Documentation of nursing care activities provided to patient

RESUME ON EMERGENCY NURSING WITH NY.H Bronchial

ASTHMA IN THE CASE OF EMERGENCY UNIT IN HEALTH
Cakranegara

A. PATIENT IDENTITY
Name : Ny H
Age : 65 years old
Religion : Islam
Jobs : House wife
Gender : Women
Medical diagnosis : Bronchiale Asthma
Date of assessment : Wednesday, March 04 2020
Medical record numbers : 00-81-86
The name of the person in charge : Tn. N
B. DATA FOCUS
1. Main complaint
Out of breath
a. Airway: A voice ronkhi, nose looks clean, no discharge
b. Breathing: Breath spontaneous respiration: 28x / minute, and it
appears there was retraction of the chest wall
c. Circulation: Blood pressure: 140/80 mmHg, N: 85x / min, SpO2:
90%
d. Disability: komposmetis awareness, and GCS: E4 M6 V5
e. exposure:
1) Thoracic: chest pain, there is a retraction of the chest wall,
heartburn
2. Disease History Now
Patients come to the Emergency Unit at 9:20 pm with complaints
of shortness of breath, cough with phlegm for more than 3 days, and felt
pain in the pit of the stomach. patients say when coughing, phlegm is
often mixed with blood.
 3. Past medical history
Patients are said to have a history of diabetes mellitus, and had
suffered from tuberculosis in 2016 and was cured after a treatment for six
months.
C. Supporting investigation
Laboratory: sputum pot Award (BTA: M. Tuberculosis)
D. Medical therapy
Collaboration: - Nebulizer (NaCl 3 cc + salbutamol 1 cc)
- Acetyl 3 x 1
- Dexamethasone 3 x 1
E. Data Analysis

No Data Etiology Problem

.
1. Subjective data : Precipitating factors: Airway
Patients report allergens, stress, weather clearance
shortness of breath, ineffective
coughing up phlegm IgE associated antigens on
and heartburn. the surface of mast cells /
Objective Data: basophils
- looks crowded
- looks dyspnea secrete mediators
- Vital sign :
 Blood Capillary permeability
pressure: increases
140/80
mmHg Mucosal edema,
 N: 85x / min productive secretion,
 Respiration: increased smooth muscle
28x / min kontriksi

 SPO2: 90%
Smooth muscle spasm of
 the bronchial glands
secretion increased

Refinement / obtruksi
proximal

Excess mucus, coughing,

wheezing, shortness of
breath

F. Nursing Diagnostics
1. Ineffective airway clearance related to excess mucus is characterized by
voice crackles and RR 28x / minute.
G. Nursing Interventions

No Nursing Objectives and expected Intervention

. Diagnostics outcomes
1. Ineffective airway After the act of nursing for 1 1) To monitor
clearance related x 30 minutes airway breathing patterns
to excess mucus clearance is expected to (frequency, depth,
is characterized improve with the expected effort breath)
by voice crackles outcomes: 2) Viewing additional
and RR 28x / 1) Effective cough breath sounds (eg,
minute. increased gurgling, wheezing,
2) dyspnea decreased wheezing, and
3) Sputum production crackles)
decreases 3) Give the semi-
Fowler position /
Fowler
4) Encourage drinking
warm water
5) Encourage effective
coughing techniques
6) Collaboration of
bronchodilators.
H. Note developments

Nursing diagnoses Day / date / Implementation Evaluation Signature

hour
Ineffective airway Wednesday, 1) Assess breathing patterns S: patient say sense
clearance related to 04/03/2020 (frequency, depth, effort sesaknya been reduced.
excess mucus is Hours: 09: 30 breath) O: - RR: 20x / min
characterized by voice pm 2) Reviewing additional - BP: 120/80 mmHg
crackles and RR 28x / breath sounds (eg, - N: 80x / min
minute. gurgling, wheezing, - S: 37 ° C
wheezing, and crackles) - No sound ronkhi
3) Give the semi-Fowler A: Problems Resolved
position / Fowler P: Intervention at the stop.
4) recommends drinking So KIE patients with:
warm water - Drinking warm
5) encourage effective water
coughing techniques
6) Collaboration of the
nebulizer (salbutamol 1
cc + 3 cc NaCl)