CASE REPORT

NURSING CARE OF BASIC PROFESSIONAL NURSING WITH

OXYGENATION NEED DISORDERS IN NY. S
IN RAJAWALI 2A
RSUP DR. KARIADI SEMARANG

CREATED BY :

LEDIKA ALMA NOVITASARI

P1337420923151

NERS PROFESSION
NURSING DEPARTMENT
POLTEKKES KEMENKES SEMARANG
2023
 NURSING CARE OF BASIC PROFESSIONAL NURSING WITH
OXYGENATION NEED DISORDERS IN TN PATIEN NY. S
IN ROOM RAJAWALI 2A RSUP DR. KARIADI SEMARANG

Date Assessment : September 19, 2023 Room / Hospital : Rajawali 2A RSUP Dr.
Kariadi
Study Hours : 14.00

A. BIODATA
1. Patient Biodata
a. Name : Ny. S
b. Age : 49 year
c. Address :
d. Education :
e. Occupation :
f. Date Entry : 18 September 2023
g. Diagnosis medical : Pleural Effusion
h. RM Number : C 8961XX

2. Responsible Biodata
a. Name : Ny. S
b. Age :
c. Address :-
d. Education :-
e. Job :-
f. Relationship : Sister

B. MAIN COMPLAINT
Ny. S said that she had been feeling short of breath and coughing since 10 days ago
C. MEDICAL HISTORY
1. Current Health History
The patient said he had been experiencing shortness of breath since 10 days ago,
because he felt it was not getting better, the patient asked his family to be taken to
Kariadi Hospital, because previously the patient had also been routinely seeking
treatment at Kariadi Hospital.
2. Past Health History
The patient said he had undergone routine treatment (chemo) at Dr. Hospital.
Kariadi has been treating Ca Mamae 26 times since 2020. The patient said he had
no history of other diseases such as hypertension, diabetes and tuberculosis. The
patient said he had undergone breast surgery, but after the operation the patient
often felt short of breath.
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 : 155 cm
Weight : 47 kg
LILA : 25 cm
BMI : 19.56 kg/m 2 (normal body weight)
B Biochemistry Hb : 13.9
Hct : 44.5
Tr : 330
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 .
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 49 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 : 100/70 mmHg
Pulse : 88x/ minute
Frequency breath : 20x/ 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, dry skin
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
k. Thorax
Inspection: Static and dynamic symmetrical wall movement
Palpation: Trunk fremitus dextra = Sinistra
Percussion: Sounds in both lung fields
Auscultation: SD ves +/+, rh +/-, wh -/-

F. LABORATORY EXAMINATION
Checking type Results Unit Normal
1. Hematology
2. Hemoglobin 13.9 L g/dl 11.7-15.5
3. Hematocrit 44.5 % 35-47
4. Erythrocytes 4.41 L 10^6/ uL 4.4-5.9
5. Leukocytes 9.7 /ul 3.6-11
6. Platelets 330 H /ul 150-400
7. MCV 100.9 fL 80-100
8. MCH 31.5 pg 26-34
9. MCHC 31.2 g/dl 32-36
10. RDW 20.3 H % 11.6-14.8
11. MPV 8.8 fL 4.0-11.00

G. DIAGNOSTIC CHECK
Abdominal Ultrasound 9/19/2023
Impression:
- Multiple metastatic nodules in the right and left lobes of the liver (largest size -
+ 1.2 x 1.1 cm in the right lobe)
- Mild hepatomegaly accompanied by dilated hepatic veins - more than likely a
congestive liver picture
- Duplex Pleural Effusion
 Ro Thorax 9/19/2023
Impression:
- Cast is difficult to evaluate
- Consolidated infiltrates in the upper middle lower field of the right lung and the
lower field of the left lung are relatively the same - more than DD/Pneumonia,
pneumonic type metastasis
- Duplex pleural effusion is relatively similar
H. THERAPY PROGRAM
1. Generator TC-99 M
2. Methylene diphosphonic acid/ml (1 piece/day)
3. Vitamin B Kompleks Tab (1 tablet every 8 hours)
4. Vitamin C tab 50 mg (50 mg every 12 hours)
5. Zinc sulphate tab dispersible 20 mg (20 mg every 24 hours)
6. Framiseton sulfat tulle 1 % ( 5 every 24 hours)
7. Morfin tab 10 mg ( 1 tablet every 12 hours - anti nyeri )
8. Infus Ringer Laktat 500 ml ( 1 ml every 8 hours)
I. PROBLEM LIST
No. Date/time Focus Data Nursing diagnoses Signed
Nurse
1. Tuesday , DS : no effective breathing Ledika
September 29 Patient say his breath related to obstacle effort Alma
14.00 WIB congested breath ( pleural effusion )
DO: D.0005
BP : 100/70 mmHg
N : 88x/ min
RR : 20x/ minute
Temperature : 36 o C
GCS: 15, E:4 M:6 V:5
Use respiratory
accessory muscles
pleural effusion
 2 Tuesday, DS: Acute pain associated with Ledika
September 19 The patient reported post-traumatic conditions Alma
14.00 WIB pain in the right side of (D. 0077)
the chest after
thoracocentesis
DO:
PAIN ASSESSMENT:
P :Pain increases when
the patient moves
Q: Pain like being
stabbed
R: Pain in the right side
of the chest
S: Scale 5
T: continuously until the
patient gets the medicine
BP: 100/70 mmHg
N : 88x/minute
RR: 20x/minute
Temperature: 36 o C
GCS: 15, E:4 M:6 V:5

J. NURSING PLAN
No. Date/time Nursing Destination Intervention TTD
diagnoses
1. Tuesday , no effective After nursing Management Street breath (I. LA
September breathing actions are carried 01011)
19 related to out for 3 times 24 Observation :
14.00 WIB obstacle effort hours , it is  Pattern monitor breath
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
2 Tuesday , Acute pain After carrying out Primary Intervention LA
September associated nursing actions for 1. Action Pain Management
19 with post- 3 times 24 hours, Observation:
14.00 WIB traumatic the pain level
conditions (D. (L.08066) is a. Identify location,
0077) expected with the characteristics, duration,
following outcome frequency,
criteria: quality, intensity of pain
1. Complaints of b. Identify the pain scale
pain c. Identify non-verbal pain
(Decreased :5) responses
2. Ability to d. Identify factors that aggravate
complete activities and relieve pain
(increased: 5) e. Identify knowledge and beliefs
3. Restless about pain
(decreased :5) f. Identify the Effect of pain on
4. Difficulty quality of life
sleeping g. Monitor the success of
(Decreased :5) complementary therapies
5. Grimace h. Monitor for side effects from
(decreased : 5) analgesic use

Therapeutic
a. Provide non-pharmacological
techniques to reduce pain (eg,
TENS, hypnosis, acupressure,
music therapy, biofeedback,
massage therapy, aroma therapy,
guided imagery techniques,
warm/cold compresses, play
therapy)
b. Control environments that
aggravate pain (e.g. room
temperature, lighting, noise)
c. Facilitate rest and sleep
d. Consider the type and source of
pain in selecting pain relief
strategies

Education
a. Explain the cause, period, and
triggers of pain
b. Explain pain relief strategies
c. Encourage self-monitoring of
pain
d. Recommend appropriate use of
analgesics
e. Teach nonpharmacological
techniques to reduce pain

Collaboration
a. Collaborative administration of
analgesics, if necessary

Supportive Interventions
1. Pain management education
Observation Action
a. Identify readiness and ability to
receive information
Therapeutic
a. Provide health education
materials and media
b. Schedule health education as
agreed
c. Provide opportunities for
educational questions
d. Explain the cause, period, and
strategies for pain relief
e. Encourage self-monitoring of
pain
f. Recommend appropriate use of
analgesics
g. Teach non-pharmacological
techniques to reduce pain

Relaxation Therapy
1. Administering oral medication
Observation Action
a. Identify possible allergies,
interactions and drug
contraindications (e.g. swallowing
disorders, nausea/vomiting,
intestinal inflammation,
peristalsis
decreased, decreased awareness,
business program)
b. Verify medication orders
according to indications
c. Check the expiration date of the
medication
d. Monitor the therapeutic effects
of the drug
e. Monitor local effects, systemic
effects and drug side effects

Therapeutic
a. Follow the six right principles
(patient, drug, dose, time,
routes, documentation)
b. Administer medication before
meals and after meals, as
appropriate
need

Education
a. Explain the type of medication,
reasons for administering it,
expected actions, and side effects
before giving
b. Teach patients and families
about how to administer
medication independently
K. NURSING ACTIONS
Date / time Problem Action Nursing Response Signed
Nursing Nurse
Tuesday , no effective Checking TTV S : LA
and Monitor
September breathing related Client say his breath
pattern breath
19 to obstacle effort congested

14.00 WIB breath ( pleural O:

effusion ) BP : 100/70 mmHg
N : 88x/ min
RR : 20x/ minute
Temperature : 36 o 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 : 99%, Use Nassal
blockage Street
Canule
breath

Monitor
saturation oxygen

Positioning the S: patient say comfortable

semi fowler
with semi fowler's position
O : semi fowler position 30º
Tuesday , Acute pain Identify location, P: Thoracocentesis LA
September associated with characteristics, Q: right and left chest
19 post-traumatic duration, R: it felt like being stabbed
14.00 WIB conditions (D. frequency, S: 5
0077) quality, intensity T: disappearing
of pain
Identify the pain
scale
 Collaborative The patient received
administration of Morphine tab 10 mg (1 tablet
analgesics, if every 12 hours - anti-pain)
necessary

Give non- Patients are given non-

pharmacological pharmacological techniques in
the form of deep breathing
relaxation techniques
Wednesday no effective Monitor existence Not there is blockage Street LA
, breathing related blockage Street breath
breath
September to obstacle effort
20 breath ( pleural
21.00 WIB effusion )
Monitor SpO2 99% on O2 NRM
saturation oxygen

Setting S: patient say tightness

monitoring already reduce
interval
O: usage respiratory accessory
respiration in
accordance with muscles reduce
condition patient
Wednesday Acute pain Identify location, P: After Thoracocentesis
, associated with characteristics, Q: right and left chest
September post-traumatic duration, R: it felt like being stabbed
20 conditions (D. frequency, S: 4
21.00 WIB 0077) quality, intensity T: disappearing
of pain
Identify the pain
scale

Collaborative The patient received

administration of Morphine tab 10 mg (1 tablet
analgesics, if every 12 hours - anti-pain)
 necessary
Give non- The patient said his breathing
pharmacological was short when he did deep
breathing relaxation

L. EVALUATION
Date / time Nursing diagnoses Evaluation Signed
Nurse
Wednesday , no effective breathing S: LA
September 20, related to obstacle The client said he was still having
2022 effort breath ( pleural difficulty breathing, and it was getting
21.00 WIB effusion ) worse
O:
BP 112/88 mmHg
N 88x/ min
RR 28x/ min
T 36.0°C
SpO2 99% on NRM 12 L
increased use of accessory respiratory
muscles
A: the problem has not been solved
P: continue the intervention
• Position semi fowler
• Give oxygen 12L/minute using
NRM if saturation decreases
Wednesday , Acute pain associated S: LA
September 20 with post-traumatic P: After Thoracocentesis
21.00 WIB conditions (D. 0077) Q: Pain like being stabbed
R: Pain in the right side of the chest
S: Scale 3
T: continuously until the patient gets
the medicine
O:
 BP 120/85 mmHg
N 83x/ min
RR 22x/ min
T 37.0°C
SpO2 97%
A: problem solved part
P: continue the intervention