Case

Mrs. N is 66 years old and came to Permata Blora Hospital on March 28, 2018.
The client was taken to the emergency room delivered by the family with
complaints of pain in the left calf and could not be moved because it broke after
being hit by a motorcycle. From the results of TTV examination obtained blood
pressure: 150/90 mmHg, respiration: 18x / minute, pulse: 81x / minute,
temperature: 36 ° C. In the emergency room the client is given RL therapy of 20
tpm (IV), and given kemolac (IV). After that the client is moved to the inpatient
room for further treatment.

A. ASSESSMENT
Date of entry: 28 March 2018
Date of assessment: March 29, 2018
No. MR: 497541
Space: Surgical Disease Room
Medical diagnosis:
1. Client identity
Name: Mrs. N
Age: 66 years
Religion : Islam
Gender : female
Occupation: Housewife
Address: Jepon village

Person in charge :
Name: Mrs. S
Age: 30 years
Gender : Female
relationship with clients: child

1
 2. Main Complaints
Clients complain of pain.
3. Health history
a. Current medical history
The client was taken to the emergency room on March 28,
2018, escorted by the family with complaints of pain in
the left calf and could not be moved because it broke after
being hit by a motorcycle.
At the time of the study on March 29, 2018 the client
looked weak, composmentist awareness, looked swollen
on the broken leg, the client complained of pain in the left
leg (calf) due to a fracture with a pain scale: 4. And the
pain increases if the foot is moved. the client's family
always helps in meeting their needs.
b. Medical history first
The client has never experienced a fracture before, the
client also has no history of hereditary and other infectious
diseases.
c. Family health history
The client's family says no family member has a
hereditary or other infectious disease.
4. Physical examination
 general state: weak
 awareness: compos mentis
 Vital signs:
Blood pressure: 150/90 mmHg
Respiration: 18x / minute
Pulse: 81x / Minute
Temperature: 36 ° c
 Extremities
- Above: in the upper limb, hands can be moved properly
- Lower: in the lower extremities, the left leg (tibia-fibula) cannot
be moved / fracture, the condition around the edema fracture,
the presence of wounds
5. THERAPY

1. RL 20 tpm fluid
2. citicholine 3 x 1 (IV)
3. kemolac 3 x 1 (IV)
4. taxef 2 x 1 gr (14 / st)
5. pronalges supp
6. dexamethason 2 x 1 amp (IV)
7. rannitidin 2 x 1 amp (IV)

A. DATA ANALYSIS

No Data etiology Problem

1. objective data: Bone / fracture Disorders of
discontinuity comfortable pain
 The client looks
weak
 Pain scale 4
 Edema was seen in
the fracture
 Pain increases if the
fracture is moved
Subjective data :
 The client said that
the pain in the left
calf was broken
2. Objective data: depormity impaired physical
 Clients always mobility
seem to be assisted
by families and
nurses in carrying
out activities
 Fracture of 1/3
tibia sinistra fibula
Subjective data :
 The client's family
says the client's
activity is always
assisted by the
family
 B. NURSING DIAGNOSES

Nursing diagnoses
date Date
No initials initials
found resolved
Impaired discomfort of pain
associated with
1 29-3-2018
disconnection of tissue
continuity in bone / fracture
Impaired physical mobility
2 29-3-2018
associated with weakness

A. INTERVENTION

No Objectives and Initi

Nursing intervention Rational
outcome criteria als
After  Maintain  Eliminates
treatment immobilizatio pain and
for 1 x 24 n of the prevents
hours, it is affected part misaligned
expected by bed rest, bones or tissue
that the plaster /  Increases
discomfort staining venous return,
of pain can  Host and decreases
be reduced support the edema, and
/ or affected decreases pain
overcome extremity  Influencing
1 with the  Evaluate pain choice /
following complaints, monitoring of
criteria: pay attention the
to the location, effectiveness
 The client characteristics of
does not and intensity interventions
complain of pain  Reduces
of pain  Do the cold edema /
pack for the hematum
 Pain scale first 24-48 formation,
0 hours as reduces pain
needed sensation
 Collaboration  To reduce
 of analgesic pain or muscle
drugs spasms

 Patients may
 Assess the be limited by
degree of self-views /
immobility self-
produced by perceptions of
the injury actual physical
 Clinging to limitations,
After requiring
the foot board,
treatment information
buckle the
for 1 x 24  Useful to
ankle
hours, it is maintain the
expected  Give / help
mobilization functional
that position of the
physical with
wheelchairs, extremity of
mobility the hand /
disorders crutches,
sticks, as soon foot, prevent
can be contractures
overcome as possible,
2 instruct  Early
with the mobilization
following security in
using reduces
criteria: complications
mobilization
tools of bed rest,
 Clients promotes
 Monitor
carry healing and
blood pressure
out normalization
activitie by doing
activities of organ
s function
indepen  Pertural
dently hypertension
is a common
problem with
prolonged bed
rest and can
require special
intervention
 B. IMPLEMENTATION

No
date Implementation Response to result initials

 maintain mobilization of
the affected part with
29-3- bed rest and spalk
 Pain is reduced but
2018  elevate and support
still edema
the extremities affected
 Pain in the left
 evaluate complaints of
lower extremity
pain location,
(tibia-fibula) Pain
characteristics and intensity
scale 4
 measure the patient's
 TD: 150/90
blood pressure
mmHg
 Collaborate administration
 ketorolac2x1 amp
of analgesic drugs according
IV
to indications namely:
 Helps heal and
kemolac helps mobilization
normalize organ
with crutches and instructs
function
safety in using mobility
 Pain is reduced
devices
but still edema
1.

 Maintain the mobilization of

 Helps healing and
the affected part with bed
normal functioning
rest and spalk
of organs
 Elevate and support
 Pain is reduced
the affected extremity
but still edema
 Evaluating pain complaints
 Pain scale 3
 Measuring patients blood
 TD: 130/90
pressure
 Ketorolac 2x1 amp
 Collaborate in
IV
administering analgesic
drugs according to
indications, namely:
ketorolac
 help mobilize with crutches
and instruct security in
using mobility tools
C. EVALUATION

date No. Nursing evaluation initials

S: The client says the pain has decreased

O: pain scale: 3
Tuesday ,
1. the client still looks weak
30 March
2018
A: The problem is partially resolved

P: Continue the intervention

S: The client's family says the client's activity
is still assisted by the family
Tuesday
2. O: Clients still seem to be helped by families in
30 march
their activities
2018
P: Continue the intervention
NURSING CARE IN Ny. N WITH CLOSE FRACTURE TIBIA FIBULA SINISTRA
IN THE DAHLIAS OF THE PERMATA HOSPITAL

Dususun Oleh
1. Risa Dwi Aprillia
2. Sinta Nur Laili

DIII KEPERAWATAN BLORA

POLTEKKES KEMENKES SEMARANG
Tahun 2020