Name :Nailil Muna

NIM :2019012193

Class. :PSIK 3B

NURSING CARE

NEED SECURITY AND COMFORTABLE

A. PENGAKAJIAN

I. Identification of patients

Name : ny.July

Age : thirty-nine years old

Family : four people

Last education : High School

Occupation : housewife

Address : jln.Mlati no.23

Hospital admission date : 06 December 2020

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 :
 Subjective data
 Objective data
 The patient said congested while sleeping on their backs The patient said chest pain
patients say often cough
 Patient appears pale
 Patients seems weak
 rimacing facial expressions

 Observation of vital signs:

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

 DATA ANALYSIS :

Name: ny.July needs: security and comfort

Age: 39 years old room: surgical treatment

Gender: female date: 6 August 2014

 DATA ETIOLOGY PROBLEM

 Subjective Data

1. The patient said congested while sleeping on their backs

2. Patients report pain in the chest area

3. Patients say often cough

 Objective data

1. The patient appears pale

 2. Patients seems weak

3. grimacing facial expression

4. Observation of vital signs

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

5. permeability changes fleura

6.ecreased plasma osmotic pressure

7. Increased systemic capillary hydrostatic pressure

8.Reduced dranaise limfatif

9. Pulmonary edema fluid movement and passing through the pleural lining viselaris

10. Increased peritoneal fluid

11. Impaired sense of comfor

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. Observed vital signs

 Results: vital signs

 Blood pressure: 100/70 mmHg
 Temperature: 37 c
 Breathing: 70x / i

3. Provided a comfortable position possible (semi-Fowler)

 Results: The patient can perform semi-Fowler's position

4. Created an environment that is quiet

 Results: The patients can calm

5. Treatmented 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