CASE STUDY 3 REPORT: NURSING ASSESSMENT

Arranged in order to completing the assignment for

Basic Nursing Concept II course

By:

Group A/class c/Semester II/ Batch 2019

Salsabila Putri Hardiansyah (I1J019016)
etc.

DEPARTMENT OF NURSING
FAKULTY OF HEALTH SCIENCES
JENDERAL SOEDIRMAN UNIVERSITY
MARCH
2020
 CHAPTER I
INTRODUCTION

A. INTRODUCTION
Diagnosis is the second phase of the nursing process. In this phase, nurses use critical
thinking in their skills. In this phase, nurses use critical thinking skills to provide
insight into assessment data and identify problems faced by clients. Diagnosing is an
important step in the nursing process, the previous phase was directed at formulating a
nursing diagnosis; care planning activities for the diagnosis phase based on nursing
diagnoses. When diagnosing must analyze data, identify health problems, risks, and
strengths of patients. After that, it is also necessary to make formulate diagnostic
statements.

In the diagnostic process when analyzing there are steps such as; comparing patient
data with standard data, grouping cues, identifying gaps and inconsistencies. After
data are analyzed, the nurse and client can together identify the strengths and
problems that occur. This is primarily a decision-making process. In formulating
diagnostic statements, most nursing diagnoses are written as mostly three parts
statements, but there are variations. The three-part nursing diagnosis statement is
called the PES format and includes; Problem (P) the statement of client's response
(NANDA label), Etiology (E) the factors that contribute to or probable causes of the
response, and the last is Sign and symptoms (S) are defining characteristics
manifested by the client.

B. AIMS
1. General aims
Students will be able to identifying nursing assessment’s data from a case study.
2. Specific aims
a. Students will be able to identifying the term that not understood by students
from the case study.
b. Students will be able to explain two steps in nursing assessments.
c. Students will be able to identifying subjective and objective data from a case
study.
d. Students will be able to explain 11 Gordon functional patterns.
e. Students will be able to give an example how to do a pain assessment using
PQRST method.
f. Students will be able to completing a nursing assessment mind mapping using
data from the case study.
 CHAPTER II

DISCUSSION

A. CASE STUDY
Mr. Wyatt, 63 years old, was diagnosed with the Chronic Bronchitis for five years. He
goes to the hospital and complains of feeling tired and unable to carryout normal
activities at home. The nurse checks the vital signs and after the patient walks back and
forth from the waiting room to the examination the frequency of the pulse increases
comparing to resting for 2 minutes. He complains of dyspnea. He feels better after he
wake up, but during the day he feel tired when tried to do some activities. The nurse
informs about this initial finding with the doctor. Electrocardiogram results show
Cardiac Arrhythmias.

B. DISCUSSION
Artemia in the American Heart Association (2016) with the topic of ablation for
arrhythmias. The term arrhythmia refers to any change of normal electrical implant.
An electrical surplus can occur too fast, slow, or erratic that will cause heartbeats that
are different from normal. If the heart does not beat normally, the heart cannot pump
blood effectively, which can kill or damage the lungs, brain, and all other organs.
Cardiac arrhythmias have many causes, one of which is fatigue (fatigue). Fatigue
caused by symptoms of buildup in blood vessels or atherosclerosis, which shows the
heart is not pumping enough blood throughout the body.
PES is the format of nursing diagnosis, P (problem) E (ethology) S (signs and
symptoms). The problem of Mr. Wyatt is disruption of activity because he had chronic
bronchitis related to felt tired and unable to carryout normal activities and the frequency
of the pulse increase. Evidence, the electrocardiogram results in an irregular heartbeat
(cardiac arrhythmia). If the data was added that Mr. Wyatt has poor food intake, only
consumes ½ portion of the meal. He also experienced a decrease of leukocytes and had
a surgical wound on the right femur due to falling in the bath room. The problem is that
he cannot take food normally it’s related to the experience that he had of leukocytes and
surgery and the evidence is that he had fall in the bathroom before and cause surgery in
the right femur. If the data was added that Mr. Wyatt wake up 2-3 times at night, it
takes about 1 hour to start falling asleep. He stated that he is worry about safety if his
work because he is easily tired. Means that he has disturbed sleep it’s related to wake
up 2-3 times at night and the evidence is he easily feel tired.
Explanation of nursing diagnosis according to the fundamental book of nursing edition
3. Actual Nursing Diagnosis (Present Problems) is defined as the human response to
problems that exist at the time of assessment such as health problems or life processes
experienced. For example, when a patient might have at least one actual nursing
diagnosis related to a lack of peripheral sensations; However, there are no signs and
symptoms given to support the diagnosis. There are social barriers related to
communication which can be proven by the discomfort in social situations.
Risk Nursing Diagnosis (Problems May Occur). Response to problems that may
develop in vulnerable patients if the nurse and the patient do not intervene to prevent
it. For example, the risk of acute confusion is related to changes in the sleep-wake
cycle. Such as loss of balance of risk factors for the diagnosis of the risk of falls even
though they do not have symptoms or a history of falls. Wellness Diagnosis (No
Problems). Describes health status, but does not describe a problem. Used when the
client is in the transition from one level of health to a higher level. Examples, when
the client wants to feel closer to God. He asked to meet with ministers from his
church; you might make a diagnosis of Readiness for Enhancing Spiritual Welfare.
 III

CONCLUSION

Mr. Wyatt has problems carrying out his daily activities. At his age, because he is
elderly, he suffers from chronic bronchitis, which is when the heart beats abnormally
because the heart does not pump enough blood throughout the body, this is also
related to what he complains of dyspnea. Because dyspnea is low blood pressure and
stress or anxiety, he also has a complaint when sleeping he always wakes up thinking
about his work. That is what caused Mr. Wyatt to feel tired and weak and unable to
carry out his usual activities. To deal with chronic bronchitis, he must try to get
enough time to rest because chronic bronchitis sufferers basically need more energy to
breathe and also exercise regularly in order to strengthen the muscles that will help in
breathing.
 REFERENCES

Wilkinson, J. M., Treas, L. S., Barnett, K. L., & Smith, M. H. (1946). FUNDAMENTAL OF
NURSING (third). Philadelphia: F.A Davis Company.
Berman, Audrey T., Snyder, Charles. Frandsen MSN, RN, Geralyn EdD (2016). Kozier &
Erb's Fundamentals of Nursing (tenth). New Jersey: Pearson Education, Inc.
Power point of lecturer.
required reading (Potter, P.A., Perry, A.G, (2009)
American Heart Association (2016). Ablation for Arrhythmias.