NURSING CARE PLAN with CLIENT SIXTH DAYS POST OP HERNIA INGUINALIS LATERALIS INCASERATA with HYSTORY of DIABETES

MELLITUS MULTAZAM WARD PKU MUHAMMADIYAH HOSPITAL SURAKATA

By : MUHAMMAD SYAFIQI A M ANNISA DANNI KARTIKA NII NU NAESEE (J210102001) (J210102005 ) (J210100035)

Bachelor of International Nursing Health Science Faculty Muhammadiyah University of Surakarta 2012

NURSING CARE PLAN MR. S SIXTH DAYS POST OP HERNIA INGUINALIS LATERALIS INCASERATA with HYSTORY of DIABETES MELLITUS MULTAZAM WARD PKU MUHAMMADIYAH HOSPITAL SURAKARTA

ASSESSMENT A. SELF IDENTITY 1. Client Name Age Gender Religion Education Job Marriage status Address No CM Informant Date of assessment : Mr. S : 61 years old : Male : Islam : Senior high school : Jobless : Married : Karangasem 1/VIIILaweyan Surakarta : 234481 : Client, family, and medical status : December, 4th 2012

Date come to hospital : November, 30th 2012 Medical diagnose 2. Care - taker Name Age Job Address Clients relation : Mr. B : 34 years old : Private / laborer : Karangasem 1/VIII Laweyan Surakarta : Child :Hernia Incarcerata, DM, and CKD

B. HEALTH HISTORY 1. Chief complaint : Client complaint that he has dypsnea, no cough,

no sputum, pain on the wound in lower right abdomen if he want to move , intermittent, like stab of needle, sometimes at the morning, at noon or night, scale 4.

2. Current health history

: before hospitalization client is suffered diabetes

mellitus, enter to emergency room with mass on scrotum, then enter to multazam ward post op hernia incaserata. 3. Past health history Genogram : : Diabetes mellitus since 10 years ago Explanation : : Female : Male : Death : Close family : One house : Client

4. Family health history

Family havent health history like client. 5. Case management History :

Date November, 30th 2012 November, 30th 2012 December, 30th 2012

Dx. Medical Hernia Inguinalis CKD Diabetes Melitus

Diagnostic support

Therapy / intervention Operation

Mass in testis

Increasing Blood Ureum Nitrogen

Hemodialisis

GDS : 175,3

Insulin therapy

C. CURRENT ASSESMENT ( GORDON FUNCTIONAL PATTERN ) 1. Health perception health management : Health is godness, if client is sick, he come to family docter. 2. Nutritional metabolic pattern: Food Intake: a. Before hospitalization :client eats anything 3 times / day full portion.

b. During hospitalization : client eats diet porridge rice DM 3 times / day plus extra fooding one times. Drink Intake : a. Before hospitalization : client drink 4 glass 200cc / day, mineral water or tea b. During hospitalization : client drink 3 glass 200cc / day, mineral water or tea, infusion ringer laktat 20 drop / minute on right hand. 3. Elimination pattern a. Bowel movement Before hospitalization : 1 times / week, color : yellow, odor : tipically, tekstur : soft. During hospitalization : 1 times, color : yellow, odor : tipically, tekstur : soft b. Urination Before hospitalization : 10 times / day drippings, color : yellow During hospitalization : using catheter 500cc per / 12 hour , color : orange 4. Activity exercise pattern: Capability self - hygiene Eat / drink Bathing Toileting Dressing Mobilization on bed mobilization Ambulation / ROM Explanation : 0 : Independent 1 : Support Tools 2 : Assissted Others - Oxsigenasion: client using nasal canul 5. Sleep rest pattern: 3 : Assissted Other And Tool 4 : Totally Depending 0 1 2 3 4

Before hospitalization : take a nap 2 hour, sleep 7 hour / day, deep sleep, rare wake up at night During hospitalization : take a nap 3 hour, sleep 8 hour / day, easy to wake up

6. Perceptual pattern : During illness : Vision Hearing Tasting Smelling Sensasion : client said blurred vision : client said hear chiming clock : client can taste sweet and salt : client can smell eucalyptus oil : client can feel pain in lower right abdomen if want to move, scale 4, intermittent and like stab of needle, sometimes at the morning, at noon or night,. 7. Self perception pattern a. Self image b. Self esteem c. Self Ideal d. Self role e. Self identity : client fell comfort with all his body although had

amputation on left leg. : client had good relation wit his environment. : client hopes health so he can stay at home. : client as father : client is a male, married and has 6 childrens

8. Role relationship pattern Client cant met neighbor and can share story with them at home 9. Coping stress tolerance pattern Client never angry, just be patient with all situation. 10. Value believe pattern Client is religious people, he believe to God that he will get well soon and never hope to die, he always does pray fifth times / day.

D. PHYSICAL EXAMINATION 1. General appearance 2. Consciousness 3. Vital Sign : composmentis : E4M6V5 = 15 : BP : 140 / 90 mmHg T : 36,5o C

RR : 22 x/ minute 4. Head Hair : mesocephal

HR

: 92 x/minute

: color : black and white, no dandruf, rare hair almost bald

Eye Nose Ear

: pupil isokor, conjugctiva : no anemis, sklera : no ikteric : simetric, clean no secret : clean no secret, no lesion : no stomatities, teeth loss 8, upper 3 lower 5 : no enlargement tyroid gland : symmetric :I Pal Per Aus : Chest expansion symetric : No pain, bloating lung power 3 cm : Dim : Dry ronchi : Ictus cordis didnt show : No pulsation : Dim : Regular : abdomen surface is flat and symetric : Intestine Peristaltic 14 times/minute : liver and lien cant touch : Tympanic

5. Mouth 6. Neck 7. Thorax a. Lung

b. Hearth

:I Pal Per Aus

8. Abdomen

:I Aus Pal Per

9. Inguinal 10. Genital 11. Extremities

: no enlargement lymph gland : genital is clean, no mass : 5 Amputation 5 5 5

E. THERAPY PROGRAM 1. Furozemid 2. Ceftriaxone : 2 ml / 12 hour : 1 gr / 12 hour

3. Ketorolac 4. Ranitidine

: 1 gr / 12 hour : 50 mg / 2 ml / 12 hour

5. Methylprednisolone : 2 ml / 8 hour 6. Nebulizer / 8 hour Antropen Birotex Pulmicord : 10 drops : 10 drops : 1 flash : 1 x 1/2

7. Fargoxin 25mg

8. Spironolactane 25 mg : 1 x 1 9. Amlodipine 10 mg 10. Nocid 11. ISDN 12. Euphylin 13. Norbirapid Ciprofloxaxin Ca.CO3 5 gr 14. RL 20 drop / minute 15. Insulin therapy F. DIAGOSTIC PROGRAM Date November 30th 2012 Examination Hematologi Lekosit Eritrosit Hemoglobin Retikolosit Feritin Urine SGOT SGPT Ureum Kreatinin December, Radiology on 14 8 73,2 3,58 1. Increasing U/L U/L < 35 < 41 8,20 2,79 8.0 2.1 622,41 % Mg / ml 0,5 1,5 68 434 Result Unit Referral :1x1 :3x2 :3x1 :3x1 : :2x1 :2x1

2nd 2012

the thorax area

vesicular movement 2. Both of sinus costofrenicus are dull 3. Both Of

Diaphragma are slick Impression cardiomegali pulmonum and : with edema bilateral 70 115

effusion pleura. November 30th December, 1th 2

th

GDS 175,3

Mg/dl

187 198 335 74 156

3th 4th 2012

308 360

G. DATA ANALYSIS No. 1 Data DS: Patient said that he got dyspnea DO: 140/90 RR/: 16/m T:36,50 Etiology Obstruction (secrets) in airway Probleme Ineffective Airway clearence

HR : 92/m

DS : Patient said that he feel pain 2 in abdomen area DO: Patient looks weak 3 DS : Patient is less of knowledge of his disease DO : Patient looks anxiety

Biologic Agent of Injury (Hernia)

Acute Pain

Lack of science about the disease

Deficit knowledge

H. NURSING DIAGNOSE 1. Inneffective airway clearance related to obstructions in airway manifested by dyspnea RR : 22/M 2. Pain related to Biologic Agent of Injury (Hernia)Manifested by pain in abdomen area 3. Anxiety related to lack of science about the disease manifested by Knowledge about the disesae Deficit

I.

INTERVENTION

No

Nursing diagnose

Goal & outcome

Planning

Rationale

Inneffectiv e airway clearance related to obstructio ns in airway

After 3 x 24 Client will 1.Auskultasi demonstrate improve and the ability to breath

1. Evaluating the of

sounds effectiveness

maintain

the every 2-4 hours or airway clearance as 2.Lakukan sucking sound needed

effectiveness of airway Expected outcomes: - The sound of breathing clean - Ronchi (-)

when ronchi by: a. explain to a. Improve

manifested - Tracheal tube obstruction-free by dyspnea RR : 22/M

clients about the understanding to purpose sucking of facilitate action participation client

b.

give b.

Give

up

oxygenation with oxygen to prevent 100% O2 prior to hypoxia inhalation, at least 4-5 x respiratory c. attended aseptic c. Preventing

technique, use of nosocomial sterile gloves, a infections sterile catheter d. enter catheter d. Aspiration can into the ETT tube lead to long cause action issue and suction

in a state does not hypoxia suck, sucking long sucking no more 10 will secretions no more oxygen

seconds e.

suction pressures e. 100-120 mmHg

Excessive

negative pressures damage can the mucosa up the

f.Lakukan

airway

oxygenation again f. with before 100%

Giving in

O2 oxygen

the next lungs

inhalation g.Lakukan exploitation repeatedly breath clean 3.Pertahankan g. Ensuring the until effectiveness sounds the 3. Help of

airway thin

secretions

10

humidifier warm temperatures to 37.8 C) (35

No

Nursing diagnose

Goal & outcome

Planning

Rationale

Pain related to Biologic Agent of Injury (Hernia)M anifested by pain in abdomen area

pain levels can be reduced / 1) eliminated after

Assess

the

receiving location of pain, pain characteristics and quality. 2) Observation of the signs discomfort 3) Provide non-verbal of

treatment for (3 x 24 hours).

information about the pain, the

cause, and plans anticipated. 4) Teach the use of pharmacologic techniques. 5) Provide relief / pain relief with analgesics non

11

prescribed. 6) Increase the

proximity of rest / sleep 7.Monitor patients for management satisfaction. 8) Perform pain

preoperative preparation causes if pain

requires surgery

No

Nursing diagnose

Goal & outcome

Planning

Rationale

Anxiety related to lack of science about the disease manifested by deficit knowlet about the disease

anxiety is reduced or absent after nursing actions during the (1 x 24 hours). 1) Assess the level of anxiety / the

client

family.

2) Assess the level of knowledge of the client / family about the hernia and the actions

that need to be done. by Deficit Knowledge about the disesae 3) Explain to the client / family

by Deficit K

about the disease,

12

hernia (definition, cause and effect) and the operative measures necessary for the client. 4) Allow the

client / family to ask questions after explanation nurse. 5) Explain the

result of anxiety experienced the 6) Record by client. the

signs of anxiety that appears on the client / family 7) Assess vital

signs 8) Describe the flow of operations and prepare the operating permit. 9) Provide mental and spiritual

support to clients and leaders appropriate families.

10) Collaboration Religious

13

religious affiliation Physicians for sedation

J.

IMPLEMENTATION

DX Date / Time I-II December,

Intervention Nursing assessment

Response S : client share about the condition

Signature Niinu

4th 2012 / Observe 08.30 am condition.

client O: client cooperative answer all question client complaint dyspnea, pain in the wound, blurred vision. BP : 140 / 90 T : 37oC RR : 23 x/ minute HR : 94 x/ minute

II

09.00 am

Wound care

S : client fell comfort, still pain Niinu but intermittent O:the wound hadnt odor, redness, and pus.

I-II 09.30 am

Injection drug IV

S : client no complaint O : drug enter by IV

Niinu

I-II 12. 00 am

Lunch

S : client feel full O : client completed all diet

Niinu

I-II 01.00 am

Take a nap

S : client feel fresh O : client look calm

Niinu

I-II 02.30 pm

Bathing

S : client feel fresh

Annisa

14

O : client look clean I-II 03.00 pm Observe condition S : client said still little dyspnea O : BP : 140 / 80 mmHg T : 37oC RR : 22 x / minute HR : 90 x / minute I 04.00 pm Deep exercise II 04.15 pm Relaxation technique I-II 04.35 pm Dinner Oral drug breathing S : client said better O : client cooperative do exercise S : client said better O : client calm, do by self S : client feel full O : diet completed, drug enter by oral I-II 05.00 pm Injection IV drug Furozemid Ceftriaxone II 06.45 pm Create calm situation III 09.00 pm Giving Injectio Ketorolac, 5 ml Ranitidine, 2 ml I 09.00 pm 5th 2012 December 05.00 am III 06.00 am Monitor VS Giving Nebulizer S: diyspneu is decreased O : Patient fell comfort S : No complaint O : Client is patient Savi Savi S : no complaint O: client look calm S : No complaint O : Client is patient Savi Annisa S : client no complaint O : drug enter by IV Annisa Annisa Annisa Annisa Annisa

of client, vital sign

II

Injection Furosemid

S : No complaint O : BP : 160/100,RR : 16, HR : 72 T :36,50

Savi

DX Date / Time

Intervention

Response

Signature

15

I-II 5th 2012 December 02.30 pm I-II 03.00 pm

Bathing

S : client feel fresh O : client look clean

Niinu

Observe

condition S : client said still little dyspnea O : BP : 140 / 80 mmHg T : 37oC RR : 22 x / minute HR : 90 x / minute

Niinu

of client, vital sign

I-II 04.35 pm

Dinner Oral drug

S : client feel full O : diet completed, drug enter by oral

Niinu

I-II 05.00 pm

Injection IV drug

S : client no complaint O : drug enter by IV

Niinu

II

06.45 pm

Create calm situation

S : no complaint O: client look calm general S : client no complaint O : composmentis, look calm

Niinu

IIII IIII

08.30 pm

Observe condition

Annisa

09.00 pm

Injection drug via S : client said no pain IV 1. 2. 3. Ketorolac Ranitidine Metil O : drug enter via IV

Annisa

prednizolon

09.00 pm

1. Nebulizer

S : client was relieved

Annisa

Antropen : 10 O : nebulizer run well drops Birotex drops Pulmicord : flash 1 : 10

16

III

09.30 pm

Educating disease

S : client said always hungry O : client understand the reason

Annisa

III

11.00 pm

Observe Sleeping

S:O : client deep sleep

Annisa

I-II 01.00 pm 6th 2012 December 05.00 am IIII 06.15 am

Control fluid intake

S:O : infusion run well S : client said cold

Annisa

II

Annisa

Bathing

O : client look fresh, no change the cloth S : client said so many drug that Annisa

Fooding Oral drug (8)

he want drink O : diet completely Drug enter via oral

07.00 am

Savii Savi Savi Savi Savi

02. 00 pm I-II 02.30 pm Bathing S : client feel fresh O : client look clean I-II 03.00 pm Observe condition S : client said still little dyspnea O : BP : 160 / 80 mmHg T : 37oC RR : 20 x / minute HR : 90 x / minute I-II 04.35 pm Dinner Oral drug S : client feel full O : diet completed, drug enter by oral I-II 05.00 pm Injection IV drug Furozemid Ceftriaxone S : client no complaint O : drug enter by IV

Savi Niinu

Niinu

of client, vital sign

Niinu

Niinu

17

II

06.45 pm

Create calm situation

S : no complaint O: client look calm

Niinu

IIII

7th 2012 December 08.00 am 10.00 am

Observe general condition

S : no dypsnea O : didnt use nasal canul

Annisa

Extra food

S : client still hungry O : diet completely S : client drank 1 glass 200cc O : infusion wida ns 20 drop/m S : client no complaint O : 149 S : no pain O : insulin enter via SC

Annisa

11.00 am

Monitor intake fluid Check blood glucose level

Annisa

11.30 am

Annisa

01.00 pm

Insulin injection

Annisa

Vi tadi qm satu shift ma aq nglakuin apa tulis urut jam ya vi

K. EVALUASI Date / time December, 4 2012 / 02.00 pm December, 4th 2012 / 08.00 pm 5th 2012 I II III
th

Dx

Evaluasion

Signature

Goal is achived in part, continued intervention: I II - Deep breathing exercise - Relaxation technique Goal is achived in part, continued intervention: - Observe clients condition - Create comfort environment - Health education

Niinu

Annisa

Savi

18

December 07.00 am 5th 2012 December 08.00 pm 6th 2012 December 07.00 am 6th 2012 December 02.00 pm 6th 2012 December 02.00 pm 7th 2012 December 02.00 pm I I III Goal is achived in part, continued intervention: Observe condition Relaxation or ROM Goal is achived in part, continued intervention : Client up nasal canul Annisa Niinu Savi III I II Goal is achived in part, continued intervention: Control oxigenasion Maintain fluid intake Goal is achived in part, continued intervention: Educate condition to client Annisa Niinu

19