CHAPTER III

A. NURSING ASSESSMENT

CASE

Patients, female 71 years came with complaints of chest pain since 4 hours
before MRS after cleaning the garden. The pain experienced was intermittent,
duration of about 30 minutes, such as punctured and needles. Chest pain radiating to
the back and left arm, Patients appear to grimace and groancold sweats and
palpitations and feeling claustrophobic since three days ago. Nausea (-), vomiting (-).
Patients suffering from hypertension since 10 years ago.
From the patient's physical examination found tampak weak, awareness compos
mentis (GCS 456), enough impression nutritional status, blood pressure 150/90 mm
Hg, pulse 100 times / minute, regular, sufficient contents, breathing 28 x / minute,
temperature 34.5 ° C.
Leukocyte hematologic examinations 12,700 cells / cmm, platelets 94,000 mg
/ dl, random blood glucose 183, AST 89, SGPT 47, ECG shows ST elevation leads II,
III, aVF.
a. Identity
Name : Ny.P
Age : 71 years
Address : ngajum
Work : Farmers
Religion : Islam
tribe : Java
Status : Married
Last Education : No school
b. Anamnesis
Autoanamnesis
Main complaint : chest pain
Disease History Now:
Patients present with chest pain since 4 hours before MRS after cleaning the
garden. The pain experienced was intermittent, duration of about 30 minutes,
such as falling loads or pinched. Chest pain radiating to the back and left arm,
Patients also complaincold sweats and palpitations since three days ago.
Nauseous vomit (-).
Past medical history:
Hypertension (+), diabetes mellitus (-), Asthma (-), heart disease (-), allergies
(-)
Family Disease History
No relatives of patients suffering from the same disease with patients.
Hypertension (-), asthma (-), heart disease (-), lung diseases (-), DM (-), drug
allergy / food (-).
Habits History
- Smoking (-)
- Drinking coffee (-)
- Drinking alcohol (-)
- Jamu (+)
- Sport (+)
c. Physical Examination
1. General Situation
Looks weak, awareness compos mentis (GCS 456), enough impression
nutritional status.
2. Vital Signs
Tension : 150/90 mmHg
Pulse : 100 x / min, regular, sufficient contents
 breathing : 28 x / min
Temperature : 34.5 oC
3. Skin
Good turgor, jaundice (-), cyanosis (-), venektasi (-), petechie (-), spider nevi
(-).
4. Head
Mesocephal shape, wound (-), the hair is not easily removed, wrinkles (+),
atrophy m. temporalis (-), the macula (-), papules (-), nodules (-), abnormal
facial expressions / Bell's Palsy (-).
5. Eye
Anemic conjunctiva (- / -), sclera jaundice (- / -).
6. Nose
Nostril breath (-), secretions (-), epistaxis (-).
7. Mouth
Pale lips (-), lip cianosis (-), bleeding gums (-).
8. Ear
Tenderness mastoid (-), secretions (-), hearing loss (-).
9. Throat
Enlarged tonsils (-), pharing hyperemia (-).
10. Neck
JVP is not increased, the middle trachea, thyroid gland enlargement (-),
enlarged lymph nodes (-), lesions on the skin (-), rigid (-).
11. thorax
Normochest, symmetrical, thoracoabdominal breathing, retractions (-), spider
nevi (-), pulsatility infrasternalis (-), widened intercostal space (-).
Cor:
Inspection: ictus cordis does not seem
Palpation: ictus cordis is not strong lift
Percussion: Top left border: SIC II Linea The sternal Sinistra
 right border : SIC II Linea The sternal Dextra
Bottom left border : SIC V 1 cm medial to the left clavicula linea medio
Bottom right border: SIC IV Linea The sternal Dextra
Auskultas i: Single S1S2, gallop rhythm (-), murmur (-)
Pulmo:
Static (front and rear)
Inspection : Development of the same right to the left chest
palpation : Fremitus touch left together with right
percussion : Sonor / sonor
auscultation : Vesicular basic sound, extra sound (Ronchi - / -), Wheezing -
/-
Dynamic (front and rear)
Inspection : Equal right chest movement with the left
palpation : Fremitus touch left together with right
percussion : Sonor / sonor
auscultation : Vesicular basic sound, extra sound (Ronchi - / -), Wheezing -
/-
12. abdomen
Inspection : Stomach looks flat, no enlargement of the liver and lien
palpation : Supple (+), tenderness (-)
percussion : timpani
auscultation : Bowel (+) normal
13. extremity
cold akral edema
+ + - -
+ + - -

14. Genitalia system: within normal limits.

d. Supporting Investigation
ECG

ST elevation leads II, III, aVF

Conclusion: IMA inferior

Hematology
hb : 15.6 g / dl L. 13.5 to 18 P. 12-18
Hematocrit: 43.6% L. 40-54 P. 35-47
erythrocytes : 5.20 million / cmm L. 4.5-6.5 P. 4.0-6.0
Leukocytes : 12,700 cells / cmm 4000-11000
platelets : 94,000 mg / dl 150000-450000

Blood Chemistry
When blood sugar : 183 <140
SGOT : 89 L. 10-42 P. 7-35
 SGPT : 47 L. 10-42 P.7-35
urea : 30 mg / dl 20-40
creatinine : 0.72 mg / dl 0.6 to 1.1 L. P. 0.5 to 0.9
Suggestion: examination CKMB, LDH, HbA1C

B. DIAGNOSIS
1. Acute pain
2. Ineffectiveness of breathing patterns

C. DATA ANALYSIS
DATA PROBLEM
DS: acute pain
1. Clients say chest pain since 4
hours before MRS after cleaning
the garden.
2. Clients say chest pain radiating
to the back and left arm
DO:
1. Visible client wince
2. Pain scale 7
3. TD : 150/90 mmHg
Pulse : 100 x / min,
breathing : 28 x / min
Temperature : 34.5 oC

DS: Ineffectiveness of breathing patterns

1. Clients say claustrophobic
DO:
 1. visible tightness
2. Visible cold sweats
3. TD : 150/90 mmHg
Pulse : 100 x / min,
breathing : 24 x / minute
Temperature : 34.5 oC

D. INTERVENTION

DIAGNOSIS NIC NOC

Painful Pain level 1. Make basis of the
Pain control comprehensive pain
Comfotr level assessment
Expected outcomes: 2. Observations
1. Being able to nonfebral reaction
control the pain of discomfort
2. Reported that pain 3. Provide a
was reduced by the comfortable position
use of pain
management
3. Said feeling
comfortable after
the pain has
subsided
Ineffectiveness of Respiratory status: 1. Position the patient
breathing patterns ventilation to maximize
Respiratory status: ventilation
airway patency 2. Monitor blood
 Vital sign status
criteria Results
1. Vital signs within
normal range
pressure, pulse,
temperature and
respiration
3. Monitor abnormal
breathing pattern

E. IMPLEMENTATION AND EVALUATION

No. Date and DX Implementation Evaluation
time
1 Tuesday 1 1. Conduct of the S: a client of said pain as
/ 12 comprehensive tingling and radiating
pain assessment punctured kepunggung
Result: as and left arm
tertusu-prick pain O: It seems grimace, scale
scale 7 and 7
radiates to the A: The problem is not
back and left arm resolved
2. Observing Q: continue Intervention
nonfebral 1, 2, and 3
reaction of Ket:
discomfort 1. Make basis of the
Results: It comprehensive
appears grimace pain assessment
3. Providing a 2. Observations
comfortable nonfebral reaction
position of discomfort
Results: semi- 3. Provide a
Fowler's position comfortable
 position

2 Tuesday 2 1. Positioning the S: client said chock

/ 12 patient to O: 1 Visible tightness
maximize 2. P: 28x / min
ventilation A: The problem is not
Results: semi- resolved
Fowler's position Q: continue intervention
2. Monitor blood 1,2, and 3
pressure, pulse, Ket:
temperature and 1. Position the patient
respiration. to maximize
Results: TD : ventilation
150/90 mmHg, 2. Monitor blood
Nadi: 100 x / pressure, pulse,
min, Breathing: temperature and
28 x / min, respiration
Temperature: 3. Monitor abnormal
34.5 ° C breathing pattern
3. Monitor the
abnormal
breathing pattern
Results:
tightness, p: 28x /
minute.
No. Date DX Implementation Evaluation
and
time
1 Wed / 1 1. Conduct of the S: client said as depressed
13 comprehensive and radiating pain and left
pain assessment arm kepunggung
Result: pain as O: It seems grimace, scale
pressure scale 5 5
and radiates to the A: The problem is not
back and left arm resolved
2. Observing Q: continue Intervention 1,
nonfebral reaction 2, and 3
of discomfort Ket:
Results: It appears 1) Make basis of the
grimace comprehensive
3. Providing a pain assessment
comfortable 2) Observations
position nonfebral reaction
Results: semi- of discomfort
Fowler's position 3) Provide a
comfortable
position

2 Wed / 2 1) Positioning the S: client said chock

13 patient to reduced
maximize O: It seems less crowded,
ventilation P: 24x / min
 Results: semi- A: The problem is not
Fowler's position resolved
2) Monitor blood Q: continue intervention
pressure, pulse, 1,2, and 3
temperature and Ket:
respiration. 1) Position the patient
Results: TD : to maximize
150/90 mmHg, ventilation
Nadi: 100 x / 2) Monitor blood
min, Breathing: pressure, pulse,
24 x / min, temperature and
Temperature: respiration
36oC 3) Monitor abnormal
3) Monitor the breathing pattern
abnormal
breathing pattern
Result: less
crowded, p: 24x /
minute.

No. Date and DX Implementation Evaluation

time
1 Thursday 1 1. Conduct of the S: a client of said pain
/ 14 comprehensive such as pain and spread
pain assessment kepunggung
Result: as O: It seems quiet, scale
smarting pain 3
 scale 3 A: The issue is
2. Observing resolved
nonfebral reaction P: keep intervention
of discomfort
Results: It seems
quiet
3. Providing a
comfortable
position
Results: semi-
Fowler's position
2 Thursday 2 1) Positioning the S: the client says is not
/ 14 patient to congested anymore
maximize O: not crowded, P: 22x
ventilation / min
Results: semi- A: The issue is
Fowler's position resolved
2) Monitor blood P: keep intervention
pressure, pulse,
temperature and
respiration.
Results: TD :
120/80 mmHg,
Nadi: 80 x /
minute,
respiratory: 22 x /
min, temperature:
36 ° C
3) Monitor the
abnormal
breathing pattern
Result: not
crowded, p: 22x /
minute.