CLINICAL EVALUATION EVALUATION / REPORT REPORT

Student 's name : Gavrila veronika Melapa

NIM / student's number : 00000025214
Room / Ward : ward 3

* Minimum 1 day of care, Minimum 1 day of

nursing care )
Patient's Initial : Ny . K
Date of Birth / Age : 28 October 1982 / 36 years

No. Patient's Medical Record : 220731

Medical Diagnose : Cronis Bronchitis

Nursing Assessment Date : January 24, 2019

Assessment / Assessment

• Major complaints / Major compliance :

Shortness of breath and cough that has never stopped since the last 8 months.

• Medical history before being admitted to health history before admitted to hospital:

Asthma

• Assessment of focus data and diagnostic supporting data (lab, xray, etc.) / Focus
assessments and diagnostic tests (lab, xray, etc):
o TTV: BP: 100/65 mmHg P : 108 x / minute T:
38 o C
RR : 36 x / minute SpO 2 : 92%
o Chest: Hear: adynamic precardium, normal rate, regular rhytm.

o Lungh: Symetric chess expanssion, clear breathing sound, expiratory

wheezer + / +.
o Extermites: war m, brisk capilary refil, no edema.
 o January 25, 2019
1. Laboratory
Urine complete Sediment
- Protein Leukocytes: 10-15 Hb: 12.2 br%
- reduction Neg (-) Erythrocytes; 25-30 Erythrocytes: 3.6/mill
- Urabilin Epithelium: 5-7 Leukocytes: 10/mm 3
- Bilirubin Crystal: uric acid = Å LED / BBS: 10 mm / hour

2. Current therapy:
Normally:
- OBH = 3x1 a day - Leukocytes = 5000 - 10,000 / mm 3
- Amoxicilin = 3x500 mg - Erythrocytes = 4.5 - 5.5 million / mm 3
- Kotrimoxazol = 3x1 - IED / BBS = (0 - 10 mmhour)
- Vitamin B - Hb = (13-16 gr%) (12-14 gr%)
- Frixity = 2 x 1/2 a day

Torax = - Grawn of the left lung bacillus

Date Hour PLT Result Limit

January 24, 2019 11:08 31 10³ / µL 150 - 400
February 25 ,
2019 7:23 a.m. 48 10³ / µL 150 - 400
 Data analysis / Data analysis

Subjective Data Subjective Objective Objective Data Nursing Problems

Data Data Nursing Problem

DS: DO: Disruption of gas exchange

- - Cianosis peripheral
. skin color.
- RR: 32 x / minute.
- Pulse: 110 x / minute
- Short breath.
- Use of respiratory aids
muscles
- Cyanosis of the lips
and base of the nail ,.

DS: DO DO : Clearing the airway is not

- Clients complain it's - Respiration 36x / min effective
difficult breathe - S greenish white ekret
(tight) - Looks tight
- Clients complain much - On auscultation the
menegeluarkan greenish-
sound of additional breath,
white colored sputum
- The client complains of wheezing
pain when swallowing
DO

. : DO: Sleep disorder

- Clients are seen very
often cough
- Conjunctiva enemis
- the client looks tight
- the client looks pale
- Respiration: 36 x /
minute
re

-
Nursing diagnosis according to priority : (actual, risk, etiology-
symptoms) Nursing Diagnose based on priority: (actual, risk, etiology-
symptoms)
1. The pattern of ineffective breathing is related to increased production of secretion

2. Ineffective airway clearance associated with coughing and secretion

3. Disorders of sleep patterns bd ter often wake up at night.

No. Diagnose Intervention and Rational Implementation and Evaluation Name
response & Signature

1. Pattern of breath 1. Observation of Hours: 08.00 S: After it's done

ineffective respiratory status,
flowering arterial blood gas results,
n with pulse
enhancement and oximetry values.
production 2. Monitor developments
mucus. mucous membrane / skin
(color).
Observation of vital signs
and
awareness status.
4. Evaluation of activity
tolerance
and limit client activity ..
5. Maintain the fowler
position
by hand abduction and
supported with pillows or
sitting leaning forward
by holding the table
6. Collaboration for giving
drug that has been
prescribed.
Rational:
1) Monitor progress
respiratory problems.
2) Peripheral oxygenation
disorders
cianosis appears.
Mandiri: treatment for 1 x
1. Observing respiratory 24 hour patient
status, say tightness
pulse and oximetry value. reduced
Patient response: O:
- RR: 32 x / minute. - Peripheral skin color
- Pulse: 110 x / minute improved (no
- SpO 2 : 92% cianosis)
Monitor development - RR: 26 x / minute
mucous membrane / skin - Inconveniences
(color). chest (-)
Patient response: - Pulse is 95 x / minute.
Just shut up, and follow A: Problem yet
instructions. Patient's resolved
mucous membrane P: Intervention
well, there is no next
mushroom.
3. Observing vital signs .
and
awareness status.
Patient response:
Following
TTV intructions:
BP: BP: 100/65 mmHg
P: 108 x / minute
Q: 38 o C
RR: 36 x / minute SpO 2 :
92%
 3) Determine respiratory GCS: E 4 V 5 M 6
status 4. Evaluating activity
and awareness. tolerance
4) Reducing energy use and limit client activity ..
excessive need Patient response:
lots of oxygen. The patient said he did not
5) Meet the needs of do activities that
oksiegen. requires a lot of energy.
6) Increase the freedom of 5. Maintain fowler
supply position
oksiegn. by hand abduction and
7) mucolytic drugs and supported with pillows or
expectoration will sit leaning forward with
thinning mucus production hold desk.
Patient Response:
Hours: 10:00
Collaboration:
6. Collaborate for giving
drug that has been
prescribed.

2. Clean the road 1. TTV Monitor 08.00 S: After it's done

ineffective breath 2. Monitor the rate, Mandiri: 2 x 24 hour treatment
associated with rhythm, 1. Monitor TTV say patient
cough and depth, and effort Patient response: feeling tight
accumulation of respiration BP: 100/65 mmHg his breath decreases.
secretions. 3. Pay attention to chest P: 108 x / minute T: 38 o C O:
movements, RR: 36 x / minute SpO 2 : TTV:
observe symmetry, 92% BP: 100/65 mmHg P
use of accessory muscles, 2. Monitor rate, rhythm, : 108 x / minute T: 38 o C
muscle retraction depth, and effort of RR: 36 x / minute
supraclavicular and respiration SpO 2 : 92%
intercostal Patient response: Rhythm of breathing
4.Monitor breath sounds RR: 36 x / minute, the no normal
additional. rhythm no normal
5. Give the position normal there is no tachypnea and
comfortable for tachypnea and bradypnea, bradypnea, patient
reduce dyspnea. patients use use
6. Clean secretions from diaphragmatic respiration. diaphragmatic respiration.
mouth and trachea do 3. Pay attention to chest There is no breath
exploitation movements, additional.
as needed. observe symmetry, muscle A: The problem is
7. Teach effective use resolved
coughing accessory, muscle in part
8. Collaborative giving retraction P: Intervention
oxygen supraclavicular and next
9. Collaborative giving intercostal
broncodilator accordingly Patient response:
indication adynamicprecardium,
10. Decide when normal
needed orally rate, regular rhytm
and / or suction trachea 4. Monitor breath sounds
11. Auscultation of breath additional
before and after Patient Response:
suction There is no breath
12. Inform additional..
family regarding 5. Give a position
suction action comfortable to reduce
13. Use universal dyspnea.
precaution, sarong Patient response:
hands, goggles, masks The patient says no
according to the needs too feel tight
with position (semi
fowler)
14. Use low flow
to eliminate
secretions (80-100 mmHg
in adults)
15. Monitor oxygen status
patient (SaO2 and
SvO2) and status
hemodynamics (MAP
and heart rhythm)
before, during, and
after suction
Rational :
1. Know the level
disturbance
and help in
determine intervention
to be given.
2. shows severity
from respiratory disorders
what happened and
determine intervention
to be given
3. additional breath sounds
can be an indicator
patency disorder the
airway
of course it will
affect on
adequacy of exchange
air.
6. Clean the secret from
mouth and trachea; do it
appropriate sucking
need.
Patient response: patient
say feel more relieved
breathe do suction
7. Teach effective coughing
Patient response:
After being shown by the
patient
can already do coughing
effective, and patient
remember feeling more
comfortable.
Collaboration:
8. Collaborative giving
oxygen
9. Collaborative giving
broncodilator as indicated
10. Decide when
oral and / or required
tracheal suction
11. Treat the breath
before and after suction
12. Inform
family regarding action
uction
13. Using universal
precaution, gloves,
oggle, mask according
needs
4. knowing 14. Using low flow
road problems to get rid of secretions
breath experienced and (80-100 mmHg in adults)
effectiveness of breath 15. Monitor oxygen status
patterns patients (SaO2 and SvO2)
client to fulfill and
oxygen demand hemodynamic status
body. (MAP)
5. The sound of ronchi and heart rhythm) before,
indicates there is when, and after suction
accumulation of secretions
or
excess secretions on the
road
breath.
6. maximizing position
lung expansion and
decrease effort
Respiratory. Ventilation
maximum open area
atelectasis and
improve movement
secretions to the airway
big to be issued.
7. Prevent obstruction or
aspirations. Suction
can be needed incapable
client
take out a secret
own.
8. Optimizing
fluid balance
and help
thin the secret
so it's easy
issued
9. Relieve lung work
to meet
oxygen demand as well
make ends meet
oxygen in the body.
10. Broncodilators
increase size
branching lumen
tracheobronchial so
reduce detainees
against air flow
11. time of suction action
right help
field the airway
patient
12. Knowing existence
additional breath sounds
and road effectiveness
breath to fulfill
O2 patient.
13. provide understanding
to the family
regarding indications
why is it done
suction action
 14. to protect
health workers and
patient from spread
infection and giving
patient safety
15. high flow can
hurt the airway
16. Knowing existence
change in SaO2 value
and hemodynamic status,
if there is a deterioration
suction can be stopped
3. Pattern disturbance 1. Monitor the general
bd sleep often condition of the patient
wake up at night and TTV
day. 2. Assess Sleep Patterns.
4. Assess the factors that
cause
sleep disorder (cough)
5. create a comfortable
atmosphere,
Reduce or eliminate
distractions
environment and sleep
disorders.
6. Limit visitors during the
period
optimal rest (eg after
eat).
7. Ask clients to limit
Hours: 09.00
1. Monitor the general
condition of the patient
and
Patient Response:
TTV: BP: 100/65 mmHg P:
108 x / minute
RR: 25 x / minute T: 38 o
C SpO 2 : 92%
2. Review Sleep Patterns.
Patient response:
The patient said before the
pattern
he slept well he slept from
the hour
10:00 p.m.
S: After it's done
2x 24 hours of treatment
patient said
time of the building
at night
usually can be 4 to 5
last night he only
wake up 3 times. Patient
say wake up
the morning is much more
immediately.
O: patient's face
Fresh plasticity, no
looks pale RR: 25
x / minute Pulse: 98x
/minute
A: The problem is
resolved
fluid intake at night and 2. Assess the factors that in part
urinate before going to cause P: Intervention
bed. sleep disorder (cough) next.
8.. Advise or give care Patient response:
in the evening (eg The patient says the
hygiene) patient has experienced it
personal, linen and coughing 8 months ago
nightgowns and coughing it up
clean). getting worse at night.
9. Collaboration 4. Provide a comfortable
doctor atmosphere, reduce it
for or eliminate environmental
drug administration .. distractions and
sleep disorders.
Rational : Patient response:
1. Knowing awareness, The patient feels that
and conditions atmosphere
the body is normal or silent, makes him feel
not. more
2. To find out the ease in comfortable.
sleep. 5. Limit visitors during the
4. To identify causes period
actual sleep disturbance optimal rest (eg after
5. To monitor how far it eat).
can be
be calm and relax.
6. To help relaxation when Patient Response:
sleep. Patients agree to reduce
Rational : the amount
1. Knowing awareness, visitors, because he feels
and conditions he needs it lenty of time to
the body is normal or rest.
not. 6. Ask clients to limit their
2. To find out the ease in intake
sleep. liquid at night and urinate
4. To identify causes before sleeping.
actual sleep disturbance Patient Response:
5. To monitor how far it The patient does what is
can be said
be calm and relax. the nurse she only drank 1
6. To help relaxation when glass before
sleep. dinner and 1 glass after
meals
night.
Hours: 16.00
7. Advise or give care
in the evening (eg
hygiene)
personal, linen and
nightgowns
clean)
Patient response:
The patient wants to be
helped to take a warm bath
and
ask us to do bed makeing.

Collaboration:
Doctor collaboration for drug
administration