NURSING CARE FOR MR.

B WITH THE MAIN PROBLEM

OF FULFILLING OXYGENATION NEEDS IN UMAR'S
ROOM, RSI KENDAL

Arraged by
Rahma Safitri (201911027)

DIPLOMA III NURSING STUDY PROGRAM

MUHAMMADIYAH KENDAL HIGH SCHOOL OF HEALTH
SCIENCES
2021
ASSESSMENT

Date of entry : 17 July 2020

Time of entry : 09.30 am

Medical record number: 13918

Date of assessment : 17 July 2020

Time of assessment : 07.50 am

Medical diagnosis : Angioedema

A. Biodata
1. Patient Identity
Name : Mr. B
Age : 49 y.o
Gender : male
Religion : mosleem
Marital status : married
Education : High school
Tribe/ nation : java/indonesian
Address : Gemuh, rt 3/ rw 3
Profession : Driver

2. Person in charge Identity

Name : Mrs. I
Age : 41 y.o
Gender : female
Religion : mosleem
Profession : taylor
Address : Gemuh, rt 3/rw 3
Relationship with patient: wife
B. Medical History
1. Main complaint
Shortness of breath and pain in the throat and chest
2. Current medical history
The client came to the hospital and was taken by a friend and went straight to the
hospital on July 17, 2020 at around 08.30 with complaints of shortness of breath
accompanied by pain in the throat and chest.
3. Past medical history
The client said he has a history of allergy to paracetamol
4. Family medical history
In the family, the client does not have a hereditary disease such as diabetes
mellitus.

C. Focus Data
1. Subjective data:
 The client complains of shortness of breath
 The client says pain in the chest
 The client says his body feels weak
 The client says he doesn't understand his illness
P: Pain is felt when swallowing
Q: Pain hurts like being pinched
R: Throat pain
S : Scale 2
T: Pain comes and goes
2. Objective data:
a. Temperature :36,5oC
b. Pulse :92x/minute
c. Blood pressure : 120/80 mmHg
d. Respiration rate : 26x/minute
- Installed oxygen cannula
- Infused RL 20 tpm
- Medicine therapy
 Oral   :
ambroxol         3x1
 Cavipilex       2x1
 njection :
Ranitidine         3x1
Methylprednisolone
3. Data Suporting

- Laboratory result:

Examiner Results Unit

Glucoses in a moment 169 Mg/dL
Urea 20,1 Mg/dL
Creatin 0,93 Mg/dL
SGOT 22,1 V/L
SGPT 29,6 V/L
Hemoglobin 15,6 g/dL
Hemafrocrite 44,02 %
Leukocytes 11.990 /mm³
Platelet 194.000 /mm³
Erythrocytes 5.20 Jt/vL
M.C.V 85 f/
M.C.H 29,9 Pg
MCHC 35,4 g/dL
RDW 13,3 %
MPV 8,1 fL

- X-ray results
X PA chest X-ray (asymmetrical)
 Cor     : Cardiac apex shifts kelatero caudal
 Pulmo: - vascular pattern looks increased
- Looks spots on the right and left perisiler
Right diaphragm at the level of os cost ae 10 posterior
Right and left costophrenic sinus
- Impression:
Cardiomegaly (LV)
Bronchopneumonia overview
D. Physical examination
- General condition     : client is weak and composmentris consciousness
- Head         : mesocephalic, gray hair, clean and no lumps
- Face / face : no signs of edema
 - Eyes          : anemic conjunctiva
- Nose           : clean and no polyps
- Mouth          : moist lip mucosa
- Ears     : no buildup of dirt, hearing is still functioning well
- Neck and throat : no enlargement of the thyroid and lymph
- Genetalia : no catheter and no abnormalities
- Skin         : skin turgor is elastic, brown in color and no signs of edema

E. DATA ANALYSIS

No Date/time Focus data Etiology Problem

1. 17 July 2020 SD: Hyperventilation Ineffective
the client says shortness of breathing
breath pattern

OD:
- the patient looks weak

-  Installed oxygen cannula

3 tpm

-  BP : 120/80 mmHg

- RR : 26X/min

- Pulse: 92x/minute

- T : 36.5

2. SD: Biological Acute pain

the client says it hurts in injury agent
the throat

P: Pain is felt when

swallowing

Q: the pain is like being

pinched

R: Sore throat

S : Scale 2

T: The pain comes and

goes.
 OD:
- The client seems to be
crying in pain.

-BP: 120/80

RR: 20      T: 36.5

P: 92
3 SD: Less Lack of
- clients say they don't information knowledge
understand the pain.

OD:
- clients look confused
when asked about their
nature.
- clients ask and ask for
information about their
illness.

F. NURSING DIAGNOSIS
1. Ineffective breathing pattern related to hyperventilation.
2. Acute pain related to biologic agents of injury.
3. Lack of knowledge is related to lack of information

A. NURSING CARE PLAN

Date/ time N Objective, outcome Intervention Rational

O criteria
D
X
17 July After taking care of 3 1. Monitor the 1. Knowing the client's
2020 1 x 24 hours of nursing vital sign. development.
actions 2.Monitor 2. Knowing the
oxygen flow. smoothness of Pxigen.
It is hoped that the 3.monitor the 3. to know the client's
client is not short of client's care for anxiety.
breath with the oxygen. 4. provide a sense of
outcome criteria: 4. Maintain a comfort and reduce
-Shows a patent comfortable shortness of breath.
airway. position. 5. provide O2 needs
-Normal vital sig 5. Set up oxygen comfortably.
equipment.
After taking nursing 1.TTv monitor. 1. Knowing the client's
actions for 3x 24 hours 2. Assess the development.
It is hoped that the level of pain 2. Know the pain scale.
 client will no longer scale (PQRST) 3. reduce pain.
have pain with the 3.Advise 4. the client is
outcome criteria: relaxation comfortable with the
techniques. environment.
- Client is able to 4.Create a 5. reduce pain.
control pain. comfortable
- pain is gone. environment.
- clientstates 5.Collaboration
comfortable after the analgesia.
pain is reduced.
After performing 1. Assess the 1. Knowing the
nursing actions for 3 x knowledge level understanding of the
24 hours of the client and client and family about
family. the illness.
The client shows 2. provide information
knowledge about the 2. Clear to clients and families
client's disease with knowledge of in order to understand
the outcome criteria: pain. about the disease.
- Clients and clients' (condition) 3. Give the client a
families convey an includes the sense of comfort.
understanding of the cause, how to
client's disease, affect the pain
condition and and its treatment.
knowledge.
- The client and the 3. Provide advice
client's family are able to clients and
to carry out the families to
procedures that have implement
been described. recommendations
through health.

G. NURSING IMPLEMENTATION

Date/time Numb Implementati Client

ND on Response
Wednesday, 1 Assess pain SD:
17 July - client says pain
2020 in throat
10.00 - p: pain is felt
when swallowing
- q: the pain
feels like being
pinched
- r: pain is felt in
the throat
- s: pain scale 2
- t: the pain
seems to come
 and go
OD:
the client looks
10.10 12 Give a comfortable wincing in pain
position like the semi-
fowler's position posisi SD:
client says ready
OD:
the client looks
10.25 2 Teach relaxation more relaxed
distraction techniques
with deep breathing
exercises SD:
the client is
willing to do
OD:
the client looks
cooperative
11.00 12 Doing vital signs doing deep
breathing
exercises

SD:
client says ready
12.45 1 Monitor oxygen flow OD:
BP: 120/80
RR: 26
P: 92
T: 36.5

SD:-

OD:
oxygen flow 3
atm
Thursday,1 12 Infusion injection SD:
8 july 2020 -ranitidine client says ready
08.00 -methylpredmisolone OD:
injection of drugs
via IV bolus in

08.50 12 Replacing the RL 500 ml SD:-

infusion fluid OD:
smooth drip 20
tpm

08.55 12 Give the client a SD:

comfortable position such client says ready
as the semi-Fowler's OD:
 position clients look more
comfortable and
more relaxed.

11.05 12 Doing vital signs SD:

the client is
ready.
OD:
BP: 120/80
RR: 25
P: 84
T: 37.3

11.20 3 Doing health education SD:

the client said he
was willing to
receive the
information.
OD:
client and family
look confused.

12.00 12 Give oral medication SD:

-        Ambroxol klein said ready.
-        Cavipilex OD:
oral medication
comes in.

12.45 2 Encourage relaxation SD:

distraction with deep the client is
breathing exercises willing to do
OD:
cooperative client
repeats deep
breaths

12.50 2 Assess pain SD:

the client says it
still hurts
OD:
P: pain when
swallowing
Q: the pain feels
like being
pinched
R: pain in the
throat
S: scale 2
T: The pain
 seems to come
and go.

Friday , 19 1 2 Infusion injection SD:

july 2020 -ranitidine client is ready
08.00 - methylpretmisolone OD: injection of
drugs via IV
bolus in

09.05 2 Encourage relaxation SD:

distraction with deep the client says the
breaths pain is a little
less.

OD:
P: when
swallowing
Q: like being
pinched
R: in the throat
S : scale 1
T: disappear

11.30 1,2 Doing vital signs SD:

client is ready.
OD:
BP: 120/70
T: 36
RR: 20
P:82

13.05 1 Monitor oxygen flow SD:

client says feel
comfortable
OD :
oxygen flow 3
atm

13.10 3 Assess the level of SD:-

understanding of clients
and families OD:
the client looks
cooperative in
explaining.
 B. DEVELOPMENT NOTES

Date/da Num Development notes

y b ND
Friday, 1 - Client says shortness of breath is reduced
19 july 2 - The pain is starting to subside
2020

H. EVALUATION

Date/Time Num Evaluation

b ND
Wednesda 1 S: the client said shortness of breath.
y , 17 july O: attached oxygen cannula
2020
RR:26                        P : 92

BP:120/80                  T : 36.5

A: the breathing pattern problem has not been resolved

P: continue the intervention

- Create a comfortable environment

- Monitor the vital sign

- Maintain patient position

2 S: the client said that his throat was sore
P: Pain when swallowing
Q: Pain feels like being pinched

R: Throat pain
S : Scale 2
T: The pain seems to come and go
O: the client looks weak and looks grimacing in pain.
BP:180/20                    P: 92
RR: 26                        T:36.5
A: the pain problem has not been resolved.
P: continue the intervention
- Teach relaxation techniques
 - Give the client a comfortable position

- Collaborative analgesics

- Assess pain
3 S: the client said he did not understand about his illness
O: the client looks confused about his illness
A: the problem of lack of knowledge has not been
resolved
Q: continue the intervention
- Perform health education

Date/Tim Numb Evaluation

e ND
Thursday, 1 S: The client says the shortness of breath has decreased
18 july
2020 O: - The client looks weak

-Installed O2 cannula

-BP : 120/80         P: 84

RR : 24               T : 37.3

A: The breathing pattern problem has not been resolved

P: Continue intervention

- Monitor oxygen flow

- monitor the vital sign

- Maintain a comfortable position

2 S: The client says it still hurts

P: Pain when swallowing

Q: Pain feels like being pinched

R: Throat pain

S : Scale 2

T: The pain seems to come and go

O: The client looks weak and looks wincing in pain

BP : 120/80            RR : 24
 P : 84                   T : 37.3

A: The pain problem has not been resolved

P : Continue intervention

- Assess the level of pain

- Give the client a comfortable position

- Advise deep breath relaxation

distraction

- Collaborative analgesics
3 S: The client said he understood a little about his illness

O: The client looks active asking about his illness

A : The problem of lack of knowledge is partially

resolved

P: continue the intervention

- Repeat health education

- Assess the knowledge of the client

and family about the disease

Time Numb Evaluation

ND
Friday , 1 S = Client says shortness of breath has reduced
19 july
2020 O = -Installed Oxygen Cannula 3 atm

BP: 120/70              T : 36

P: 82                    RR: 20

A = partially resolved breathing pattern problem

P = Continue intervention

- Monitor oxygen flow

- TTV monitor

- Maintain a comfortable position.

2 S = the client says the pain is decreasing.
 P: pain when swallowing.

Q: pain like being pinched.

R: sore throat.

S: scale 1

T: The pain comes and goes.

O = The client looks more relaxed.

BP: 120/70              T: 36

P: 82                    RR: 20

A = Pain problem partially resolved.

P = Continue intervention

- Assess pain

- Advise deep breath relaxation

distraction

- Maintain a comfortable position

- Collaborative analgesics

3 S = the client said he understood about his illness.

O =the client looks cooperative when asked about the

disease.

A = the problem of lack of knowledge is resolved.

P = Maintain intervention.