Nama: Puput Setia Widianingsih

NIM: 2019012199
Kelas: PSIK 3B

NURSING CARE
NEED SECURITY AND COMFORTABLE

A. PENGAKAJIAN
I. Identification of patients
Name : ny "N"
Age : thirty seven years
Family : five people
Last education : elementary school
Occupation : housewife
Address : jln.T.A.Gani
Hospital admission date : 16 December 2014
Diagnostic medic : effusion fleura

II. Family history

1. The main complaint : tightness
Trigger factor : due to accumulation of fluid in the cavity fleura
Nature of complaint : settle
Location anddistribution : chest
Scale complaint : severe (6-10)
Start and duration of pain : from entering the hospital
Things that ease / burden : break / tightness

2. Past health history

Patients say the illness / complaint that is often experienced shortness
Patients say never hospitalized earlier
The patient said he had never had surgery
Patients say no allergies

III. Vital signs:

a. Blood pressure : 100 / 70mmHg
b. Pulse : 70x / i
c. Body temperature : 37 C
d. Respiratory : 32x / i
IV. History needs comfort
Patients say never suffered trauma resulting in pain
Location of pain: chest area
The nature of pain: sedentary
Patients say never impaired body temperature changes
Patients say the disease is often experienced shortness
Patients say never experienced flatulence
Physical examination
1. Inspection
a. Vocal: wince
b. Facial expressions: grimacing
2. Palpation
a. Pain scale: severe (6-10)
b. Quality of pain: sharp
3. Percussion
a. Beep: timpani
4. Auscultation
a. Bowel sounds: wheezing
 DATA FOCUS

Name: ny "N" needs: security and comfort

Age: 37 years old room: surgical treatment
Gender: female date: 8 January 2015

Subjective data Objective data

The patient said congested while sleeping on Patient appears pale
their backs
Patients seems weak 
The patient said chest pain

Patients say often cough Grimacing facial expressions

Observation of vital signs:

Blood pressure: 100/70 mmHg
Temperature: 37 c
Nadi: 70x / i
Respiratory: 32x / i
 DATA ANALYSIS

Name: ny "N" needs: security and comfort

Age: 37 years old room: surgical treatment
Gender: female date: 8 January 2015
DATA ETIOLOGY PROBLEM
Subjective Data permeability changes fleura Impaired sense of comfort
1. The patient said congested while
sleeping on their backs Decreased plasma osmotic
pressure
2. Patients report pain in the chest area

3. Patients say often cough Increased systemic capillary

hydrostatic pressure

Objective data Reduced dranaise limfatif

1. The patient appears pale
Pulmonary edema fluid
movement and passing
2. Patients seems weak through the pleural lining
viselaris

3. grimacing facial expression Increased peritoneal fluid

4. Observation of vital signs

Blood pressure: 100/70 mmHg
Temperature: 37 c
Nadi: 70x / i
Respiratory: 32x / i

V. DIAGNOOSA NURSING
Impaired sense of comfort associated with shortness
Objective: after the act of nursing 2x24 hours expected of patients showed comfort with criteria
results:
a. Shortness bekurang
b. Pain is reduced
c. Cheerful facial expressions

VI. INTERVENTION NURSING

1. Assess breathing pattern
Rational: to determine the pattern of breathing
2. Observation of vital signs
Rational: to recognize and facilitate action
3. Give a comfortable position
Rational: to reduce pain with semi-Fowler's position
4. Create a quiet neighborhood
Rational: to improve comfort
5. Collaboration with other nurses and other medical team in delivering drugs
Rational: to reduce the complaints

VII. IMPLEMENTATION OF NURSING

1. Assess breathing pattern
Results: Respiratory 32x / i
 2. Observe vital signs
Results: vital signs
Blood pressure: 100/70 mmHg
Temperature: 37 c
Breathing: 70x / i
3. Provide a comfortable position possible (semi-Fowler)
Results: The patient can perform semi-Fowler's position
4. Creating an environment that is quiet
Results: The patients can calm
5. Treatment with nurses and other medical team in delivering drugs
Results: The administration of analgesic drugs

VIII. EVALUATION OF NURSING

  Subjective:
patients say claustrophobic when sleeping on their backs
Clients say pain in the chest
Clients say often cough
    Objective:
patient appears pale
patients seems weak
grimacing facial expressions
observation of vital signs
Blood pressure: 100 / 70mmHg
temperature: 37 C
Pulse: 70x / i
Respiratory: 32x / i
  Asesmennt: Issues not resolved interference comfort
  Planning: continue intervention
1. examine the pattern of breathing
2. The observation of vital signs
3. give a comfortable position
4. create a calm environment
5. collaboration with nurses and medical teams provide drug