Nursing care to AN.

N with
BRONCHOPNEUMONIA
Group Name
1. AJENG SAGITA WIAGTAMA
2. QOD'RUNNADHA M.
1. Biodata
Patient identity
Name : AN. N
Age : 0 year 7 month 29 day
Date Born : January 19, 2019
Female : gender
Marital status :-
Religion : Islam
Address : Podorejo Rt 003 / VII Podorejo
Profession :-
Dx. Medica l : BRPN (bronchopneumonia)
No. RM : 53-80-12
Entry Date : September 17, 2019
2. MAIN COMPLAINTS: Cough
3. HEALTH HISTORY
A. Current Medical History
Patients were delivered to the hospital on September 17 2019 morning
at 05.00 WIB due to complaints of coughing and tightness since last night.
When examined the patient's mother said her child was coughing and
tightness since one day ago, the patient's mother also asked why the
cough was heard grok-grok and no sputum came out and then defecated
frequently so that it changed pampers 5 times a day, when assessed
ronkhi breath sounds gurgling. Installed IV RL 10 tpm and Metrodinazol 3 x
120 mg.
B. Past Medical History: Patients have been treated in June 20 days at
Tugurejo Hospital with the same complaint or disease.
C. Family Health History: The family says no family member has ever
experienced a disease as experienced by the patient now.
4. PHYSICAL EXAMINATION
 Vital Signs
TD: -
Pulse: 102 x / minute
RR: 22 x / minute
Temperature: 36.2 0c
 - Chest / Thorak
• Heart
I: ictus cordis does not appear
P: ictus cordis is palpated in ICS 5 midclavicula
P: dim sound
A: Pure and regular heart sounds from LUB DUB
• Lungs
I: symmetrical chest expansion left and right, no use of breath muscles, no lesions,
respiration rate 22x per minute, regular rhythm.
P: no tenderness, no palpable mass.
P: resonant / sonor
A: ronchi sounds, the sound of breathing gurgling.
5. SUPPORTING DATA
1. Laboratory results
2. Thorak's photo results
Cast: normal size and shape
Pulmo: rough vascular pattern
Right-sided parakardial gloom and blotches
Diaphragm: good
Sinus costophrenicus: acute
 Data Analysis
SIGN & SYMPTOM PROBLEM ETIOLOGI

DS: The patient complained of her child coughing, Ineffective Airway Excessive mucus
tightness, when coughing sounds grok-grok and not
sputum
DO:
• The patient coughs and cannot remove sputum.
• Gurgling breath sounds.
• S: 36.2 0C
• N: 102 x / minute
• RR 22x per minute
• Gurgling breath sounds
• Sputum is difficult to get out

DS: The patient looks weak and pale Sleep / rest Increased
DO: The patient looks weak and pale disturbance sputum / cough
 NURSING DIAGNOSIS
A. The ineffectiveness of airway clearance associated with
excessive mucus is characterized by the patient coughing,
spasms, rhythmic sounds gurgling, and sputum can not get
out.
B. Sleep disturbance associated with sputum production and
cough is characterized by the patient looking weak and pale.
 NURSING ACTION PLAN
N Dx
Day / Date / Goals and Criteria Results Intervention TTD
O .
Hour Ke
p

1  
Monday / I After taking nursing actions for 3 x 24 hours the 1. Observation of airway patency
September 18 client's airway is effective. 2.Auscultation of additional breath
2019 07.00 Result criteria: sounds (snoring, gurgling, stridor)
1. Effective airway compliance 3.Perform chest physiotherapy
2. Effective breath sounds 4. Collaboration on giving nebulizer
3. Vital signs are normal 5.Inserting nasoparinghial airway to do
nasotraseal suction as needed.

2 II  
Monday / Setelah dilakukan tindakan keperawatan selama 3 x 1. Monitor sleep patterns
September 18 24 jam diharapkan pola istirahat tidur teratasi. 2. Position the patient as comfortable
2019 11:00 Kriteria hasil: as possible
1. Jam tidur normal 3. Create a comfortable environment
2. Pola tidur normal 4. Intravenous drug administration
 NURSING ACTION
Day / Dx kep Implementation Patient response Ttd
Date /
Hour
Monday II Give intravenous injection. cefotaxime 5 Ds: mother said her child was willing to
/ cc, RL 10 Tpm, Metronidazole 3 x 120 mg be given drugs intravenously
Septem   Do: patient looks calm
ber 18    
2019
Hours
08.00
WIB Ds: The patient's mother said she was
  willing to have her child checked by
Monitor vital signs TTV.
11:00 I,II   Do: N: 102 x / minute, S: 36.2 oC, RR:
WIB   22x / minute
     
 
 

 
12.00 I Do nebulizer therapy. Ds: The patient's mother said
WIB want her child to be treated with
nabulazer.
Do: patients appear calm when treated.

12:30 Auscultation for additional Ds: -

WIB I breath sounds (snoring, Do: sound of gurgling (slime and water)
  gurgling, stridor)  
   
   
  Insert nasoparinghialairway Ds: The patient's mother said willing his
13.00 I to do nasotraseal suctioning child to do suction
WIB as needed Do: sputum out of the nose and mouth

13:30 Position the patient as Ds: The patient's mother said her child
WIB comfortable as possible was comfortable
    Do: the patient looks comfortable
     
14.00 Monitor the patient's sleep Ds: -
WIB patterns Do: patients often wake up during sleep
due to coughing
Tuesda Ds: mother said her child was willing
y/ Give intravenous injection of to be given drugs intravenously
Septem cefotaxime 5 cc, RL 10 Tpm, Do: patient looks calm
ber 19 Metronidazole 3 x 120 mg  
2019  
At
08.00
WIB
 
Ds: The patient's mother said she
09.00   was willing to be physio in her
WIB Do chest physiotherapy, as it child's chest therapy as where it
  should. should be.
    Do: pond patients crying, coughing
    until sputum comes out
      
   
11.00   Ds: The patient's mother said her
WIB Monitor vital signs child would be checked by TTV.
Do:
- N: 100 x / minute
- S: 36 oC
- RR: 22x / minute
12.00 Ds: The patient's mother said her
WIB Nebulizer therapy child was willing to be treated
    with nabulazer.
    Do:
    - The patient coughs and cannot
    remove sputum,
    - Gurgling breath sounds
     
  Ds: the patient's mother said the
    patient's position was
13.00 Position the patient as comfortable
WIB comfortable as possible Do: patient looks calm
     
 

    Ds: -
14.00 Monitor the patient's sleep Do: the patient has not woken up
WIB patterns during sleep
Wednesday / Give intravenous Ds: mother said her child was willing
September injection. Cefotaxime 5 to be given drugs intravenously
20 2019 cc, RL 10 Tpm Do: patient looks calm
Hours 08.00    
WIB
 
09.00 WIB Do chest physiotherapy, Ds: The patient's mother said she
as it should. was willing to be physio in her
child's chest therapy as where it
should be.
Do: patient coughing until sputum
comes out

11:00 WIB Monitor vital signs Ds: The patient's mother said she
    was willing to have her child
checked by TTV.
Do:
- N: 96 x / minute
- S: 36.5 oC
- RR: 22 x / minute
 
12.00 Nebulizer therapy. Ds: The patient's mother said
WIB   her child was willing to be
    treated with nabulazer.
    Do: patient looks calm
   
 
13.00 Position the patient as Ds: the patient's mother said
WIB comfortable as possible the patient's position was
    comfortable
   
 
14.00 Monitor the patient's sleep Ds: The patient's mother said
WIB patterns her child slept comfortably
  Do: patient already seems calm
  EVALUATION / DEVELOPMENT NOTES

NO DAY/DATE/HOUR EX.K EVALUATION TTD

EP

1 Monday / September 18 1 S: The patient's mother said her child coughed, heard a grok-grok, tightness and no sputum, often
2019 waking up at night
08.00 WIB O:
- The patient cannot remove sputum
- Ronkhi sounds
- N: 102 x / minute, S: 36.2 0C, RR: 22 x / minute
A: the ineffectiveness of airway clearance has not been resolved
P: Continue intervention:
- Monitor vital signs
- Encourage drinking warm milk
- Nebulizer therapy
ll S: Mother says her child is having trouble sleeping and often wakes up
O:
- The patient looks pale and is still awake due to coughing
- RL 10 tpm
- Metrodinazole 3 x 120 mg
A: Disorders of sleep patterns have not been resolved
P: Continue Intervention:
- Monitor patient's sleep patterns
- Create a comfortable environment
2 Tuesday / 19 September I S: The patient's mother said her child coughing was reduced, sputum had started to come  
2019 At 14.00 WIB   out through feces
  O:
  - Sputum has started to come out through feces
  - Ronkhi, gurgling
  - N: 100 x / minute, S: 36 0C, RR: 22 x / minute
  A: the ineffectiveness of the airway clearance is partially overcome
  P: Continue NIC:
  - Monitor vital signs
  - Nebulizer therapy
  - Encourage drinking warm milk
   
II S: The mother says her child doesn't wake up often anymore
  O:
  - The patient looks calm, but is still awake due to coughing
  - RL 10 tpm
- Metrodinazole 3 x 120 mg
A: Sleep disturbance partially resolved
P: Continue Intervention
- Monitor patient's sleep patterns
- Create a comfortable atmosphere
3. Wednesday / I S: Ibu pasien mengatakan anaknya sudah tidak batuk tetapi masih terdengar  
September 20 2019   grok-grok saat bernafas
At 14.00   O:
  - Sputum sudah mulai keluar melalui feses
  - Ronkhi sounds
  - N: 96 x / minute, S: 36.5 0C, RR: 22 x / minute
  A: the ineffectiveness of the airway clearance is partially overcome
  P: Continue the NIC
  - Monitor vital signs
  - Nebulizer therapy
   
I S: Mother says her child sleeps comfortably
I O:
  - The patient looks calm
  - RL 10 tpm
  A: disturbed sleep patterns resolved
  P: Continue interrupted NIC intervention
   
 
 
THANK YOU