ENGLISH NURSING ASSIGNMENTS

MEDICAL SURGICAL CASE PULMONARY TB

Lecturer:

Istiroha, S.Kep., M.Kep

Members of the group:

Nasya Adistya Islami (2022080003)

Ibtisama Manissa S. (2022080012)

Faculty Of Health Science

Gresik University
2024
 PULMONARY TB CASES

A 56 year man was treated in the Pulmonary Ward with a medical diagnosis of Pulmonary TB.

The patient complained of shortness of breath and a cough with Sputum. The patient also

reported heartburn, nausea and no appetite. At night he often can't sleep. Physical examination

results: BP 130/80 mmHg, Pulse 90 x/min, RR 25 x/min, Temperature 37.7 °C. Abnormal

breath sounds (Ronchi ), thick yellowish sputum and sometimes there is red film

(blood). The patient has O2 nasal cannulas 2 lpm installed. With SpO2 95%, the patient looked

thin and the weight decreased from 67 to 62 during the illness. The results of the chest X-ray

showed soreness in the right lobe of the lung. The patient received streptomicyn injection.
 ASSESMENT FORM

MEDICAL SURGICAL NURSING

FACULTY OF HEALTH NURSING SCIENCES STUDY PROGRAM

GRESIK UNIVERSITY

IDENTITY

Name : Tn.A Gender :Man

Age : 56 Th Marital Status :Marry

Religion :Islam Person Responsible :Ny.B

Ethnic group :Java Addres :Jl.Jawa

Education :Senior High School Date Admission :6 March 2021

Work :Farmer Date Assesment :6 march 2021

Address :Jl.Jawa Regitration No : 123456

Dx. Medical :pulmonary TB

ILLNES & HEALTH STORY

1. The Main Complain : the patient said Shortness of breath and a cough with sputum.The
patient also reports heartburn,nausea and no appetite. At night he often cant sleep.

2. History Of current Illness : The patient said he had experienced TB disease 1 year ago
with medication no complete.

3. Disaese that has been suffered:The patient says that there are no other diseases besides
pulmonary TB that he is currently suffering from.

4. Diseases previously suffered by the family : The patient said the family had no history of
serious illness.
5. Alergy History :  Yes √ No Explain : ............
PHYSICAL EXAMINATION

1. General Condition : good √medium  weak

2. Awareness :
√ compos mentis  sopor somnolent  coma  etc :

Vital Signs :

Pressure :130/80 mmHg Pulse:90x/mn Temperatur: 37,7 °C

Respiration :25 x/mnt

3. Breathing Pattern :
Rhytm :  Reguler √ Irreguler

Type : √ dispnoe  kussmaul  ceyne stokes  etc :

Breath sounds :  vesikuler  stridor  wheezing √ ronchi

 etc : .........

Out of breath : √ yes  no

Cough : √ yes  no
Explain :The patient Complained of Shortnes Breathing and A cough with sputum.
Nursing Problem: Ineffective Airway Clearence

4. Cardiovascular :
Heart Rhytm : √reguler  irreguler S1/S2 Single : √ yes  no

Chest pain :  yes √No

Heart sound : √normal  murmur  gallop  etc :

CRT : √ < 3 detik  > 3 detik

Acral :  warm  hot  cold wet  cold dry

Nursing Problem : There is no problem
5. Nerves :
GCS : Eye :5 Verbal :5 Motorik :5

Phsycological Reflex: + patella + triceps + biceps  etc:

Phatological Reflex: + babinsky + budzinsky + kernig  etc:

Rest/Sleep : 3 hour/day

Sleep Disorder : √ there is  no

Type : Sleep related breathing disorder
Nursing Problem : sleep disorder

6. Sensing :
a. Eye
Eye Movement : √normal  no , Explain………

Eye shape : √normal  tidak , Explain………

Pupil: √ isokor  anisokor  etc:

Palpebra: cekung √No

Konjungtiva:  anemis √No

Sklera:  ikterus √No

Lensa :  Cloudy √No

Visus ka/ki : 6/6 / 6/6

Visual Impairment:  yes √No

Aids :  yes √No

etc:
b. Ear
Ear Shape : √normal  No , Explain………

Hearing Disorder:  yes √No Explain:...........

Aids :  yes √No

etc:
 c. Nose
Form : √normal  No Explain:...........

Smell Disorder:  yes √No Explain:...........

Etc:
Nursing Problem: There is no problem

7. Urination :
Cleanliness : √Clean  Dirty

Urine : amount: 800 cc/day color :yellowish smell :distinctive smell

urine

Aids (chateter):  yes √No

Bladder Growt:  yes √No

Tenderness  yes √No

Disturbance : - anuria - oliguria - retensi -inkontinensia

-nocturia  etc :
Nursing Problem : There is no problem
8. Digestion :
Apetite :  good √ Decreased

Meal Portion:  Finished √No Explain: only ¼ portion

Drinking: Amount: 1.500 cc/day Type of drink:Water

Mouth and Throat

Mouth: √ Clean  Dirty  Smelly

Mucosa: √Moist  Dry  stomatitis

Throat: - Pain swallowing - Dificulty swallowing

- enlarged tonsil  etc:

 Abdomen

Stomach : - Tense - Bloated - ascites √Tender Pain,

location : around the abdomen

Peristaltis: 10 x/minute

Liver enlargement: yes √No Explain:............

Splenic enlargement: yes √No Explain:............

Defecation:1x/Day Regulary√yes  No etc:

Consistency: Solid odor:Characteristic odor color:Brown

Nursing Problem :Nutritional Deficit

9. Musculosceletal & Integument :

Joint Movement Ability: √ Free  Limited Explain:.........

Muscle Strength:

5 5

5 5

Skin : √ Moist  Dry  eksoriasis

Skin color: - Jaundice - Cyianosis - Reddish

- pale - hyperpimentation

Turgor: √Good  Moderete  poor

Edema:  Present √None Location:......... etc:.....…

Wounds/gangren:  yes √ No Explain : ................................

Nursing Problem : There is no problem

10. Endocrine:
Thyroid enlargement:  yes √No

Lymph enlargement:  yes √No

 Hyperglycemia:  yes √No

Hypoglycemia:  yes √ No

Nursing Problem : There is no problem

11. Personal hygiene :

General Cleanliness: √Clean  dirty  smelly

Bathing:3x/day Tooth brush :3 x/day

Shampoo:2x/day

Nail Hygine √Clean  Dirty

Change Cloths:3 x/day

Nursing Problem: There is no problem
12. Phsycological – Social – Spiritual :

Obediencein carrying out worship: √ obedient  disobodient Sometimes

Activities in carrying out worship: Praying 5 times a day and sunnah prays.
People who are most valuable /meaningful: he patient said the people who are often with
him and are most valuable are his wife and children.
Relationships with friends & surrounding environment: patients say relationships with
friends and people around them are good.
Current Feelings:  anxious  stressed √Normal/calm
Nursing Problem : There is no problem
Supporting Data (Lab/ Photo/ etc) :

- X-Ray : Soreness in the right lobe of the lung

Therapy received:

1. Streptomycin 1 x 1 Mg for 3 days

LIST OF NURSING PROBLEMS

1. Ineffective Airway Clearence related to the presence of exudate

2. sleep disorder related to environmental barriers

3. Nutritional Deficit associated with anorexia

...........................,....................................

...

Data Taker,

_____________________
 DATA ANALYSIS

DATA ETIOLOGY PROBLEM

DS: Microbacterium tuberculosa Ineffective airway clearance

-The patient says his breath is D.0001

short and his coughs with Enters the lung fields to the

sputum. alveoli

DO:

-breathing rhythm: irregular Formation of inflammatory

- type of breathing: dyspnoea tubercles

Primary infection of the

- Ronchi alveoli

- thick yellowish sputum and

sometimes there is a red Excessive secretion

coating (blood). production

- Vital Signs

Pressure: 130/80 mmHg Thick secretions

Respiration: 25 x/min

Pulse:90x/min

Temperature: 37.7 oC

SpO2: 95%

-X-ray : soreness in the right

lobe of the lung.

DS: Increased sputum in the Sleep disorder related

-The patient said that he airway D.0055

often couldn't sleep at night.

DO:

-The patient's feel sleepy Out of breath

-The patient's general

condition is moderate Disturbed sleep patterns

- The patient's rest is not

enough, even night only 3 Sleep pattern disorders

hours.

DS: Nausea Nutrition Deficit D.0019

- The patient says he has no

appetite Decreased appetite

-The patient says there was

tenderness in the abdomen the body's nutritional intake

DO: is lacking

-The patient's weight

decreased from 67 to 62 nutritional deficit

during the illness.

-The patient's peristalsis is

hyperactive 10x/min

-Portion only ¼
Nursing Diagnoses

1. Ineffective Airway Clearence related to the presence of exudate D.0001

2. Sleep disorder related to environmental barriers D.0055

3. Nutritional Deficit associated with anorexia D.0019

NURSING INTERVENTION

Name :Tn. A Room :Melati

Age :56 Y.o No. RM :080405

Dx. Medical : Pulmonary TB

NO DIAGNOSA KEPERAWATAN RENCANA TINDAKAN

1. Ineffective Airway Clearence related to the presence of Effective Cough Exercises I.01006

exudate D.0001 Observation

Objective : -Identify coughing ability

After nursing intervention for 3 x 24 hours, airway clearance -Monitor for sputum retention

increased, with -Monitor for signs and symptoms of respiratory tract infection

Result criteria: -Monitor fluid input and output (e.g. amount and characteristics)

1.Increasing of effective coughing Therapeutic

2. Decreasing Sputum production -Set the semi-fowler and fowler positions

3. Decreasing Ronchi -Place the pillow and bend in the patient's lap

4. Decreasing Dyspnea -Dispose of secretions in the sputum container

 Education

-Explain the purpose and procedures for effective coughing

-Recommend to inhale deeply through your nose for 4 seconds, hold

for 2 seconds, then exhale from your mouth with your lips pursed

(rounded) for 8 seconds

-Suggest repeating deep breaths up to 3 times

-Continue to cough vigorously immediately after the 3rd deep

breath

Collaboration

-Collaborative administration of mucolytics or expectorants, if

necessary.

2. Sleep disorder related to environmental barriers D.0055 Sleep Support I.05174

Objective: Observation

After nursing intervention for 3 x 24 hours, sleep patterns -Identify activity and sleep patterns

improved, with
Result criteria: -Identification of sleep disturbing factors (physical and/or

1. Decreasing of Complaints of difficulty sleeping psychological)

2. increasing of sleep duration -Identify foods and drinks that disturb sleep (eg: coffee, tea, alcohol,

eating close to bedtime, drinking lots of water before bed)

-Identify the sleeping pills consumed

Therapeutic

-Environmental modifications (ex: lighting, noise, temperature,

mattress and bed)

-Limit nap time, if necessary

-Facilitates eliminating stress before bed

-Set a regular sleep schedule

-Perform procedures to increase comfort (eg: massage, positioning,

acupressure therapy)

-Adjust the medication administration schedule and/or procedures

to support the sleep-wake cycle

Education
 -Explain the importance of getting enough sleep during illness

-Encourage compliance with bedtime habits

-Suggest avoiding food/drinks that disturb sleep

-Recommend the use of sleeping pills that do not contain REM sleep

suppressors

-Teach factors that contribute to disturbed sleep patterns (eg:

psychology, lifestyle, frequently changing work shifts)

-Teach autogenic muscle relaxation or other non-pharmacological

methods

3. Nutritional Deficit associated with anorexia D.0019 Nutritional Management I.03119

Objective: Observation

After nursing intervention for 3 x 24 hours, nutritional status -Identify nutritional status

improved, with -Identify food allergies and intolerances

Result criteria: -Identify preferred foods

1. Increasing appetie -Identify calorie needs and types of nutrients

2.Increasing the portion of food consumed -Identify the need for use of a nasogastric tube
3. Improvesing Body weight -Monitor food intake

4. Body mass index (BMI) improves -Monitor body weight

-Monitor laboratory examination results

Therapeutic

-Perform oral hygiene before eating, if necessary

-Facilitate determining dietary guidelines (ex: food pyramid)

-Serve food attractively and at the appropriate temperature

-Give foods high in fiber to prevent constipation

-Provide foods high in calories and high in protein

-Give food supplements, if necessary

-Discontinue nasogastric tube feeding if oral intake can be tolerated.

Education

-Teach sitting position, if able

-Teach the programmed diet

Collaboration
-Collaborative administration of medication before meals (eg: pain

relievers, antiemetics), if necessary

-Collaborate with a nutritionist to determine the number of calories

and types of nutrients needed, if necessary.

IMPLEMENTATION AND EVALUATION

Name :Tn. A Room :Melati

Age :56 Y.o No. RM :080405

Dx. Medical : Pulmonary TB IMPLEMENTATION AND EVALUATION ARE CONDUCTED 3 X 24 HOURS

Date and NURSING DIAGNOSE TIME IMPLEMENTATION EVALUATION SIGNATURE

Time O’CLOCK:

Monday, 7 Ineffective Airway Clearrance 09.00 -Identifying coughing ability 09.00 -10.00 O’CLOCK

march 2021 related to the presence of exudate -Monitoring for sputum S:

D.0001 retention -The patient says his

breath is short and his

09.30 -Setting the semi-fowler and cough with sputum

fowler positions -The patient says he had a

little understanding of

how to cough effectively

O:
 -Dispose of secretions in the -breathing rhythm:

sputum container irregular

- type of breathing:

10.00 -Explaining the purpose and dyspnoea

procedures for effective - there are additional

coughing sounds in the lungs:

-collaborative

administration of
Ronchi
mucolytics or expectorants
- thick yellowish sputum

and sometimes there is a

red coating (blood).

-Dyspnea (+)

- Vital Signs

Pressure: 130/80 mmHg

Respiration: 25 x/min
Pulse:90x/min

Temperature: 37.7 oC

SpO2: 95%

A: the problem has not

been resolved

P: intervention continues

Which is continued

-Identifying coughing

ability

-Monitorimg for sputum

retention

-Setting the semi-fowler

and fowler positions

-Dispose of secretions in

the sputum container

 -collaborative

administration of

mucolytics or

expectorants

Sunday, 8 Ineffective Airway Clearence 09.00 -Identifying coughing ability S:

march 2021 related to the presence of exudate -Monitoring for sputum -The patient says his

D.0001 retention shortness of breath was

-Setting the semi-fowler and reduced

fowler positions -The patient says the

sputum was coming out a

- Dispose the secretions in lot and smootlhy

the sputum container O:

-collaborative -breathing rhythm:

administration of irregular

mucolytics or expectorants
12.00 -Monitoring for signs and - here are additional

symptoms of respiratory sounds in the lungs:

tract infection

-Monitoring fluid input and

rhonchi
output (e.g. amount and
- thick yellowish sputum
characteristics)
- Vital Signs

Pressure: 130/80 mmHg

Respiration: 23 x/min

Pulse:90x/min

Temperature: 37.7 oC

SpO2: 95%

-Dsypnea (-)

A: problem partially

resolved

P: intervention continues.
 Which is continued

-Monitoring for sputum

retention

Thursday, 9 Ineffective Airway Clearence 09.00 -Monitoring for sputum S:

march 2021 related to the presence of exudate retention -The patient says the

D.0001 -Monitoring fluid input and shortness of breath was

10.00 output (e.g. amount and reduced

characteristics) -The patient says there

-Setting the semi-fowler and was a lot of sputum

fowler positions coming out

O:

-breathing rhythm:

irregular

- type of breathing: eupnea

-no additional breathing

sounds.
A:problem resolved

P:intervention stopped.