NURSING ENGLISH ASSIGNMENT 2

SBAR Communication Worksheet and Nursing Care In Patients

With CHRONIC BRONCITIS

Supporting Lecture :
Sugesti Aliftitah, S.Kep.,Ns.,M.Kep.

By :

mohammad hamid sabibi

Npm :720621465

PROGRAM STUDI ILMU

KEPERAWATAN FAKULTAS ILMU
KESEHATAN UNIVERSITAS WIRARAJA
2023
 SBAR Communication Worksheet
Patient name : Mr. o’ Patient date of birth : No data
Date : No data Time : No data
Location : No data Room number : No data

Situation :
Good morning, I am Bibi the nurse in the asmine room. I would like to report that a patient
named Mr. o who is 62 years old with a diagnosis of CHRONIC BRONCITIS.The patient
said that His problem began four days ago when "I got a cold." His "cold" consisted of a sore
throat, rhinorrhea and myalgia. His job forces him to work in the cold and damp air. At first he
just felt tired but later he developed a cough* and shortness of breath. Initially, the cough was
dry but within 24 hours of onset, it produced abundant yellow-green sputum. He states, "I
cough up a cup of this stuff every day." He didn't think much of the cough because he
continually coughs during the winter of each year. His wife states that he "hacks and spits up"
every morning when he gets up from bed. The shortness of breath has worsened so that he can
hardly speak now. He also has pain in the left side of his chest when he coughs. He becomes
very tired after walking up a flight of stairs or during a coughing spell. He denies hemoptysis,
night sweats, chills, and paroxysmal nocturnal dyspnea. However, he does complain of
swelling of his ankles

Background :
The patient has been treated for high blood pressure, pneumonias and infections of his hands.
He has been treated for similar episodes of coughing and shortness of breath during the past
two years. Once he was hospitalized because "I was drinking too much and my pancreas acted
up." A previous doctor gave him nitroglycerin. He smokes 1-2 packs of cigarettes per day and
has done so for the past 35 years. And The patient appears much older than he stated age of 62
years. He is a stocky man who appears haggard, tired and anxious. He speaks with difficulty,
quickly becoming breathless. There is cyanosis which intensifies during coughing spells.
Blood pressure is 146/82 mmHg. Apical heart rate is 96/minute and regular. Respiratory rate is
28/minute. Temperature is 100.2 F.

Assesment :
 Blood preassure : 146/82 mmHg.
 Laboratory test results :
 CBC:
  Leukocyte count is 12,500/mm3; 58% neutrophils, 7% bands, 28% lymphocytes, 6%
monocytes, 1% eosinophils. Hemoglobin = 19.8 g/dL; Hematocrit = 60%; Platelet count =
320,000/mm3.
 Chemistry:
 Glucose 112 mg/dL (non-fasting); BUN 16mg/dL, Creatinine 1 mg/dL;
 Cholesterol 240 mg/dL; Aspartate aminotransferase (AST) 18 U/L, Alanine
 aminotransferase (ALT) 32 U/L, Creatine kinase 72 U/L; Sodium 130 mEq/L,
 Potassium 4.8 mEq/L; Chloride 90 mEq/L, Bicarbonate 33 mEq/L.
 Arterial Blood Gases:
 pH 7.38, Pa O2 44 mmHg, Pa CO2 58 mmHg, HCO3 31 mEq/L.
 Electrocardiogram: review attached sheet
 Chest x-ray and sputum culture results are pending.
 The patient is hospitalized. Spirometry is performed. The results are as follows:
 FEV1 = 0.5L, Predicted = 2.9L, Percent of Predicted = 17%
 FVC = 1.7L, Predicted = 3.9 L, Percent of Predicted = 43%
 FEV1/FVC = 29%

Recomendation :
Teach patiet effective cogh Ascltasi lg for sigs of icreasig airwa swelling ad possible
obstrctio icldig dispenia,takipnea and whezing ad rochi Set semiflower position for the patiet
Colloboratio In providing therap with a team doctors
 NURSING PROCESS FORM CREATED
NURSING STUDENT, FACULTY OF HEALTH
WIRARAJA UNIVERSITY
By : mohammad hamid sabibi
1. ASSESSMENT

NURSING HISTORY

Admission Date : No data Time : No data

No. Reg : No data Medical Dx : CHRONIC BRONCITIS
Date of Assessment :
I. Patient Identity:
1. Name : Mr. o’cor
2. Age : 62 years old
3. Race : No data
4. Religion : No data
5. Education : No data
6. Occupation : No data
7. Address : No data

II. HISTORY OF PRESENT ILNESS

1. Chief Complain :
The patient complained short of breath .
2. Present illness history :
He Has progressive shortness of breath for the past several days. His problem began four days
ago when "I got a cold." His "cold" consisted of a sore throat, rhinorrhea and myalgia
1. History of Related Diseases :
 Mr. O'Connor has been treated for high blood pressure, pneumonias and infections of his
hands. He has been treated for similar episodes of coughing and shortness of breath during the
past two years. Once he was hospitalized because "I was drinking too much and my pancreas
acted up." A previous doctor gave him nitroglycerin. He smokes 1-2 packs of cigarettes per
day and has done so for the past 35 years.
2. History of contagious diseases : None  YesMentioned :
- The patient said that he had no history of infectious diseases.
3. Hereditary Diseases : None  YesMentioned :

4. Allergic history : None  medicine,  food

Mentioned :
- The patient said that he had no allergies to either food or medicine.

III. FAMILY HEALTH HISTORY (Genogram)

Explanation :

: feMale : Died

: male

: Patient : Live together

: Family relationship

: Child
 OBSERVATION AND PHYSICAL EXAMINATION

VS: T: within normal limit P: within normal limit R: within normal limit
BP: ranging from 150 to 155/110 up to 114 mmHg

1. B1 : BREATHING (RESPIRATORY SYSTEM)

1) complain :  SOB pain, breathing
Cough  others, mentioned :
2) RR pattern : Eupnea Frequency : within normal limit
Rhythm : regular Irregular
Breathing : Vesicular  Bronchovesiculr
Sounds Ronchi Wheezing
O2 adm :  Yes None
Others, mentioned : The patient's respiratory system PROBLEM :
is normal or there is no respiratory disorder.

2. B2 : BLEEDING (CARDIOVASCULAR SYSTEM)

1) complain :  chest pain dizziness

headache  palpitation
2) Heart sounds : Normal Abnormal: S3  S4  Murmur
3) Edema : None Yes

PROBLEM :

3. B3: BRAIN (NERVOUS SYSTEM)

1) Orientation: Person Place Time
2) Complain:
- None, patient can respond to person, place and time.
3) Awareness : Composmentis  Apathies  Somnolent
 Sopor  Coma
GCS: E : 4 M : 5 V : 5, Total : 14
4) Eye
Pupil : Isochors  An isochors
Sclera : Icterik  bleeding Others:
Conjungtiva: Pale  light red
 5) Nerves disturbance :
Trismus :  Yes, None
Paralyze :  Yes, None
Sensory Perceptual :  Yes, None
Others, mentioned :
- The patient’s nerve condition is normal or there is no neurogical problem.
PROBLEM :

4. B4: BLADDER (GENITOURINARY SYSTEM))

1) Complain :
- None, the patient has no complains to the genitourinary system.
 Polyuria Oliguria  Anuria  Nocturia
2) Urine output : no data ml/day. Color : no data Smell : no data
3) Fluid Intake : Oral : no data, Parenteral : no
data Others : no data on genitourinary system
PROBLEM :

5. B5: BOWEL (GASTROINTESTINAL SYSTEM – GI TRACT)

1) Mouth:  None  Pain-swallowed  Trachea wound
Other :
2) Abdomen :  Press pain  Wound operation  Colostomy
3) Alvi elimination : no data  Normal  Abnormal
Consistency :  hard  soft  fluid  blood
4) Diet : no data  hard  fluid  soft
Others : no data on gastrointestinal system
PROBLEM :
6. B6: BONE (BONE-MUSCLE-INTEGUMENT)
1) Joint Activity : Free  Limited, Reason;
2) Extremities complain :  Yes None
3) Back Injury :  Yes None
4) Integuments :  Icterik  cyanosis
 Redness  Hyper pigmentation
Acral :  Cold Warm  dry  redness
Turgor :  Excellent Good  Poor

PROBLEM :

7. ENDOCRINE SYSTEM
Complain :  Yes  None
 Polydepsia  Polyphagia  Polyuria
Others : : no data on endocrine system
PROBLEM :

IV. PSYCHOOSOCIAL ASSEMENT

1. Client perception about her disease

 God-struggle Penalty  Other
2. Client expression toward his/her disease
 Quit  restlessness Anxiety  Angry / crying
3. Year reaction
 Cooperatif Not Cooperatif  prejudice
4. Self concept disturbane
 Yes; self ideal, identity, role, self -esteem, and body
image Not,
 Others,
Explain, Others : The patient's psychological assessment
condition is normal or there is no problem

PROBLEM :
 DIAGNOSTIC TEST AND MEDICAL TREATMENT
1. Laboratory :

The patient is first seen in the emergency room. The following data reflects the initial tests.
CBC:
Leukocyte count is 12,500/mm3; 58% neutrophils, 7% bands, 28% lymphocytes, 6% monocytes, 1%
eosinophils. Hemoglobin = 19.8 g/dL; Hematocrit = 60%; Platelet count = 320,000/mm3.
Chemistry:
Glucose 112 mg/dL (non-fasting); BUN 16mg/dL, Creatinine 1 mg/dL;
Cholesterol 240 mg/dL; Aspartate aminotransferase (AST) 18 U/L, Alanine
aminotransferase (ALT) 32 U/L, Creatine kinase 72 U/L; Sodium 130 mEq/L,
Potassium 4.8 mEq/L; Chloride 90 mEq/L, Bicarbonate 33 mEq/L.
Arterial Blood Gases:
pH 7.38, Pa O2 44 mmHg, Pa CO2 58 mmHg, HCO3 31 mEq/L.
Electrocardiogram: review attached sheet
Chest x-ray and sputum culture results are pending.
The patient is hospitalized. Spirometry is performed. The results are as follows:
FEV1 = 0.5L, Predicted = 2.9L, Percent of Predicted = 17%
FVC = 1.7L, Predicted = 3.9 L, Percent of Predicted = 43%
FEV1/FVC = 29%
 DATA ANALYSIS
DATA ETIOLOGY PROBLEMS
Subjective Data: Airway
- The patient said that at the first he Age, smokig Hypersecretion
just felt tired sice 4 day ago he
Airway irritation
caught a cold, runny nose,
rhinorrhea, mylalgia
Iflammation
- The patient said that he has a cough
and shortness of breath Brocitis
- The patient said that at first it
seems to have a dry cough, but mucus gland pertrop
within 24 hours it prodces a yellow
cough mucus persecretion
- The patient said that if he enter the
cold season he reall like coughig Prodctive cough
- The patient said that if the cough is a Airway clearance
little sore no the chest befohand, tired
whe clibing stairs and when couging
- The patient said that often smokes 1-
2pack of ever day
Objective Data :
- The patient looks much older
- The patient looks tired and axious,
when he speak hard and is out of
breath quickl, he has cyaosis
- BP : 14/82 hg pulse 9/nute. RR
28/inte teperature 3 jugular vein
dilated up to 5c with proinet globose

B. Nursing Diagnosis

1.Airway Hypersecretion by Airway clearance

C. Nursing Intervention
Nursing Intervention
Goal Statement
Diagnosis Nursing Order Rational
Airway After carrying out 1. Identification ttv of 1. Ensure that the
Hypersecretion nursing actions for pasie patient is ready to
by Airway 1x24 hours, it is 2. Teach patiet effective receive
clearance expected that the level cogh information
of knowledge will
3. Ascltasi lg for sigs of 2. Presentation of the
improve with the material will be
icreasig airwa
following outcome easier to
swelling ad possible
criteria: understand
obstrctio icldig
- Recommended dispenia, takipnea 3. So as not to
behavior increases and whezing ad rochi interfere with each
- Wrong perception 4. Set semiflower other's schedule
of the problem position for the patiet 4. To determine the
decreased 5. Colloboration In extent of
- Behavior improves providing therap with understanding of
a team doctors the patient
5. As knowledge in
the future to better
maintain health