Nama : Alif Lusy Wulandari

Nim : 01.2.17.00592
Mata Kuliah : Bahasa Inggris II

Data Etiology Problem

Subjective data: Invasion of TB (BTA Ineffective airway
She said that she suffered gram +) clearance
cough, dyspnea because
viscous secret in respiratory Hypersecretion
tract. mucous
Objective data: respiratory tractus
Sounds of breathing: ronchi
+/+, secret: yellow viscous, Increasing vicous
RR: 30x/minute. secretion

ineffective airway
clearance
Data Etiology Problem
Subjective data: Distress Metabolic, Altered Nutrition:
She said that she losses her compressing of less than body
appetite N.vagus on gaster requirements
Objective data:
weight: 22 kg (before ill: 24 gastrin
kg) Alb: 3.0 , portion of
eating: ½portion disorder of gastric

HCL of gastric
increase

Inadequate nutrition
intake

Data Etiology Problem

Subjective data: Invation of BTA Sleep pattern
She said that she can not disturbance
sleep well because hard Metabolism of body
cough and dyspnea at night.
Activity of TB (BTA
Objective data: gram +)
she looks like sleepy,
weakness, vital signs: BP: severe coughing at
110/70 mmHg, HR: 90 night
 beats/minute, T: 36.5 C, RR:
24 x/minute. sleep pattern

1. Make 3 Implementations based on data above

2. Make 3 Nursing Evaluation with SOAP or SOAPIER

DIAGNOSE 1 :
DIAGNOSE TIME IMPLEMENTATION SIGN
Ineffective October 7, 1. Monitor breathing patterns Ns. E
airway 2020 - R: 22 x / minute
clearance 08.00 2. give semi fowler position
- The patient feels comfortable
08.30 and the breath is not short
3. teaches effective coughing
10.00 techniques
- the patient says they can apply
the technique
10.30 4. teaches deep breathing
exercises
October 8, 1. Monitor breathing patterns Ns. E
2020 - R: 20 x / minute
08.30 2. give semi fowler position
- The patient feels comfortable
09.00 and the breath is not short
3. teaches effective coughing
10.00 techniques
- the patient says they can apply
the technique
10.30 4. teaches deep breathing
exercises

Evaluation
October 7, 2020
S: The patient says he can breathe But
it was still coughing and there was a
yellow ret
O: The patient does not seem to have
difficulty breathing anymore and no
additional sounds are heard when the
patient breathes
A: The problem of clearing the airway
is partially ineffective
P: Intervention is continued
Evaluation
October 7, 2020
S: The patient says he can breathe and
the secretion has decreased
O: The patient does not seem to have
difficulty breathing anymore and no
additional sounds are heard when the
patient breathes
A: The problem of clearing the airway is
partially ineffective
P: Intervention is continued
DIAGNOSE 2 :
Implementation: Nutritional Deficits (D.0019) Wednesday, 7th October 2020

Time and Implementation and Patient Response Sign.

Date
Wednesday, Nutrition Management (I.03119) Ns. E
October 07, 1. Measure the patient's vital signs
2020 R/: The patient is available for vital signs and
08.30 am results are obtained:
Term : 36֠C
RR: 22x/minute
P : 80x/minute
Blood Presure : 110/80 mmHg
2. Identify the patient's nutritional status
08.40 am R/: The patient is willing to have his nutritional
status checked, and the results of the examination
show that the patient has no appetite, eats only 1/2
portion, and has lost weight.
3. Monitor the patient's food intake
09.00 am R/: The patient is only able to finish 1/2 portion of
each meal because he does not feel an appetite
4. Provide foods high in calories and high in
09.15 am protein
R/: The current patient cannot eat much. the nurse
tries to feed little but often
09.40 am 5. Teach a programmed diet
R/: If given education, the patient receives it well
and is willing to be given diet therapy as an effort
to increase the patient's nutritional needs
10.00 am 6. Collaboration with nutritionists to determine
the number of calories and types of nutrients
needed
R/: Patients are willing to increase their
nutritional needs with a diet that has been
provided by nutritionists so that the patient's
appetite increases
Implementation: Nutritional Deficits (D.0019) Thrusday, 8th October 2020

Time Implemntation & Patien Response Sign.

09.00-09.15 am Monitor food intake Ns. E
R /: The patient can finish a meal
Monitor body weight
R /: The patient's weight increases to 24Kg
10.00-10.15 am Provide foods high in calories and high in protein Ns. E
R /: The patient wants to eat foods high in calories
and high in protein
Provide supplements
R /: The patient has an increased appetite
10.20-10.50 am Teach programmed diets Ns. E
R /: Patients listen to and understand education
about programmed diets
Evaluation Nutritional Deficits (D.0019) Wednesday, 7th October 2020

Collaborative Date / Time Development notes Sign

nursing
problems
Nutritional 7th October 2020 S = the patient said he still had Ns. E
Deficits 12.00 wib a loss of appetite
O = weight: 22 kg (before ill:
24 kg) Alb: 3.0 , portion of
eating: ½portion
A = problem not resolved
P= the intervention was
continued
1. Measure the patient's vital
signs
2. Identify the patient's
nutritional status
3. Monitor the patient's food
intake
4. Collaboration with
nutritionists to determine
the number of calories
and types of nutrients
needed
Evaluation nutritional (D.0019) thrusday, 8th October 2020
Collaborative Date/time Development notes Sign
nursing
problems
Nutritional 8th October 2020 S = the patient said his Ns. E
deficits 12.00 wib appetite has increased
O = weight: 22kg, (before ill,
24 kg) Alb: 3.0 , portion of
eating 1 portion
A – The problem is resolved
P = the intervention was
stopped
DIAGNOSA 3 :
Implementation : Sleep Pattern Disturbance (D.0055) Wednesday, 6th October 2020

No. Time Implementation & Patient Response Sign

1. 7th October 2020 Checking Mrs A body Temperatue

07.15 am RR : 36,5 C N : 90 beats/minute Ns. E

P : 24 beats/minute TD : 110/70 mmHg

09.00 am Identify sleep activity patterns Ns. E

R/ : The patient looks like sleepy and weakness

11.00 am Environmental modification Ns. E

R/ : Limit the number of visits to patients

12.30 – 13.30 am Carry out procedures to increase comfort Ns. E

R/ : Semifowler positioning

Explain the importance of getting enough sleep during illness

R/ : The patient apprears calmer

Evaluation : Sleep Pattern Disturbance (D.0055) Wednesday, 6th October 2020

Collaborative
nursing Date / Time Development Notes Sign
problems
Sleep Pattern 7th October S : The patient said she can’t sleep because any esternal Ns. E
Disturbance 2020 disturbing factors
14.00 WIB O : 1. The general state appears weak
1. RR : 36,2 C N : 96 beats/minute
P : 23 beats/minute TD : 120/80 mmHg
A : Problem not resolved
P : The intervention was continued
1. Checking Mrs A body Temperatue
2. Identify sleep activity patterns
3. Environmental modification
4. Carry out procedures to increase comfort
5. Explain the importance of getting enough sleep
during illness

Evaluation : Sleep Pattern Disturbance (D.0055) Wednesday, 7th October 2020

Collaborative
Date /
nursing Development Notes Sign
Time
problems
Sleep Pattern 7th October S : The patient said she sleep has increased Ns. E
Disturbance 2020 O : 1. The general state appears weak
14.00 WIB 2. RR : 36,7 C N : 92
beats/minute
P : 22 beats/minute TD :
110/80 mmHg
A : The problem is resolved
P : The intervention was stopped