I. HEALTH HISTORY A.

DEMOGRAPHIC DATA
FULL NAME GENDER AGE BIRTHDATE CIVIL STATUS RACE/NATIONALITY RELIGION
MUSLIM

: J.P

: MALE √

FEMALE

:46 tahun :sonder,12/01/1966 :
MARRIED √ SINGLE DIVORCED √ INDONESIA CHATOLIC OTHER √ PROTESTANT WIDOWED / WIDOWER

: :

BORN AGAIN CHRISTIAN OTHER

FULL ADDRESS CONTACT NUMBER E-MAIL ADDRESS EDUCATIONAL BACKGROUND

:Sonder, Kauneran Jaga III :::
√ ELEM. GRAD ELEM. UNDERGRAD H.S. UNDERGRAD COLLEGE UNDERGRAD H.S. GRAD COLLEGE GRAD

OTHER SIGNIFICANT TRAINING OCCUPATION SIGNIFICANT TRAINING OCUPATION (PRESENT/USUAL) USUAL SOURCE OF MED. CARE

:-

:: FARMER : (Check all that applies.)
HILOT ALBULARYO HEALTH √ CENTER SELF-MEDICATION OTHER FAMILY DOCTOR

DATE OF ADMISSION ADMISSION DIAGNOSIS

: 20 Juni 2012 : GOUT ARTHRITIS

B. SOURCE & RELIABILITY OF INFO.
√ √

PATIENT PATIENT’S SISTER OTHER :

C. REASONS FOR SEEKING CARE : Patient come with joint pain, pale, and feel nausea.

Patient feel the pain in scale 6 ASSOCIATED PHENOMENA/FACTORS: life style AGGRAVATING FACTORS :consume the foods with high purines and smoking ALLEVIATING FACTORS CLIENT’S PERCEPTION ADMITTED BY : reduced the activity. pain in thejoints ofthe feet andhands andapain2 to3 hours. PAST MEDICAL HX CHILDHOOD ILLNESS ADULT ILLNESS INJURIES/ACCIDENTS :::- PRIOR HOSPITALIZATIONS : At Gunung maria Hospital PAST SURGICAL OPS. pain scale6 (moderate). IMMUNIZATIONS :: COMPLETE √ INCOMPLETE FOOD ALLERGIES MEDICATION ALLERGIES ::- MEDICATIONS BEING TAKEN BEFORE HOSPITALIZATION : medicine just from shop LAST MEDICAL CHECK-UP : May 2012 MENSTRUAL HISTORY FOR FEMALE CLIENT : - . ONSET FREQUENCY DURATION LOCATION QUALITY/CHARACTER QUANTITY/SEVERITY : since a year ago : moderate : a pain in the joints two up to three hours : joints of the feet and hands :the pain feel like stabbing : on the scale 0-10 with 10 the worst. HX OF PRESENT ILLNESS/HEALTH : The painhas beengoing on sinceoneyearago. consume the food with low purines and consume the medicine from doctors : patient hope to get the health condition :SELF ADMIITED RELATIVE OTHER √ ADMITTED VIA :AMBULATORY STRETCHER AMBULANCE √ E. Clientsalsosaid thepainfeltlike stabbing.D.

FAMILY HISTORY :  Tn. SOCIO-ECONOMIC DATA HOUSE OWNERSHIP : OWNED RENTED SHARED √ HOUSE’S NUMBER OF STOREYS HOUSEMATES :: parents : WARM & FRIENDLY FAIRLY WELL HOSTILE √ RELATIONSHIP WITH HOUSEMATES SOURCE OF INCOME MONTHLY INCOME : garden :- RECEIVES FINANCIAL CONTRIBUTION FROM ANYONE ? WATER SOURCE : WATER DISCRIT COMMUNAL √ WATER REFILLING STATION DEEP WELL OTHER .AGE OF ONSET REGULARITY :- USUAL # OF DAYS : REGULAR :- :- IRREGULAR AGE OF MENOPAUSAL ONSET OBSTETRIC HISTORY FOR FEMALE CLIENT : IF PREGNANT : GRAVIDA : PARA : IF NON PREGNANT : F. JP Legend : male female G.

all subjective Patient said that he felt pain since a year ago.METHOD OF GARBAGE DISPOSAL : OPEN PIT BURNING √ GARBAGE COLLECTOR OTHER FACILITIES & INSTITUTIONS NEARBY HOME :HEALTH CENTER POLICE STATION CHURCH SCHOOL BARANGGAY HALL FIRE STATION HOSPITAL WET MARKET MALL/COMMERCIAL CENTER OTHER MODE OF TRANSPORTATION USUALLY USED :TRICYCLE SIDE CAR JEEPNEY MINI BUS OWNED VEHICLE √ RELATIONSHIP WITH NEIGHBORS IN GENERAL : WARM & FRIENDLY FAIRLY WELL HOSTILE √ INVOLVEMENT IN COMMUNITY SERVICES : UNINVOLVED INVOLVED √ H. ROS AND PE ROS (includes history of illness or complaints) . there no wound and the skin is good The head looks symmetrical. b.all objective the patient seemed to withstand the pain.the pain like stabbing in the foot and hands. no lessions. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. c. General/overall health . no lumps. the skin seemed dry. DEVELOPMENTAL HISTORY I.the scalp System a. Integument Patient said there were no injuries but the skin feel dry. PE (includes assessment via IPPA) . the scale of pain is 6(moderate). Head Patient said there is no lesion.

Mouth and Throat - . g. conjunctiva anemis. Neck There is no swelling in lymph nodes. m. n. h. Endocrine Palpated suprapubica the bladder is empty. k. Cardiovascular Ictus cordis can’t be seen but can palpated with gentle vibration. l. the ears looks symmetrical. Mouth looks clean and there is no swelling. Hematologic q. regular rhythm. e. Genitalia There is no hemoroid or inflamation. Respiratory breast and axially looks symmetrical. Eyes Patient said never had eye disease before and not use glasses. sklera icterus. i. Neurologic p. The eyes looks symmetrical. Frequency of respiratory is 22X/m.000cc and have a pee about 4 time a day.clean. and kind of respiratory is chest. Breast and Axially j. Nose and Sinuses Patient said never had ear disease. Musculoskeletal o. d. Ears f. and the hair slightly oil. Urinary Patient said he always consume the water about 2. patient doesn’t use a pacemaker.

Dll 1. 1. + 4. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN CLIENT’S PERCEPTION OF HEALTH :patient thinks that health is the most important thing and must keep health. Leukosit 2. Silinder 6. LABORATORY STUDIES/DIAGNOSTICS Procedure Date 20 June 2012 Indication Normal Values / Findings Actual .4mg/dl 3. Amoniumurat + 5. – 6. POST) Urine Check up : 1. Sel e. OTHER ASSESMENT TOOLS Date (s) taken Comprehensive Actual Content / Legend Actual Result J. Uric-acid 1. Creatinine 3. 219mg/dl 2. – 20 June 2012 Blood Check up : 1.47mg/ dl. 3. . 01. Eritrosit 3.Findings Nursing Responsibillities/Implications (PRE. Urea-UV 2. Bacterium 7.p 4. 0-2 2. 0-1 3.3m g/dl 3. Kristal 5. 1050m g/dl 2. 8. 10.5mg/dl 3.2. INTRA. – 7. FUNCTIONAL ASSESMENT A.

B.L : EXERCISE PATTERN. COMPLIANCE WITH DOCTOR’S ORDERS. MOBILITY COOKING HOME MAIN SHOPPING :2 :2 :5 :5 :5 at garden Legend 0 1 2 Full self-care Functional Level Code Requires use of equipments or device Requires assistance or supervision from another person . MOST IMPORTANT THINGS DONE TO MAINTAIN HEALTH : to keep the diet especially do not consume the foot with high purine CLIENT’S PERCEPTION OF WHAT MIGHT HAVE CAUSED CURRENT ILLNESS :because bad life style. & TYPE(S) : LEISURE / RECREATIONAL ACTIVITIES : FUNCTIONAL LEVEL CLASSIFICATION : FEEDING BATHING TOILING/WORKING BED MOBILITY DRESSING :2 :2 :2 :1 :2 GROOMING GEN. FEAR? WHAT HELPS TO RELIEVE THESE FEELINGS?) : sometimes he feels anxiety about his condition. DRUG REGIMEN. ACTIVITY / EXERCISE PATTERN TYPICAL ACTIVITIES OF DAILY LIVING :work SUFFICIENCY OF ENERGY FOR A. drug regimen and medical. REGULARITY. & MEDICAL TREATMENTS :there is no complaint about doctor’s orders. CLIENT’S UNDERSTANDING / AWARENESS OF HIS / HER MEDICAL DIAGNOSIS: client understand about her medical diagnosis. SELF PERCEPTION / SELF CONCEPT PATTERN CLIENT’S PERCEPTION OF SELF (FEELS GOOD / BAD ABOUT SELF?) : feels LEVEL OF COMFORT WITH SELF : good good PERCEPTION ON BODY IMAGE :good CHANGES IN FEELINGS ABOUT SELF SINCE ILLNESS BEGAN :he felt slightly inferior with him self. C. ANY CURRENT EMOTIONS (ANXIETY.D.HEALTH BEFORE HOSPITALIZATION :when sick patient just a buy the medicine of shop and use without doctor instruction.

SLEEP – REST PATTERN TYPICAL HOURS OF SLEEP AT NIGHT. STRAIGHT SLEEP OR THERE TIMES WHEN SLEEP IS DISTURBED? : Sometimes patient FEELS GOOD UPON WAKING UP? : No USE OF SLEEPING AIDS :DAYTIME NAPS. E. NUTRITION / ELIMINATION PATTERN CLIENT’S HEIGHT : 166 cm CLIENT’S WEIGHT : 54 kg USUAL EATING PATTERN. PRESENCE OF ODOR PROBLEMS : - F.3 4 Requires assistance or supervision from anotherperson or device Is dependent and does not participate D. SATISFICATION/ DISSATISFICATION : USE OF CONTRACEPTIVES : REPRODUCTIVE PATTERN : - . FOOD INTAKE: ¾ portion. TIME USUALLY ASLEEP & TIME USUALLY AWOKEN:6 hours. CHANGES OR PROBLEMS. SEXUALITY / REPRODUCTIVE PATTERN ORIENTATION TO OWN SEXUALITY (IF APPROPRIATE) : STATUS OF SEXUAL RELATIONS. USE OF SUPPLEMENTS : RECENT WEIGHT LOSS OR WEIGHT GAIN : APPETITE :moderate FOOD ALLERGIES : EATING DISCOMFORTS : DIET RESTRICTIONS : high purine DENTAL PROBLEMS : CONDITION OF INTEGUMENT. SPEED OF HEALING WHEN () WOUNDS:BOWEL ELIMINATION PATTERN : 2 times a day URINARY ELIMINATION PATTERN : 4 times a day EXCESS PESPIRATION. TYPICAL DAILY FOOD INTAKE : patient usual eating 30gr protein with carbohidrat. SLEEPING PATTERN. DAILY? FROM WHAT TIME & UNTIL WHAT TIME? : yes. wake up at night because the pain.

G. PROBLEM LIST A. The patient seen grimacing. DS : patient said the activity has stop and the daily activity should need the help of others. PEERS.P.D. INTERPERSONAL RELATIONSHIPS PATTERN FAMILIAL ROLE : GOOD SOCIAL ROLE : GOOD GETS ALONG WELL WITH FRIENDS. 1. CHANGES IN LIFESTYLE : YES METHOD USED TO RELIEVE STRESS. ENVIRONMENTAL HAZARDS NEIGHBORHOOD AIR POLLUTION : NEIGHBORHOOD WATER POLLUTION : NEIGHBORHOOD SOIL POLLUTION : NEIGHBORHOOD NOISE POLLUTION : OVERALL SAFETY OF NEIGHBORHOOD : WORK ENVIRONMENT. PERSONAL HABITS P. EFFECTIVENESS.D. PERSON APPROACHED FOR HELP : DISSCUS WITH HIS FAMILY I. Data Identified DS : patient said the pain has been going on since 1 year ago. CO-WORKERS.P. Pain associated with inflammatory processes. 22 june 2012 Date Resolved / Remarks 22 june 2012 . METHOD OF HANDLING BIG PROBLEMS. PRESENCE OF WORK ENVIRONMENT HAZARDS : - II.X ALCOHOL : SOMETIMES STREET DRUGS : YR. (S) OF SMOKING TOBACCO : √ J. (PACK PER DAY) :1 P. COPING / STRESS – TOLERANCE PATTERN CURRENT CONCERNS : YES STRESS IN LIFE. STRESS-RELIEF METHOD’S EFFECTIVENESS: WALK OUT AND ACT ACCORDINGLY. physical mobility impaired associated with pain. NEW ACQUAINTANCES? H. DO : the pain felt like stabbing and scale is 6. 2. ACTUAL or Active Problem Problem No.

urination. The patient seen grimacing. defecation. 3. dressing.Assesspain leveland recordthe location andintensity of pain(scale0-10) 3.Preventin gthe . 4.assist indetermini ng the need forpain managemen t. grooming. Problem Data Identified III. Investigate complaints of pain and ons 2.Paincan affectTTV 2. and mobilization in bad need help by the others.Let thepatienttakea comfortable positiononabed orsittingin a chair. NURSING CARE PLAN CUES NURSING DIAGNOSIS BACKGROUND KNOWLEDGE LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION ndx 1 Pain associated with DS : patient said the pain has been going Patien patient t can cope the pain s showe dpainr esolve din time 3X24 hours 1. 4. B.DO : the daily activity like eat. HIGH RISK or Potential Problem No.Pushtofrequen tobtained) tlychange positions.TTVobservati 1.Bed restis necessaryto limit pain/joint injuries(up toobjective and subjectivei mprovemen S: Patients say his legs are still aching joints O: patients seen still wince when the foot touched A: Pain is not resolved P: Intervention s continued 1. DO : the pain felt like stabbing and scale is 6. TTV observations 2. ago. Boostbreaks atappropriatein dications inflammato on since 1 year ry processes. bath.

Collaborat iononanalge sicmedicatio n/therapyco ntinue.Encouragethe use ofstressmanage menttechniques eg. 5.As ananalgesict o relieve pain. Boost breaks at appropriate indications. 7.Focus attention individualsituati andincrease on. tomovein bed. 5. 5. relaxationte chniques 6. occurrence ofgeneral fatigueand joint stiffness.Increasere record the location and intensity of pain (scale 0-10) 3.Collaboration ofanalgesicdrug s. the sense ofself andfeeling healthycele brants 7. 4. relaxationtechni laxationand ques a sense 6. Let the patient take a comfortable position on a bed or sitting in a chair.Engageinrecre ofcontrol ational activitiesapprop riatetothe whenpain 6.Encourage the use ofstressman agementtech niqueseg. .tomovein bed.Pushtofreq uentlychang e positions.

maintainb ed restbreaks 2.Ndx 2 physical mobility impaired associated with pain. Evaluation of monitoring the level of pain / inflammation in the joints. tomovethem selves O: patientsstill can notperform daily activitiesthe mselves A: Activity intoleranceis not resolved P: Intervention scontinued 1. defecation. and mobilization in bad need help by the others. 2.Relieving pressure on thetissueand increase circulation 4. patien patient tis able to donor is able to dodail y malda activiti ilyacti eswith vities again out thehel p of othersi n the 3X24 hours. Assist with range of motion active / passive if possible 3. 1. 1. DS : patient said the activity has stop and the daily activity should need the help of others. muscle strength andgenerals tamina. urination. Maintain bed rest breaks if necessary. dressing.assistivera nge of motionactiv e /passivewith therequested moving thelegsandar msslowly 3. Change the position of patients with frequent 4. bath. DO : the daily activity like eat.reposition thepatient .Dependin g on theactivity levelofresol ution/progre ssionof inflammator yprocesses.Restis recommend edtoprevent S:The patientsays it is fatigueandm stillweak aintainpowe r 2.Mengingk atkanjoint function. grooming. 3.

.4.evaluation of monitoringl evelsof pain /inflammati onin the joints.

kes NURSING CARE IN PATIENTS WITH GOUT ARTHRITIS By group 5 Members of group : Renitha Pumadada Charly Londa Novilia P Tambajong Nelva Sagala Vica Safitri Ayu Indri H Solitan Ketut Swiranata FACULTY OF NURSING DE LA SALLE CATHOLIC UNIVERSITY MANADO 2012 .Subject Lecturer : English in nursing 3 : Wahyuni Langelo BSN M.

.

We thank the subjects English lecturers in Nursing who has provided guidance and direction for us. Desember17th 2012 Group V . In making this paper we realized is far from perfection. for that we are expecting criticism and constructive suggestions from readers for better preparation of the next paper to be useful for all of us. this paper can provide a benefit to us. Hopefully.INTRODUCTION Thank God we prayed to the Lord the Almighty's blessings and His grace so that we can complete the group of five papers "NURSING CARE IN PATIENTS WITH GOUT ARTHRITIS" well. especially for my friends in learning and increase student knowledge about gout arthritis. Manado.

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