CASE REPORT

NURSING CARE OF BASIC PROFESSIONAL NURSING WITH

OXYGENATION NEED DISORDERS IN TN. S
IN RAJAWALI 2B
RSUP DR. KARIADI SEMARANG

CREATED BY :

SHINTA SALSABILA
P1337420922072

NERS PROFESSION
NURSING DEPARTMENT
POLTEKKES KEMENKES SEMARANG
2022
 NURSING CARE OF BASIC PROFESSIONAL NURSING WITH
OXYGENATION NEED DISORDERS IN TN PATIENTS. S
IN ROOM RAJAWALI 2B RSUP DR. KARIADI SEMARANG

Date Assessment : September 6, 2022 Room / Hospital : Rajawali 2B RSUP Dr.

Kariadi
Study Hours : 11.00

A. BIODATA
1. Patient Biodata
a. Name : Mr. S
b. Age : 66 year
c. Address : Karanggandalam
d. Education : SD
e. Occupation : Entrepreneur
f. Date Entry : 2 September 2022
g. Diagnosis medical : Ca Lungs
h. RM Number : C 9038xx

2. Responsible Biodata
a. Name : Mrs. _ H
b. Age : 56
c. Address :-
d. Education :-
e. Job :-
f. Relationship : Neighbor

B. MAIN COMPLAINT
Mr. S says he feels short of breath

C. MEDICAL HISTORY
 1. Current Health History
Patient say what you feel moment this is congested . Patient cough since 3 weeks
ago _ and sigh congested breath a week final then treated in hospital. Neighbor
patient deliver patient to House sick . Patient say already get treatment routinely
at Dr. Kariadi Hospital for 8 months for treat cough and congested his breath .
2. Past Health History
Patient say already get treatment routine ( chemo ) at Dr. Kariadi Hospital for 8
months for treat cough and congested his breath . Patient say no have history
other diseases such as hypertension , diabetes and tuberculosis. Patient say
already used to smoke since 17 years old .
3. Family Health History
The patient's family said that no one in his family had the same pain as the
patient's. Family members do not experience chronic diseases, such as
tuberculosis, diabetes, and heart disease.

D. ASSESSMENT OF GORDON'S FUNCTIONAL PATTERNS

1. Health perception pattern
Patients say that health is very important. If patient experience sick , right away
brought to hospital .
2. Nutrition & metabolism pattern
Before the illness, the patient's diet was 3-4 times a day and his appetite was
normal. Meeting fluid needs is also normal ± 8 glasses per day. After sick ,
patient use up eat it half portion
A Anthropometry TB : 165 cm
Weight : 54 kg
LILA : 23 cm
BMI : 54 / (1.65) 2
54 / 2.7225 = 19.834 kg/m 2 (normal body
weight)
B Biochemistry Hb : 10.7
Hct : 32.4
Tr : 446
C Clinical Sign Normal turgor, no capable walk distance far
 D Diet Solid / regular diet , frequency 3x a day

3. Elimination pattern
Patient said the patient 's bowel movements were normal once a day, many, soft
consistency, normal color. BAK 5-7x a day and clear urine color. After sick ,
patient CHAPTER 2 days once .
4. Rest & sleep pattern
Before being admitted to the hospital, the patient's sleep pattern was 6-8 hours of
sleep a night. After treated at home Sick , patient many use up time for rest sleep .
5. Activity and exercise patterns
Before the illness, the patient carried out normal activities, there were no activity
aids . After sick , activities _ _ patient only lying in place sleep because weak for
walk .
6. Role & relationship patterns
Patient say relationship with family fine course . Patient stay alone at his house .
7. Sensory perception patterns
The patient has no sensory disturbances. Pasin explained that he was not afraid of
the health workers.
8. Self-perception pattern
Patient say no embarrassed with condition moment this and hope want to quick
get well so you can activity like ready when .
9. Sexual and reproductive patterns
Patient 66 years old and say that patient no once experience disease / disorder
sexual .
10. Coping mechanism pattern
Patient feel worried and restless , however can get over it with enough rest .
11. Value & belief patterns
Patient Christian . Before treated at home sick , patient diligent To do worship in
accordance his belief . patient always pray of his recovery.

E. PHYSICAL EXAMINATION
state general : looks weak
Awareness : Composmentis with GCS : 15, E:4 M:6 V:5
Pressure Blood : 114/77 mmHg
Pulse : 112x/ minute
Frequency breath : 22x/ minute
Temperature : 36 o C
a. Head
Inspection : symmetrical shape, no lesions
Palpation : no lump, no pain
b. Hair
Inspection : color black and already gray , straight , short , clean , scattered
equally
Palpation : dry hair
c. Eye
Inspection : good visual system, good light reflex, normal pupil
shaped round , no use viewing aids _
Palpation : no there is bump and no feel painful moment palpated
d. Skin
Inspection : tan skin, no lesions, no edema
Palpation : normal turgor, not dry skin (normal)
e. Nose
Inspection : symmetrical, good olfactory function
Palpation : no there is polyps nose
f. Mouth
Inspection : mucous membranes are normal and no difficulty open mouth
g. Ear
Inspection : symmetrical ears, clean, no buildup of cerumen, and no
use hearing aids . _
h. Neck
Inspection : symmetrical, no enlargement of the thyroid gland
Palpation : normal, no scars
i. Lungs
Inspection : shape seen symmetrical , and no seen existence lesson . Seen use
muscle help breathing .
Palpation : no palpable mass and tenderness
j. Abdomen
 Inspection : no visible lesions on the abdomen
Palpation : there is no tenderness in the abdomen
Percussion : no deafening sound
Auscultation : heard movement peristalsis ±12 times/ min

F. LABORATORY EXAMINATION
Checking type Results Unit Normal
1. Hematology
2. Hemoglobin 10.7 L g/dl 11.7-15.5
3. Hematocrit 32.4 % 35-47
4. Erythrocytes 3.44 L 10^6/ uL 4.4-5.9
5. Leukocytes 9.4 /ul 3.6-11
6. Platelets 446 H /ul 150-400
7. MCV 94.2 fL 80-100
8. MCH 31.1 pg 26-34
9. MCHC 33 g/dl 32-36
10. RDW 15.7 H % 11.6-14.8
11. MPV 9.2 fL 4.0-11.00

G. DIAGNOSTIC CHECK
MSCT Thorax with contrast September 4, 2022
- Look left pleural effusion
- Look lymphadenopathy on subaorta
- Cor: normal heart shape & location (not enlarged)
- Still look lesson isohypodens (CT number 28-43 HU) with consolidation and
surrounding fibrosis on segment 7,8,9 lung left

H. THERAPY PROGRAM
1. nebulization combivent 1 resp /8 hours
2. N Acetylcysteine 200mg/8 hour PO
3. Injection methylprednisolone 125 mg/12 hours IV
 4. Esomeprazole 40mg/12 hours IV injection
5. Injection moxifloxacin 400mg/24 hours IV

I. PROBLEM LIST
No Date/time Focus Data Nursing diagnoses Signed
. Nurse
1. Tuesday , DS : no effective breathing shinta
September 6 Patient say his breath related to obstacle effort
11.00 WIB congested breath ( pleural effusion )
DO: D.0005
BP : 133/89 mmHg
N : 96x/ min
RR : 22x/ minute
Temperature : 36 o C
GCS: 15, E:4 M:6 V:5
Use respiratory
accessory muscles
Look left pleural
effusion _

J. NURSING PLAN
No. Date/time Nursing Destination Intervention TTD
diagnoses
1. Tuesday , no effective After nursing Management Street breath (I.
Septembe breathing actions are carried 01011)
r6 related to out for 3 times 24 Observation :
12.00 obstacle effort hours , it is  Pattern monitor breath
WIB breath expected that ( frequency , depth , and effort
(pleural pattern breath breath )
effusion ) getting better  Sound monitor breath addition
(L.01004) with the  Sputum monitor
 following result Therapeutic :
criteria:  Position semi fowler
- Ventilation  Give oxygen 4L/ min using a
minute nasal cannula
(5:increase) Education :
- Dyspnea  teach Technique cough effective
(4:moderately Monitoring Respiration (I.01014)
decreased ) Observation :
- Elongation  Monitor presence blockage
phase Street breath
expiration (4:  Saturation monitor oxygen
moderately Therapeutic :
decreased )
 Set monitoring interval
- Frequency
respiration in accordance with
breath
condition patient
(5:improves)
 Document results monitoring
- Depth breath
Education :
(5:improves)
 Tell destination monitoring
 Inform results monitoring

K. NURSING ACTIONS
Date / Problem Action Nursing Response Signed
time Nursing Nurse
Tuesday , no effective Checking TTV S :
and Monitor
September breathing related Client say his breath
pattern breath
6 to obstacle effort congested

13.00 WIB breath ( pleural O:

effusion ) BP 130/80 mmHg
N 82x / min
RR 23x/ min
T 37.4°C
Breath shallow and fast
 Monitor sound Not sound voice breath
breath addition addition

Monitor presence Patient no produce sputum

of sputum
Monitor existence SpO2 : 97% NRM mask
blockage Street
installed
breath

Monitor
saturation oxygen

Positioning the S: patient say comfortable

semi fowler
with semi fowler's position
O : semi fowler position 30º
Wednesda no effective Monitor existence Not there is blockage Street
y, breathing related blockage Street breath
breath
September to obstacle effort
7 breath ( pleural
10.00 WIB effusion )
Monitor SpO2 98%
saturation oxygen

Setting S: patient say tightness

monitoring already reduce
interval
O: usage respiratory accessory
respiration in
accordance with muscles reduce
condition patient

L. EVALUATION
Date / time Nursing diagnoses Evaluation Signed
Nurse
Wednesday , no effective breathing S: Shinta
September 7, related to obstacle Client say difficulty breathe reduce
2022 effort breath ( pleural O:
13.00 WIB effusion ) BP 120/85 mmHg
N 83x/ min
RR 22x/ min
T 37.0°C
SpO2 97%
use respiratory accessory muscles
reduce
A: problem solved part
P: continue the intervention
 Position semi fowler
 Give oxygen 4L/ min with using
a nasal cannula if saturation
decrease