RESUME OF RESPIRATORY PROBLEM

CLIENT WITH PLEURA EFFUSION

Name : Ferishandy Bagaskara

NIM : P1337420617026

Ward : Elang II (Men)

A. Client Biodata
1. Name : Mr. H
2. Age : 30 YO
3. Gender : Male
4. Religion : Islam
5. Tribes/nation : Javaneese/Indonesia
6. Pendidikan : Senior Highschool
7. Pekerjaan : employee
8. Alamat : Weleri, Kendal regioon, Central Java
9. Tanggal masuk : 13 May 2019
B. Main Complaint
Client Mr. H feels difficulty to breath (dyspnea)
C. Health History
1. Now Health History
At the first time client has diagnosed by doctor in RSUD Kendal
that he has the Lymphoma desease that attack his lymphatic system. He
had been sugery before because his disease in RSUD kendal. but lately he
felt short of breath and breathing very fast, after that he was treated at the
Muhammadiyah RSI kendal. However, RSI referred him to Kariadi
Hospital, and here he was diagnosed with pleural effusion.
2. Health History Before
Client has done the lymphoma surgeon before
3. Family Health History
Client’s family has no desease related to MR.H

D. The Obtained data

Subjective Data Objective Data

1. Client feels weak 1. Vital Sign measuring:
2. Dyspnea  BP: 120/90 mmHg
 HR: 120 x/min
 RR: 40 x/min
 T: 36,6 C
 SPO2: 91%
 2. Compos Mentis
3. Thorax (Lungs)Assesment
 Inspection: rapid movement of
chest, the chest’s form is
normal
 Palpation: after client said
“tujuh puluh”, found that left
lung does not vibrate
 Percussion: Found “pekak”
sound at left lung
 Auscultation: weak vesicular
sound in the left lung
4. Diagnostic assesment (lab)
(date of assesment:13/5/2019)
 Hemoglobin 9.3 gr/dl (Low)
 Hematokrit 29% (Low)
 Eritrocytre 3.71 10^6/uL (low)
 MCH 25.1 pg (low)
 MCV 78.2 fL
 MCHC 32.1 g/dL
 Leukocyte 6.8 10^3/uL
 Trombocyte 561 10^3/uL (H)

E. Therapy Program
X May 14th
PO Clindamycin 300 mg/ 8 h
N Acetylcystein 200 mg/ 8h
PCT 500 mg/ 8 h
Inj. IV Levofloxacyn 750 mg/ 24 h
Ondansetron 4 mg/8 h
Omeprazole 40 mg/12 h
Parenteral NaCl 20 Drips/m

F. Nursing Diagnose and Data Analysis

Nursing Diagnose Data Analysis

Ineffective breath patterns related Decreased rate of absorption of

to the effect of hypoventilation lymph vessels due to lymphoma
due to the pressence of pleural
Pleural Effusion
effusion
 The lungs cannot do a complete
expansion

Hypoventilation

Ineffective breath patterns

G. Nursing Intervention

Date Nursing Purposes Intervention Rational

/time
Diagnose

13 Ineffective within 1x24 1. Semi-fowler 1. Semi-fowler

May breath patterns hours it is positioning position give
2. Give enough
2019 related to the expected that patient’s lung
oxygen that
effect of the breath an extra spcae
enough to
hypoventilation pattern will to expand
fulfill the body 2. With an
due to the be effective
needs enough oxygen
pressence of with the
3. Educate the
patient wont
pleural results
client about
complain of
effusion criteria:
deep breathing
1. The weakness
4. Monitor the
3. Deep breathing
client is
Vital sign
has a role to
able to
(SPO2
decrease the
breathe
included)
high RR rate,
without
 dyspnea so the patient
2. Clients
could be relax
get 4. vital sign
adequate monitor has a
oxygen function to
3. The
monitor the
client
extent of the
expresses
patient's
comfort
development
after
missing
dyspnea

H. Implementation
Implemetation Patient’s respond
1. Educates the patient about the 1.
benefits of semi fowler position,
and ask them to lay down in semi
fowler position

2. Give rebreathing mask with O2

velocity 9 l/m

3. Educating the patient about deep

breathing

4. Monitoring the oxygenation status

I. Evaluation (14 May 2019)

Nursing Diagnose Evsluation
Ineffective breath patterns related to
the effect of hypoventilation due to
the pressence of pleural effusion
J. Practical Reflection
Today, I do simple assesment and intervention with the patient with
breathing difficulty. I hope I can reduce the patient’s problem. For the next
time I hope I could find an oxygenation problem with a unique condition