NURSING CARE REPORT ON THE CHILD “X”

WITH NON HODGKIN LYMPHOMA MEDICAL DIAGNOSIS

AT PEDIATRIC WARD , SEHAT HOSPITAL
3.2 Focus Data
3.2.1 Subjective data
3.2.1.1 The patient complained about the pain on both leg in a whole day.
3.2.1.2 The patient said that he is lack of appetite.
3.2.1.3 The patient said that he always feels full.
3.2.1.4 The patient verbalized he was dizzy.
3.2.1.5 The patient verbalized that he felt hot
3.2.1.6 The patient verbalized easy to fatigue.
3.2.1.7 The patient verbalized his legs were pain so he could not move his legs.
3.2.1.8 His father said that his son’s weight loss about 8 kg in a month since he
got ill.
3.2.1.9 His father said that his son has got fever since a week ago
3.2.1.10 His father said that his son refuse and difficult to eat since a month ago.
3.2.1.11 His father said that his son always bents his knees since a month ago
when he got ill.
3.2.1.12 His father said that his son could not sit or stand up.
3.2.1.13 His father said when his son wants to sit he must help
him to get up.

3.2.2 Objective data

3.2.2.1 Inspection
a. The patient facial expression of pain was grimace.
b. The patient always bents his knee to ease pain.
c. Protecting behavior of his legs.
d. The patient refused to strengthen his legs and said it was pain.
e. The patient looked irritable.
f. Abdominal distension
g. The patient used NGT.
h. The patient was insufficient interest in food.
i. The patient refused to eat.
j. Pale and dry mucous membrane
k. The patient looked thin and weak
l. The patient suffered from NHL (neoplasm) which is high risk for malnutrition.
m. Conjunctive was anemic
n. Decrease in peripheral pulse.
o. Pain on lower extremity.
p. Palms and soles were pale.
q. Slowed movement
r. Decrease in range of motion
s. The patient looked difficulty turning and moving.
 t. The patient spent his time in lie down only. 72
u. All of the patient’s activity was helped.
v. The patient was weak and can not stand up.
w. The patient suffered from malnutrition.
x. Activity scale was 4
y. Muscle strength scale was
3.2.2.2 Palpation
a. Decrease in muscle tone in extremities.
b. CRT > 2 seconds
c. Decrease in muscle tone and contraction in extremities.

3.2.2.3 Percussion
3.2.2.4 Auscultation
3.2.2.5 Vital Signs
a. Heart rate was 140 beats/min.
b. Respiration rate was 20 breaths/min
c. Body temperature was 38.2℃.
3.2.2.6 Additional Data
a. CDC 2000 interpretation was 75 % (moderate malnutrition)
b. Weight for stature calculation was – 2.2 ( thin)
c. Body weight was 12 kg, age 4.2 years.
d. Arm circumference was 12cm
e. Hb level was 7.6 g/dl
3.3 Data Analysis

no data problem etiology

1 Subjective data: Acute pain Biological injury
1. The patient complained about pain agent (neoplasm).
on both leg in a whole day. (NANDA 2015-
P : when the patient moved his 2017 : 440)
legs
Q : stabbing pain
R : both legs
S : 6 (hurt even more)
T : getting worst in the night.
2. His father said that his son always
bents his knees since a month ago
when got ill.

Objective data:
1. The patient facial expression of
pain was grimace.
2. The patient always bents his knee
to ease pain.
3. Protecting behavior of his legs.
4. The patient refused to strengthen
his legs and said it was pain.
5. Heart rate was 140 beats/min.
6. Respiration rate was 20
breaths/min
7. Body temperature was 38.2℃.

2 Subjective data : Imbalance Biological factor

1. The patient said that he was lack nutrition less than (hypermetabolism
of appetite. body requirement due to neoplasm).
2. The patient said that he always (NANDA 2015-
feels full. 2017: 161)
3. His father said that his son weight
loss about 8 kg in a month since
he got ill.
4. His father said that his son refuse
and difficult to eat since a month
ago.

Objective data
1. Body weight was 12 kg, age 4.2
years.
2. CDC 2000 interpretation was 75
% (moderate malnutrition)
3. Weight for stature calculation was
– 2.2 ( thin)
4. Arm circumference was 12cm
5. Abdominal distension
6. The patient used NGT.
7. The patient was insufficient
interest in food.
 8. The patient refused to eat.
9. Insufficient muscle tone
10. Pale mucous membrane
11. The patient refused to eat.
12. The patient is thin and weak
13. The patient suffered from
NHL(neoplasm) which is high risk
for malnutrition

3 Subjective data Ineffective Decreased Hgb

1. The patient verbalized was dizzy. peripheral tissue concentration
2. The patient verbalized easy to perfusion (NANDA 2015-
fatigue. 2017:237)

Objective data
1. Conjunctive was anemic
2. CRT > 2 seconds
3. Hb level was 7.6 g/dl
4. Decrease in peripheral pulse.
5. Pain on lower extremity.
6. Palm and sole were pale.

3.4 Nursing Diagnosis Problem Priority

3.4.1 Hyperthermia ralated to increase in metabolic rate.
3.4.2 Acute pain related to biological injury agent (neoplasm).
3.4.3 Ineffective peripheral tissue perfusion related to decrease Hb concentration.
3.4.4 Imbalance nutrition less then body requirement related to decrease muscle mass.
3.4.5 Impaired physical mobility related to malnutrition.

3.5 Nursing Care Plan

no Diagnosis NOC NIC Rationale

1 Hyperthermia After given 1. Assess and 1. Temperature
related to nursing monitor the 38.9ᴼC – 41ᴼC
increased in intervention in 30 patient’s may suggest
metabolic rate minutes, temperature and acute infectious
evidenced by: hyperthermia note for disease process.
problem is solved presence of 2. Reduce fever by
Subjective data: with evaluation chills/ profuse evaporation.
1. The patient criteria: diaphoresis; 3. Thin clothe make
verbalized Expected outcome also note for easy to heat
that he felt 1. The patient will degree and evaporate from
hot. be able to report pattern of the patient’s
2. The Patient’s and show occurrence. body.
father said manifestations 2. Perform warm 4. It is helpful in
that his son’s that fever is compress. reducing
body was relieved or 3. Encourage the increased body
 warm since a controlled patient to use temperature
week ago. through verbal. thin clothes. especially with
2. Temperature 4. Provide cooling temperatures of
Objective data within 36 - blanket as 39.5ᴼC – 40ᴼC.
1. The patient’s 37ᴼC per axilla. indicated. 5. Water regulates
skin was 3. Respiration rate 5. Encourage the body
warm to of 16 - 20 patient to temperature
touch. breaths per increase fluid 6. To replenish
2. Body minute. intake. fluid losses
temperature 4. Heart rate of 6. Start during shivering
was 38.2. 100 - 120 beats intravenous line chills.
3. The patient per minute. indicated. 7. Antipyretic agent
was irritable. 5. Free of chill 7. Administer work in
4. Heart rate was 6. Absence of antiphyretic as hypothalamus
140 Muscular rigidity indicated. blocking the release
beats/min. of heat
and reduce fever.
2 Acute pain After given 1. Assess pain 1. Assessment in
related to nursing characteristics: pain experience is
bilogical injury intervention in 30 P (provocation the first step in
agent (neoplasm) minutes pain or palliation), Q planning pain
evidenced by: problem is soved (quality and management
with evaluation quantity), R strategies.
Subjective data: criteria: (region and 2. Some people
1. The patient Pain Level radiation), S deny the
complained 1. Report pain is (severity [scale experience of
about pain on relieved or of 1-10]), T pain when
both leg in a controlled. (timing). present. Attention
whole day. 2. Pain scale is 0 2. Observe or to associated
P:when the or 2 in range 1 monitor signs signs may help
patient moves – 10. and symptoms the nurse in
his legs. 3. Appear relaxed associated with evaluating pain.
Q: stabbing and able to pain, such as 3. Pain that has
pain. sleep and rest BP, heart rate, been
R:both legs. appropriately. temperature, chronic and
S : 6 (hurt 4. Vital sign color and longstanding
even more) within normal moisture of may
T : getting limit. skin, have devastating
worst in the Pain Control restlessness, emotional effects
night. 1. The patient able and ability to on the patient and
2. The patient’s to demonstrate focus. these emotional
father said behaviors to 3. Assess for complications
that his son manage pain. effects of may make
always bents 2. The patient able chronic pain effective
knees since a to cope with such as treatment of the
month ago incompletely depression; pain more
when got ill. relieved pain. guilt; difficult.
3. Relax facial hopelessness; 4. Method to
Objective data: expression. sleep, sexual, relieve pain.
1. The patient’s and nutritional a. The use of
facial disturbances; a mental
expression of and alterations picture or
pain was in interpersonal an
grimace. relationships. imagined
2. The patient 4. Assisting in event that
looked always involves
bents his knee pain relief the using
to ease pain. method as of the five
3. Protecting follows ; senses to
behavior of a. Imagenery distract
his legs. b. distraction oneself
4. The patient techniques from
refused to c. Relaxation painful
strengthen his exercise. stimuli.
legs and said d. Hot or cold b. Heightenin
it was pain. compress. g one's
5. Heart rate was e. massage of concentrati
140 beats/min affected on upon
6. Respiration area when nonpainful
rate was 20 breaths/m appropriate: stimuli to one's
7. Body Provide rest awareness
temperature periods to and
was 38.2℃. facilitate experience
comfort, of pain.
sleep, and c. Technique
relaxation. s used to
5. Eliminate bring
additional about a
stressors or state of
sources of physical
discomfort and mental
whenever awareness
possible. and
6. Administer tranquility.
pain d. Hot moist
medication as compresse
indicated. s have a
evaluating penetrating
effectiveness effect. The
and warmth
observing for rushes
any signs and blood to
symptoms of the
untoward affected
effects. area to
promote
healing.
Cold
compress
may
reduce
total
edema and
promote
some
numbing,
thereby
promoting
comfort.
e. Massage
decreases
muscle
 tension
and can
promote
comfort.
5. The patient
may experience
an
exaggeration in
pain or a
decreased
ability to
tolerate painful
stimuli if
environmental,
intrapersonal,
or intrapsychic
factors are
further
stressing them.
6. Use therapautic
medication to
block pain
sensation to
central nervous
system.
3 Ineffective After given 1. Assess for 1. To know early
peripheral tissue nursing and report and determine
perfusion intervention in 24 signs and appropriate
evidenced by: hours maintain symptoms of intervention.
adequate tissue diminished 2. Diminished or
Subjective data perfusion with tissue absent peripheral
1. Patient evaluation perfusion pulses indicate
verbalized criteria: (e.g. arterial
was dizzy. 1. Strong decreased insufficiency
2. Patient palpable blood 3. Skin pallor or
verbalized peripheral pressure, mottling, cool or
easy to pulses. restlessness, cold skin
fatigue. 2. Reduction in confusion, temperature, or
or absence of cool an absent pulse
Objective data pain. extremities, can signal arterial
1. Conjunctive 3. Warm and pallor or obstruction,
was anemic. dry cyanosis of which is an
2. CRT > 2 extremities. extremities, emergency that
seconds 4. Adequate diminished or requires
3. Hb level was capillary absent immediate
7.6 g/dl refill (less peripheral intervention
4. Decrease in than 2 pulses, slow 4. Nail beds usually
peripheral seconds), and capillary return to a
pulse. prevention of refill, edema, pinkish color
5. Pain on lower ulceration. oliguria). within 3 seconds
extremity. 5. Pink-colored 2. Check after nail bed
6. Palm and sole conjunctiva dorsalispedis compression.
were pale. and nails tip. and posterior 5. To fulfill fluid
6. Absence of tibial pulses need for the
dizziness and bilaterally. If patient.
fatigue unable to find 6. WBC
 felling. them, use a transfussion to
Doppler increase hgb
stethoscope level.
and notify
physician if
pulses not
present.
3. Note skin color
and feel
temperature
of the skin.
4. Check
capillary
refill time.
5. Administer
intravenous
fluids (e.g.
crystalloids,
colloids) as
ordered.
6. Collaborate
in planning
blood
transfussion.

3.6 Implementation

NO DAY/DATE NO DX TIME Implementation Action’s Sign

Evaluation
1 Monday, 09.00 1. Assessing and 1. The Ayu
June 1st
2015
I am
09.30
monitoring the
patient’s
patient’s
body
am temperature and temperature
09.40 note for was 37.9.
am presence there were no
09.40 of chills/ sign of chill
Am : 12 malam am profuse or
sampai 12 siaang 10.00 diaphoresis. diaphoresis.
am 2. Performing 2. Warm
warm compress. compress
Pm : 12 siang sampai 3. Encouraging was done and
11.59 malam the the fever was
patient to not decrease
increase fluid significantly.
intake. 3. The patient
7 malam : 7 pm 4. Encouraging drank more
the water after
8 pagi : 8 am patient to use suggested.
thin clothes. 4. The patient
5. just wore
Administering short pants
antiphyretic as and thin
indicated clothes.
 5.
Paracetamol
was given
125 mg
intravenously
2 Monday, 09.30 1. Assessing 1. P : when AYU
June 1st
2015
II am
09.30
pain
characteristics:
the
patient
Am P, Q, R, S, T. moved his
am 2. Observing or legs
09.55 monitor signs Q : stabbing
am and symptoms pain
10.00 associated with R : both legs
am pain, such as , S : 6 (hurt
heart rate, even more)
temperature, T: getting
color and worst in the
moisture of night.
skin, 2. HR : 132
restlessness, and beats/min,
ability to focus temp : 37.9,
3. Assisting in RR: 21
pain breaths/min.
relief method. Skin
Relaxation moisture was
exercise (deep dry. The
breath). patient was
4. Eliminating passive.
additional 3. The patient
stressors or follow to
sources of take deep
discomfort breathe and
whenever did it when
possible. pain was
5. come.
Administering 4.
pain medication Encouraging
as indicated. the patient
family to
visit him one
by one and
do not make
noise.
5. The patient
took a
medication
cancer pain
one sachet.
3 Monday, 11.00 1. Assessing for 1. The patient ayu
June 1st
2015
III am
11.10
and reporting
signs and
was not
restlessness,
am symptoms of extremities
11.10 diminished was war,
am tissue CRT > 2
11.10 perfusion (e.g. seconds,
 am restlessness, peripheral
confusion, cool pulses was
extremities, weak, the
pallor or patient did
cyanosis of not develop
extremities, edema.
diminished or 2. Patient’s
absent skin
peripheral color was
pulses, slow dark and
capillary refill, looked pale
edema,). on palms and
2. Noting skin soles.
color 3. CRT was >
and feel 2
temperature of seconds.
the skin. 4. The patient
3. Checking was given IV
capillary refill therapy D5-
time. ½ Ns 20
4. drop/min.
Administering
intravenous
fluids as
ordered.

CONTINUE TO EVALUATION TABLE……………..