CHAPTER III

REVIEW CASES

No.Register: 11252540
dates: 06-09-2017
Date ofAssessment:06-09-2017
Medical Diagnosis:HIV / AIDs Stage 4
A. Assessment of
I. Identity Client
Name: Ny. SW
Age : 34 years
Gender : Female
Education : High School
Job : singer
Status : married
Address :-
Religion : Islam
II. Identity Person in charge
Name : Mr. A
Job : laborer
Age : 35 years old
Education : High School
Religion : ISLAM
Address :
Tribe / Nation : Java
Relationship with client : Husband
III. Main complaint
Client says body is weak
IV. Current disease history
Client has diarrhea, nausea vomiting, fever and limp body ± 1 month , since the BB
illness fell 20 kg. Worsening for the past 5 days, the client feels dizzy, pain
swallowed, mouth sores, appetite drops, tightness, walking like a drunk person.
 Then the client was taken to Lawang Hospital and then referred to RSSA
Malang.
V. Past Disease History The
first MRS client for the first time, before the client had never suffered from
hypertension, tuberculosis, diabetes mellitus, or a disease that required
hospitalization, a disease that had suffered by a client was only a fever and
cough History of Family Disease
Clients said they did not have hereditary diseases.
VI. Family Health History: No
client's family suffers from diseases such as clients and no family has an infectious
disease.
VII. Assessment of Menirit Gordon Functional Pattern
1. Health perception and health management pattern Health
and illness meaning for clients,
2. Metabolic patterns
Number and type of food : soft food, tofu and eggs, vegetables, with
total energy 1000 kcal
Feeding time : 06.00, 12.00 , 17.00
Amount and type of liquid : milk 3 × 200cc, infusion fluid 2000 cc / 24 hours
When administering fluids : infusion fluid is given for 24 hours
Precaution : no
Feeding and Drinking Problems:
Difficulty chewing : there, client feels pain due to sprue
Difficulty Ingestion:No, the client feel pain when swallowing
Nausea and vomiting:there, the client regurgitate food given
Unable to feed themselves:the client fed her family members
efforts to resolve the problem:installing NGT and provide dietary liquid on
the client
3. elimination pattern
CHAPTER: clients Chapter in pampers, liquid stool, replace the pampers only one
time
BAK : Clients BAK assisted by cateter, urine production 650cc / day
Difficulty defecating / BAK: Clients experience diarrhea
Efforts / Ways tation of the issue: Giving cotrimoxazol 1 × 960 mg

4. Activities-pattern exercises
Activities Description

ting 3

e clothes 2

Description::
1
2 self:aided by
3 tools:help
4 others:assisted tools and
5 others:depending
5. Patterns break-Sleep
▪ Time sleep: the client spends his day sleeping because his body feels
weak
▪ When Waking up: Clients wake up when fed and given drugs
injections
▪ Sleep problems: -
▪ Things that make it easier to sleep: -
▪ Things that facilitate the client to wake up: -
6. Cognitive-perception pattern
The process of thinking (memory, attention, decision, calculation): both
7. self-concept self-perception
 8. Patterns of Relationship roles The
client is married and has 1 daughter. Relationships with other people are good, but their
interaction with others decreases because of poor conditions. The person
closest to the client : older sister. clients cannot take care of their husbands
and children at home and cannot sing in cafes anymore.
9. Sexuality
Clients are female.

10. Patterns of stress-tolerance coping

Before getting sick: when a client has a problem it can deal well and be discussed
with his family first.
11. Values ​of
● ObedienceWorship: clients do not practice worship during illness
● Confidence in healthy sickness: families assume this disease is God's
will, so they must be patient and try to find healing
● Confidence in healing: Families just surrender to God and submit to the
medical team and accept whatever happens despite their worse for
VIII. Physical Examination
1. general appearance:weak
Awareness: CM
2. TTV
R: 30 x / min
S: 38, 5 ° C
N:. 100 x / minute
TD : 110/70 mmHg
3. TB / BB
TB: 160cm
BB: 48 kg
4. Head and hair Head
a. shape : Symmetrical
Crown : Normal, no lumps or lesions
Scalp : Clean
 b. Hair : Clean
Spread and hair condition: Evenly spread
Odor : Odorless
Color : Black
c. Face : symmetrical
Skin colorskin : brown
Face Structure: normal
5. Eye
a.​ Angeness and symmetry: symmetrical eye movements
​

b.​ E
​ yelid (palpebra) : normal, no lumps
c.​ Conjunctiva and sclera
​ : conjunctiva anemis, non-jaundiced sclera
d.​ P
​ upil : Isokor
e.​ Cornea and iris
​ : RCL / RCTL + (miosis)
f.​ Visual acuity / vision
​ : not studied
g.​ E
​ ye pressure : not studied
6. Nose
a.​ Nasal bone and position of the nasal septum: septum right in the middle
​

b.​ Nostrils : symmetrical, there is no discharge or cerumen that comes out

​

c.​ Nostril : No breathingnostrils

​

7. Ear
a.​ E
​ ar Shape : Normal
Ear Size : normal
Ear tension : normal
b.​ E
​ ar Holecerumen : no- / -, no liquid coming out of the ear hole
c.​ H
​ earing sharpness: decreased

8. mouth and pharynx:

a.​ L
​ ip Conditions: chapped lips

b.​ G
​ ums and teeth: yellow gums and dirty teeth

c.​ T
​ ongue state: there is candidiasis of the

9. neck
a.​ T
​ rachea position : normal
b.​ ​ Thyroid : within normal limits
c.​ ​ Voice : clear but soft
d.​ ​ Lymphe Gland : there is lymphedenopathy
e.​ ​ Jugular vein : no jugular vein enlargement
f.​ ​ Coratis : normal, palpable
C. Integumen (Skin) Examination:
a. Cleanliness : clean
b. Warmth : cold feeling
c. Color : brown sap
d. Turgor : good
e. Texture : supple, supple, solid
f. Humidity : normal
g. Skin disorders : no
10. breast examination and armpit:
a.​ B
​ reast size and shape: normal

b.​ B
​ reast color and Aerola: brown

c.​ B
​ reast abnormalities and putting: no lumps or lesions, no abnormalities

d.​ A
​ xila and Clavicula: nolesions or lumps

11. Thorax / Chest Examination:

1. ThoracicThoracic Inspection
a) Shape : Symmetrical
b) Respiratory
∙​ F
​ requency : 30 × / minute
∙​ R
​ hythm : regular
c) Signs of difficulty breathing: no
2​ L
​ ung Examination

a. Inspection
b. Palpation of sound vibrations (vocal Fremitus): decreased
c. Percussion: sonor
d. Auscultation
∙​ B
​ reath sounds : bronchial
∙​ S
​ peech sound : normal, clear
∙​ A
​ dditional sound : ronchi (+)
3.​ C
​ ardiac Examination

a.​ I​ npection and Palpation

∙​ P
​ ulpation :
∙​ I​ ctus Cordis: ICS 4-5 mid clavicle cystic
b.​ P
​ ercussion

c.​ A
​ uscultation

∙​ H
​ eart Sound I : single sound
∙​ H
​ eart Sound II : single sound
∙​ N
​ oisy / murmur : no
∙​ H
​ eart rate: 100 × / minute

F. Examination of the abdomen

a.​ ​Inspection
∙​ A
​ bdomen shape : normal, flat
∙​ L
​ ump / mass : none
b.​ A
​ uscultation

∙​ B
​ owel Peristalsis : 8 × / minute
c.​ P
​ alpation

∙​ M
​ arks of tenderness : no
∙​ L
​ ump / mass : no
∙​ S
​ igns of Ascites : none
d.​ P
​ ercussion

∙​ A
​ bdomen Voice : dullnes
G. Sex and Area Surrounding
1. Genetalia Pubic
✓ hair : clean
✓ Urethra Meatus : catheter attached
✓ Abnormalities in Genetalia External and Inguinal Area: no
2. Anus Anus
✓ Hole : normal, no hemorrhoids
✓ Abnormalities : no
H Musculoskeletal Examination
a.​ Muscle
​ symmetry: symmetrical
 b.​ E
​ xamination Edema : none
c.​ Muscle strength
​ : 4 in all extremities
d.​ E
​ xtremity and stiffness disorders: none

I.examination
1. Level of consciousness (quantitative) Neurological: composmetis
2. Signs of brain stimulation (Meningeal Sign): none
3. Awareness level / GCS: 456
4. Motor Function: weak
5. Sensory function: good, still able to feel touch
6. Reflexes:
a. Physiological Reflex: normal
b. Pathological Reflex: babinski (-) reflex, bubinzky 1 and 2 (-)
IX. Mental Status Examination
a. Emotional / feeling condition : restless
b. Orientation : time, place and good people
c. The process of thinking (memory, attention, decision, calculation): good
d. Motification (ability) : bad
e. Language : Java
X. SUPPORTING EXAMINATION
A. Medical Diagnosis: stage 4 HIV / AIDS
B. Diagnostic / Supporting Examination Medication:
1. Laboratory :
Type of Result Type of examination Result
examination
Blood urine Clear
Hemoglobin 8.30 g / dl Color Yellow
Erythrocyte(RBC) 3.34 10​6​/ mL pH 5.5
Leukocyte (WBC 6.53 10​3​/ mL density 1,020
)Hematocrit (Ht 25% Glucose -
Platelet) 229 10​3​/ μL Protein 2+
MCV 74.90 Fl Ketones -
MCH 24.90 pg Bilirubin -
MCHC 33.20 g / dL Nitrite -
SGOT 117 / μL urobilin -
SGPT 51 / μL Lekosis -
blood gas analysis urea 91, 60 mg / dl
of pH 7.30 Creatinine 3.76 mg / dl
PCO​2 24.0 mmHg blood 2+
PO​2 46.1 Albumin 2.42 g / dl
HCO​3 11.8 mmol / L Fecal
Saturation O​2 77.1% Color Chocolate
temperature 37 Forms Liquid
Imunoserologi epithelium +
HIV Determine Reactive leukocytes +
HIV Bioline Reactive Parasitic -
HIV Oncoprobe Reactive worm egg -
CD 4 5 mm​3​ of blood Larva -
Trophozoit -
Kiste -
muscle fiber -
Dietary fiber is -

2. X-rays :-
3. ECG :-
4. Ultrasound :-
5. Other :-
C. MANAGEMENT OF THERAPY
1. Omeprazole 1 × 40 mg
2. Metoclopramide 3 × 10 mg
3. Fluconazole 1 × 400 mg
4. Aminofluid 1 × 500 cc
5. Ceftriaxon 2×1g
6. Paracetamol 4 × 500 mg
6. Cotrimoxazole 1 × 960 mg
7. Prednisone 2 × 40 mg
 DATA ANALYSIS
patient name:Ny.SW
Age: 34 th
No. Reg : 11252540
DATA SUPPORTING PROBLEMS ETIOLOGY
DS: Clients complain of shortness of Ineffectiveness of airway over mucus
breath production
DO:
1. TTV:
▪​ ​RR: 30 × / minute
▪​ ​TD: 110 / 70mmHg
▪​ ​N: 100 × / minute
▪​ ​Temperature: 38.5 ° C
▪​ ​Additional breath sounds: ronchi
(+), cough (-)
▪​ ​Lab examination results:
Blood gas analysis:
pH: 7.30; Po​2​: 46,1;
HCO​3​: 11.8 mmol / l
O​2​: 77.1%
KU: weak
DS: The client said that the client did Insufficient nutritional diarrhea and mouth
lesions
not want to eat because his mouth was imbalance from
sore, there was thrush, pain when
swallowing, BB dropped ± 20 kg
DO:
▪​ ​Clients do not want to eat
▪​ ​Clients spit out food that is given
▪​ ​On the tongue clients are candidiasis
▪​ ​There lymphadenopathy
▪​ ​Client diarrhea, liquid stool
DS: hyperthermia Increased disease
The client's sister said that her sister's metabolism
body was feeling hot
DO:
▪​ ​Temperature: 38.5 ° C
▪​ ​Taikardia
▪​ ​Tachypnoea
▪​ ​RR increases by 30 × / minute
▪​ ​Clients sweat a lot of
DS: - Deficit self-care weakness
DO:
▪​ ​KU: weak
▪​ ​Clients cannot access the bathroom
▪​ ​Inability to cleanse the body
▪​ I​ nability to bribe food from dishes to
mouth

​Nursing Diagnosis
No TGL problemTABLE is resolved initials
TGL
1 06-09-2017 bersan Ineffective airway
is associated with excess mucus
production
2 06-09-2017 utrisi less darikenutuhanimbalance of the
body associated with diarrhea and mouth
lesions
3 06-09-2017 associated increaseHyperthermia
metabolism of disease
4 06-09-2017 Self-care deficits are related to the
weakness of
 NURSING CARE PLANNING
N DIAGNOSIS OBJECTIVES OF
O KEP.
1 Ineffectiveness of After nursing action for 2 ×
airway joints 24 hours, respiratory status
Associated with is expected: patency of the
excess mucus airway with results criteria:
production ▪​ ​Breath frequency is within
normal limits
▪​ ​Having clear breath sounds
▪​ ​Ease of breathing
2. Uterine imbalance After nursing actions for 3 ×
is less than the 24 hours nutritional status is
body's compliance expected: adequate food
with diarrhea and intake with results criteria:
oral lesions ▪​ ​Did not happen nausea,
vomiting and diarrhea
▪​ ​Appetite increases
▪​ ​BB is within normal limits
3. Hypothermia is After nursing actions for 1 ×
associated with 24 hours it is expected that
increased body temperature can be
INTERVENTION TT
1.​ ​Monitor vital signs
2.​ ​Set the semi fowlerclient
position
3.​ ​Give O​2​ according to order
4.​ ​Give information to clients
and families about smoking
restrictions in the treatment
room
1.​ M
​ onitor the ability to
chew and swallow
2. ​Increase food intake
through installation of NGT
hose
3.​ G
​ ive antiemetic according
to order
4.​ ​ Collaboration with
nutritionists to determine
calorie counts and client's
daily nutrition
TTV monitor
​
Wear thin clothes on client
​
 metabolism and maintained within normal
disease limits with the results Give IV fluids according to
​

criteria: order
▪​ ​Body temperature between
36-37 ° C Give antipyretics according to
▪​ ​RR and pulse are within order
normal limits
▪​ ​Free from excessive
sweating

4. Self-care deficits After nursing actions for 1 ×
associated with 24 hours, the client and
weakness family are expected to be
able to treat themselves with
the results criteria:
▪​ ​Clients appear clean and
fresh
▪​ ​Clients are able to take
care of themselves or with
help
▪​ ​Receive assistance or care
from care givers
-​Help clients to eat by feeding
them
-​Change clothes and clients'
dirty towels
-​Give assistance until the
client is able to self-care or
family can help
- ​ Involve families in providing
care nursing

No. DATE / TIME ACTION NURSING TT

Dx
07- 1. 1.​ M
​ onitor vital signs
09- 11.00 TD: 120/70 mmHg RR: 30 × / minute
201 N: 100 × / minute S: 37 ° C
7 08.00 2. Set the position of the semi-fawler client
08.15 3. Give oxygen according to order 3l / minute using
simple mask
 12.00 4. Give information to clients and families about the
prohibition on smoking in the treatment room
2. 07-09-2017 1​ ​Monitor the ability to chew and swallow clients
08.00 2.​ I​ nstalling NGThose
08:30 3.​ P
​ rovide injection of drugs according to order:

08:45 metoclopramide 10 mg, omeprazzole 40 mg, give

cotrimoxazole 960 mg orally
4.​ C
​ ollaborate with nutritionists to determine the

10:00 number of calories and nutrients needed by the

client: Provide clients with liquid diit

3. 07-09-2017 1. Monitor TTV

11.00 2. Provide clients with thin clothing
3. Provide liquids according to the order of 2000 cc /
24 hours
4. Provides paracetamol 500 mg according to order
4. 07-09-2017 / 07.00 1.​ F
​ eed clients through the NGThose

08.00 2.​ C
​ hange clothes and dirty client towels

3.​ W
​ iping clients
4.​ ​Involving families in providing nursing care

NURSING INSURANCE