin, diflucan, Fortison, Dexamethasone, streptomycin,
7. oral medicine: Anti Tb
VIII. SUPPORTING INVESTIGATION
1. Laboratory
attached
2. Radiology
Can be TB
3. Miscellaneous information
Regular Cadence ECG

Lawang, 09 August 2020

Nurse

(Firda Ayu Maghfiro)

 DATA ANALYSIS

Name : Mr. X
Age : 50 Year

Date Focus Data Etiology Problem

No. 1 DS: Droplet / air contains Ineffective Airway
The patient has decreased TB bacteria Cleansing
01 consciousness 
April Inhalation through the
2020 DO: respiratory tract
 The patient is 
unconscious Get into the lungs

 GCS: 3,1,5 

 Installed O2 NRBM An inflammatory

process occurs
 Yellow thick discharge

 Ronchi's breath sound +
production of secretions
increases

Secret is difficult to
remove

Airway clearance is not
effective

No. 2 DS: Limfadentis Tb Damage to Skin

Not assessed  Integrity
Inflammatory reaction
DO: 
 The patient is Abscess Formation
unconscious 

 open wound on left neck A lump appears

 TTV: 
121 Damage to Skin
T: Mm / Hg
82 Integrity
N: 88 x / m
S: 37.2 0C
RR: 24 x / m
 NURSING DIAGNOSES

No.
Date
Diagnosi Problem / Diagnosis Date Found Sgd
Resolved
s
1 Airway clearance is not - - Firda
effective due to airway
obstruction d / d decreased
consciousness, thick yellow
secretions

2 Damage to skin integrity b / d - - Firda

damage to skin layers
 NURSING PLAN

Name : Mr. M
Age : 20 Years

Objectives and
Date No DX Nursing diagnoses Intervention Rational TTD
outcome criteria
9 1 Airway clearance is Aim : 1. RR and Spo2 monitors 1. To find out the frequency Firda
Aug not effective After 3x7 hours of 2. Position the patient to of breathing and oxygen
2020 nursing action, maximize ventilation levels in the body
hopefully the nursing 3. Remove the sputum by 2. To maximize ventilation
problem can be coughing / suction 3. To clear the airway
resolved 4. Auscultate breath sounds 4. To find out if there are
Result criteria: 5. Give bronchodilators additional breath sounds
 Clean breath 6. Collaboration with the 5. For bronchial vasodilation
sound medical team 6. Maximizing care for the
Ronchi - patient
 Spo2 within
normal limits
95% - 100%
 Reduced
sputum
2 Damage to skin Aim : 1. wound observation 1. To find out the state of the
integrity After 3x7 hours of 2. Position the patient wound
nursing action, 3. Get wound care 2. Knowing the pressure on
hopefully the nursing 4. Collaboration with the the wound
problem can be medical team 3. To prevent infection
Firda
resolved 4. Maximizing care for the
Result criteria: patient
 shows the
process of
wound repair
 NOTE OF ACTION (IMPLEMENTATION)

Name : Mr. X
Age : 20 Years

Date Nursing diagnoses Nursing Actions and Outcomes Initials

9 Airway clearance is not 1. Monitor RR and Spo2
Aug effective RR: 24 x
2020 Spo2: 100%
2. Positioning the patient to
maximize ventilation
Head up 30o
3. Expelling the sputum by
Firda
coughing / suction
Suction: sputum +, thick yellow
4. Auscultate breath sounds
Ronchi +
5. Give bronchodilators
Ventolin
6. collaborate with the medical team
9 Aug Damage to skin integrity 1. Monitor Wounds
2020  white wound on the left side
and there is a lump
2. positioning the patient reduces
pressure on the wound Firda
3. Perform wound care with sterile
principles
4. Collaborating on drug delivery

DEVELOPMENT NOTE
No. Date Nursing diagnoses
Airway clearance is not effective Ineffective breathing pattern
S: - S: -

O:
 The patient is unconscious
 GCS: 3,1,5
 Installed 02 NRBM
 Yellow thick discharge
O:
 The patient is
unconscious
 The wound is covered
with clean sterile

 Ronchi's breath sound + gauze, there is no

 TTV: seepage

121  TTV:
T: Mm / Hg
82 121
T: Mm / Hg
N: 88 x / m 82

S: 37.2 0C N: 88 x / m

RR: 24 x / m S: 37.2 0C

A: Partially resolved problem RR: 24 x / m

1 09 Aug 2020

P: continue Intervention A: Partly Solved Problem

I: P: continue Intervention

1. RR and Spo2 monitors

2. Position the patient to I:

maximize ventilation 1. Wound monitor

3. Remove the sputum by 2. Position the patient to

coughing / suction avoid pressure

4. Auscultate breath sounds 3. do wound care

5. Give bronchodilators 4. Collaboration with the

6. Collaboration with the medical team

medical team

E: Yellow thick secretion, Ronchi

breath sound +