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I. Client Identitiy
Name : Mr. S
Age : 68 years oldTrible/nation : Banjarise Indonesia
Religion : Muslim
Educatoin : Junior high school
Medical record number : 1062719
Address : Kelayan B
Occupation : Private goverment
Enterance date : Augustus 26 2013
Assessment date : Augustus 29 2013
Medical diagnose : Anemia
II. The next of kind
Name : Mr. R
Sex : Male
Age : 36 year old
Addres : Kelayan B
Relationship with client : Children
III. Health History
A. Main Complaint:When assessment client said that he feel weakness and breathing shorrness and can.tsleep and disturbance for swallowing
B. Health History Of Current DiseaseWhen assessment client said that before he enter the ulin general hospital he feelfatigue and weakness and sometimes breathing shortness that condition make he
disturbance for do activity. Remember that condition he after a few days he feel that
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of body condition is not recovery client finally decided to check herself in the hospital
after getting the results of the examination client said that he suffered of anemia andget suggested from docter for hospitalization for get a treatment and recover from he
disease
C.
Health History Of Previous
Client said that saince 3 year ago he was when do devicate sometime that feces
mixced with blood the colour feces is black and after do devicate he feel that bodyweaknees
D. Family Health HistoryClient said that in the family never was suffered like he disease like he suffered right
now
IV. 1. Phyisical Examination
A. General Condition And ConciousnessClient looked weaknees and just lie down and sit down on the bad cient conciousnessis was composmenthis with gcs 4, 5, 5
Information:
Eyes : 4 eyes open response spontaneous
Verbal : 5 verbal response good can introduce / Orientation
Morotic response : 5 motor response can follow order but no to have energy
B. Vital signs:Blood Pressure :110/80mmHg Respiration : 28x/minutePulse : 68X/minute Temperature : 36,8.C
C. Antropometrik DataBody Weight : 48.kg Ideal Body Weight : 43.kg
Body Hight : 160.cm Body Maximum Ideal : 45.kg
2. Skin
Client skin white texture is a bit abrosive but there looked cynosis of the skin nolooked lesions on the skins. Skin turgor no looked edema while in the press back (-) 2
second there looked little dirt on the skin. Body temerature is 36,8c whilemeasurement using digital thermometer and when do palapation the client skin feel
warm
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3. Head And NeckStructure of the head and neack are symmetric. In the head there is no trauma, lession,
and lumps. The color hair white and blac, distribution hair is good. In the neck there isno enlargement of the thyroid gland and lymph nodes, normal neck movement
4. vision And EyeStructure of the eye is symmectric between left and right. The eyeball could be movedin any direction, there is looked dark circles around the eyes, amd conjunctiva anemis,
and client did not use glasses. Client can not see name tag 2 meter, visus client can see
2 meter.
5. Olfactory and nose
Structure of the nose is symmectric. There is no use nasal canula in the nose, no blood
out of the nose. Client can distinguish a either the smell of perfume and alcohol, client
had no complaint about olfactory problem
6. Hearing and ear
Structure of the ear is symmectric between right and lift. Client does not use hering aid,
client can be heard talking around client, and client can heard what nurse instruction.
Client had no complaint about hearing, in the ear ther is no lession, trauma, massa, and
blood.
7. Mouth and theeth
Structure of the mouth and theeth are symmectric. teeth client looked clean, there is
no inflammation. Lip mokus is good, in lip is no stomatitis, palatum is redness, and
client do not use dentures.
8. Chest, breathing, and circulation
Structure of the chest is symmectric. Client is 24 times/minute, tactil premetus is
normal when palpation, the sound sonor when percussion, when auscultation is sound
visikuler. Client do not use oxygen, in the chest there is no inflammation, edema,
lession, and trauma
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9. Heart and ciculation
Inspection : heart spead is normal
Palpation : The heart sound dim
Auscultatio : The heart sound is S1, S2, and S3 is no
addional heart. Circulation priphal blood perfussion to the fast.
10. Abdomen
Inspection : General state abdomen looked clean no lession and trauma,
shape normal breathing movement
Auscultatio : Perictaltic intestine 6/ minute
Palpation : Skin turgur back in 2 second, there is no tendress in hepar
Percussion : The sound is timpany
11. Genetalia and reproduction
Client is male. 60 years old was marreid and have 1 children, client looked no use
cateter and pempres to elimination. Client there is no complaint about genetalia and
reproduction.
12. Upper and lower extremitiesStructure of the upper and lower extremities are good. In lower extremities in right use
infuse Nacl, join movement in upper and lower extremities are abnormal because guot,
the client said there is limition of motion because gout, client said that pain in lower
right and lift because gout since 1 year ago. Still weak, client do its own mobility whit
muscle scale :
4444 4444 0 : Paralysis total
1 : Movement palpable or visible muscle contraction
4444 4444 2 : Full muscle movement against gravity and endorsement
3 : Normal movement against gravity and endorsement
4 : Normal movement against gravity whit little resistance
5 : Full normal movement against gravity whit full eustady
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V. Need physical, psychological, scocial, and spiritual
1. Activity and rest
At home : Activity at home is not heavy. Client can sleep 7 until hours. Client
said that sometimes help by his family do activity
At hospital : Clien said that just laying on the bed for rest, activity not to heavy
and client said that activity help by clients family. And said he cant sleep because
light to brighter, client said that he sleep 2-3 hour at night client scale activity is 3
0 : Unable to care for them selves in full
1 : Require tools
2 : Require assistance, or supervision of another person
3 : Require assistance, monitor and supervision of another
4 : Very dependent and unableto perfrom or practipaeta intreatment
2. Personal Hygine
At home : Client said that he took a bath two times / day at home, used shampoo
once every two days, brushed her teeth after a meal, client said that the nail food
and hand are restong since 1 years ago
At hospital : Client said that just swabbed by her son twice a day.
3. Nutrition
At home : Client said that eat 3 a day, client said that have food allergies like
beans, abbage, belinjo, and water spinach because have gout. Drink water 8
glasses a day
At hospital : Client said that cant eat because any stomatitis in the tongue client
just eat of spood
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4. Elimination
At home : Client said that defecation 1 a day, and urinate 46 a day
At hospital : Client said that to day defecation is never 1 a day, and urinate 3 a
day
5. Sexuality
Client is male 60 years old. Client was marreid and have 2 children
6. Psychosocial
Client relationship is harmonious, many families that come to visit. Relationship
whit nurse, doctor and medical team looked good
7. Spiritual
Client is a moslem, client and family alwasy pray to Allah SWT hope fully speady
recovery from disease.
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VI. Focus data
Subjective date
Client said that he feel weakness
Client said that he cant sleep because light to brighter
Client said tat e cant swallowing te food
Client said that he just eat spood of food
Client said that he cant do personal hygiene idependenly
Client said that e activity helped by famly
client said that he sleep 2-3 hour at night
Objective data
inspection
Client HB 2,9
Client lekosit 93,2
Looked client cant do activity independenly
Looked client just lie down on te bad
Looked client breathing sortness
Looked stomatitis on the client tongue
Additional data
BP: 110/80mmHg RR: 26X/Minute
P: 68x/minute T : 36,8c
Looked black cycle under client eyes and anemis
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looked cynosis of the client skin
looked client sleeply wen morning
looked stomatitis on te client tongue
looked client just can eat slightly
looked there is dirt on the client body
looked client just lie down on te bad
VII. Diagnostic examination
Laboratorium examination on august 26 2013
Parameter Result Limit
Hemoglobin 2,9 14,0018,00
Leucosit 93,2 4,010,5
Eritrosit 2,95 4,506,00
Hematokrit 21,9 42,0052,00
Trombosit 358 150450
RdwRcv 13,6 11,514,7
Mcv 74,3 80,097,0
Mch 26,4 27,032,0
Mchc 34,3 32,038,0
Gran % 83,7 50,070,0
Limfosit % 4,9 25,040,0
Mid % 6,7 4,011,0
Gran # 11,87 2,507,00
Limfosit # 4,9 1,254,0
Mid # 0,9
SI 55 55175
TIBC 350 300400STI 35 20 - 45
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VIIII. Therapy farmokology
Nam
e
Medicine Type Dose Time
M E N
Mr. s LasixCefriaxone
Infuse Nacl
Blood transfustion
DiureticAntibiotic
elektrolite
1x1 amp1x1 amp
20 minute
08.0008.00
08.00
11.00
12.0012.00
12.00
21.0021.00
21.00
IX . Analysis data
No Data Problem Etiology
1.
2.
3.
-Subjective data:-Client said that he feel weakness
Objective date:
-Client HB 2,9
-Client lekosit 93,2
l-ooked cynosis of the client skin
Subjective data:
-Client said that e activity helped by
famly-Client said that he feel weakness
Objective data:
-looked client just lie down on te bad-Looked client cant do activityindependenly
subjective data-Client said tat e cant swallowing te
food
-Client said that he just eat spoodof food
IneffectiveTissue
perfussion
Activity
Intolerance
Inbalence
nutrition lees
than bodyrequement
In adequate oxygenRequement body
need
General weakness
Swallowing disoder
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4.
5.
Objective data:-Looked stomatitis on the client
tongue
-looked client just can eat slightly
Subjective data:-Client said that he cant sleepbecause light to brighter
-client said that he sleep 2-3 hour at
night
Objective data :
-Looked black cycle under client eyes
and anemis
-looked client sleeply wen morning
Subjective data:
-Client said that he cant do personalhygiene idependenly
-Client said that e activity helped by
famly
Objective data-looked there is dirt on the clientbody
Insomia
Deficit ofpersonal
hygiene self
care bating
Hospitalization
weakness
X. Problem Periorty
1) Ineffective tissue perfussion related to inaequat oxygen requement body need2) Activity intolerance relate to general weakness3)
Inbalance nutrition less than body requement related to swallowing disoder4) Insomnia related to hospitalization
5) Deficit personal hygeiene self care bating related to weakness
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XI. Intervention
No Nursing diagnose Goal Intervention Rasional
1.
2.
Ineffective tissueperfussion relatedto inaequat oxygen
requement body
need
Subjective data:
-Client said that he
feel weakness
Objective date:
-Client HB 2,9-Client lekosit 93,2
l-ooked cynosis of
the client skin
looked clientsometimes breating
shortness
Activity intolerancerelated to general
weakness
Subjective data:-Client said that e
activity helped by
famly
-Client said that hefeel weakness
Objective data:-looked client just
lie down on te bad
-Looked client cantdo activity
After donusing action1x24 hour
expected
ineffectivetissue
perfusion can
be resoved
with outcome:
-Client saidthat e not feel
weakness
agains
-Client HB
14,0018,00
Client lekosit4,010,5
No looked
cynosis in te
client skin
After doNusing action
1x24 hour
expected
activityintolerance
can be
resloved
without come:
-client said he
cant doactivity witout
helped
by family
1).examine ofcause ineffectivetissue perfussion
on the client
2 set client
position semi
fowler
3).pullpilled
oxygen on theclient body need
4).set thepetilizaton of air
on te client room
5).Set fluid intake
the body needs
1).Examine causeof activity
intolerance
2).provide clienteat food that many
carbohydrate
3).Encourageclient rest more
4).Provide clientfood high iron
substance
5).give blood
1). for easydetermine nextintervention
2).smooth the the
entry of oxygen in
to the body
3).for comply
oxygen body need
4).to maximun of02 in air on the
client room
5).optimize the
balance of O2
status in the client
body
1).for easydetermine next
intervention
2).for make clienthave energy do
Activity
3).for collect client
energy
4).fullpiled client
evenue base
material ofhemoglobin
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.
3.
4.
Independently
inbalance nutrition
less than body
requement related
to swallowing
disoder
subjective data-Client said tat he
cant swallowing te
food-Client said that he
just eat spood of
food
Objective data:
-Looked stomatitison the client tongue-looked client just
can eat slightly
Insomnia related to
hospitalization
Subjective data:-Client said that he
cant sleep because
light to brighter-client said that he
sleep 2-3 hour at
night
-clint said he
feel energyfor do
activity
looked clientcan walking
looked clientcan do activty
independently
After do
Nusing action
1x24 hour
expected
inbalancenutrition
can beresolved with
out come:
-client said
that he can
swallowing
food
-client said hecan eat allfood portion
-no looked
stomatitis onthe client
tongue
After do
Nusing action
1 x shift
expectedinsomnia
can be
resolved without come
client said that
transfusion
1).examine cause
of inbalance
nutrition
2)ecorage clienteat slightly but
often
3).give client foodwarm
4).help client on
oral ygiene
5).give client foodhigh nutrition andvitamin
1).Examine cause
of insomenia on
the client
2).explaint to the
client inportance
sleep for heality
3).position client
5).increase of
hemoglobin on theclient bloodfor
binds nutrition in
the blood
1).for easy
determine nex
intervention
2).maxsimalizefulpiled nutrition on
the client body needin slowlly
3).to improve clienttest
4). Give frest felling
On the clint mouth
5).For increaseclient imunesystem
1).For easy
determine next
intervention
2).for client
understand about
very infortancesleep for heality
3).for provide client
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5.
Objective data :
-Looked black cycleunder client eyes and
anemis
-looked client
sleeply wenmorning
Deficit personal
hygeiene self care
bating related to
weakness
Subjective data:-Client said that he
cant do personal
hygiene idependenly-Client said that e
activity helped by
famly
Objective data-looked there is dirton the client body
he can sleep
at night clientsaid he
can sleep 6-7
hour
no looked
black cycleunder client
eyes and
anemis
After do
Nusing action
1 x shift
Expecteddeficit
personalhygiene can
be resloved
with outcome:
client said that
he can dopersonal
hygieneindependenlyclient said that
he can do
activity
withouthelped with
he family
no looked
there is dirt
on the client
body
as a comfortable
when try to sleep
4). Set ambiance a
quet environtment
5).set client roomtemperature
1).Examine te
cause of deficit of
personal hygiene
2).helped client on
the body personalygiene her self
3).do secking onthe client 1-2
times a day
4).Encourageclient
family for helpclient on clientpersonal hygiene
5).change the
client shirt andblacked 1 time a
day
comfotable wen
sleep
4)for give client
quetness when
sleep
5).for make clientnot dhydration
when sleep
1).for easy
determine
next intervention
3).to easy client on
do body personalygiene
3).for maintainclient body of
hygiene
4).maximilizefullpiled personal
hygiene on theclient body
5).give comfortabe
end fiiled clean on
theclient
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XIII. Implementation and evaluation
No Time No Diagnose Implementation
with nursing actionevaluation
Evaluation
1. 08.00
08.10
08.15
09.00
09.00
I 1).assessing ofcause ineffective
tissue perfussion
on the client
E because
Client HB 2,9
-Client lekosit 93,2
2).setting client
position semifowler
E: Client said that e feel
comfortable with thisposttion because easy for
brearthing
3).pullpiling oxygen on
The client body need
E: looked client no use
asesory muscle for
brething
4).setting the
petilizaton of airon te client room
E:loeeked client feel
comfort when brthing
5).Setting fluid intake
the body
S: Client said that e feelcomfortable with this
posttion because easy for
brearthing
O: looked client no use
asesory muscle for
brething
A: ineffective tissue
Perfussion has beenresolved
P: Stop intervention
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2. 09.10
09.33
09.35
09.37
09.40
II 1).assessing cause of
activity intolerance
E: bcause supply
nutrition no maximalize
on the client body
2).providing client eatfood that manycarbohydrate and
nutrition
E looked client eat
carbohydrate food
3)suggesting client rest
more
E: client said that he justlie down and shit down
one te band
4).Providing client food
high iron substance
E;looked client eat foodhight iron sbstance
5).giving bloodtransfusion
E:Client HB begin
increase Client HB 10,9Client lekosit 93,6
S: client said that he just
lie down and shit downone te band because still
feel weakness for o
activity independenly
O: looked client just liedown and shit down one
te band
A : activity intoleranceHas been not resoved
P: countinue intervetion
by nurse ward
-providing client eat food
that manycarbohydrateand nutrition
-Providing client foodhigh iron substance
-giving blood transfusion
acrding doctor instrution
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3. 09.45
10.00
10.12
10.18
10.20
III 1).asessing cause of
inbalance nutrition
E:because on the client
tongue any stomatitis
2)suggesting client
eat slightly butoften
E: looked client eat
slightly butoften
3).giving client food
Warm
E:client said he have
Appetae for eating warmfood
4).helping client onoral ygiene
E: Client said he feel
Frest after get oralHygiene
5).giving client food highnutrition and vitamin
E: client said he feel have
little energy for doactivity
S: client said he have
appetae for eat warmfood
O: looked client
eat slightly butoften after give warm
food
A: inbalance nutrition
problem part has
been resolved
P: countinue intervetion
by nurse ward
-giving client food
Warm
-helping client on
oral ygiene
-giving client food high
nutrition and vitamin
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4. 10.21
10.23
10.25
10.30
10.32
IV. 1).Assessing cause of
insomenia on the client
E: Client said that he
cant sleep because
light to brighter
2).explaint to the client
inportance sleep for
heality
E: client said he
understand with nurse
explain
3).positioning client as a
comfortable when try tosleep
E: looke client cmfortwhen try to sleep
4). Setting ambiance a
quet environtment
E:Client said e feel calmwhen try to sleep
5).setting client room
temperature
E: Client said he not feel
hot when sleep
S: Client said he can
sleep comfortble andcalm
O:looked client comfort
when sleep
A: InsomeniaHas been resolved
P: Stop intervention
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5 10.35
10.37
10.40
10.50
11.00
V. 1).Assessing the
cause of deficit ofpersonal hygiene
E:because client feel
weakness for do activty
2).helpeing client on thebody personal ygiene her
self
E: client said he feel frestafter get personal
hygiene rom nurse
3).do secking on
the client 1-2times a day
E: looked client bod
y clean
4).suggesting client
family for help
client on client
personal hygiene
E: looked client familiyCollaborative in helpclient on personal
hygiene
5).changing theclient shirt and
blacked 1 time a
day
E: looked client shirt is
clean
S: Client said he feel
frest after get personalhygiene from nurse
O: looked client body is
ClientLooked client family
collabortive in helpclient on do personal
hygiene
A: problem has beenresolved
p: stop intervention
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