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DEMOGRAPHIC DATA
FULL NAME GENDER AGE BIRTHDATE CIVIL STATUS RACE/NATIONALITY RELIGION
MUSLIM
: J.P
: MALE
FEMALE
: :
OTHER SIGNIFICANT TRAINING OCCUPATION SIGNIFICANT TRAINING OCUPATION (PRESENT/USUAL) USUAL SOURCE OF MED. CARE
:-
C. REASONS FOR SEEKING CARE : Patient come with joint pain, pale, and feel nausea.
D. HX OF PRESENT ILLNESS/HEALTH :
The painhas beengoing on sinceoneyearago. Clientsalsosaid thepainfeltlike stabbing, pain scale6 (moderate), pain in thejoints ofthe feet andhands andapain2 to3 hours.
: since a year ago : moderate : a pain in the joints two up to three hours : joints of the feet and hands :the pain feel like stabbing : on the scale 0-10 with 10 the worst. Patient feel the pain in scale 6
ASSOCIATED PHENOMENA/FACTORS: life style AGGRAVATING FACTORS :consume the foods with high purines and smoking ALLEVIATING FACTORS CLIENTS PERCEPTION ADMITTED BY : reduced the activity, consume the food with low purines and consume the medicine from doctors : patient hope to get the health condition :SELF ADMIITED
RELATIVE OTHER
ADMITTED VIA
:AMBULATORY
STRETCHER AMBULANCE
E. PAST MEDICAL HX
CHILDHOOD ILLNESS ADULT ILLNESS INJURIES/ACCIDENTS :::-
PRIOR HOSPITALIZATIONS : At Gunung maria Hospital PAST SURGICAL OPS. IMMUNIZATIONS :: COMPLETE
INCOMPLETE
::-
MEDICATIONS BEING TAKEN BEFORE HOSPITALIZATION : medicine just from shop LAST MEDICAL CHECK-UP : May 2012 MENSTRUAL HISTORY FOR FEMALE CLIENT : -
:-
:-
IRREGULAR
IF NON PREGNANT :
F. FAMILY HISTORY :
Tn. JP
Legend :
male
female
G. SOCIO-ECONOMIC DATA
HOUSE OWNERSHIP : OWNED
RENTED SHARED
: garden :-
BARANGGAY HALL
:TRICYCLE
SIDE CAR JEEPNEY MINI BUS OWNED VEHICLE
: UNINVOLVED
INVOLVED
H. DEVELOPMENTAL HISTORY
I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. ROS AND PE ROS (includes history of illness or complaints) - all subjective Patient said that he felt pain since a year ago,the pain like stabbing in the foot and hands. b. Integument Patient said there were no injuries but the skin feel dry. c. Head Patient said there is no lesion. PE (includes assessment via IPPA) - all objective the patient seemed to withstand the pain. the scale of pain is 6(moderate). the skin seemed dry, there no wound and the skin is good The head looks symmetrical, no lessions, no lumps,the scalp
System
a. General/overall health
clean, and the hair slightly oil. d. Eyes Patient said never had eye disease before and not use glasses. The eyes looks symmetrical, sklera icterus, conjunctiva anemis. e. Ears f. Nose and Sinuses Patient said never had ear disease. the ears looks symmetrical. Mouth looks clean and there is no swelling. h. Neck There is no swelling in lymph nodes. i. Breast and Axially j. Respiratory breast and axially looks symmetrical. Frequency of respiratory is 22X/m, regular rhythm, and kind of respiratory is chest. k. Cardiovascular Ictus cordis cant be seen but can palpated with gentle vibration, patient doesnt use a pacemaker. l. Urinary Patient said he always consume the water about 2.000cc and have a pee about 4 time a day. m. Genitalia There is no hemoroid or inflamation. n. Musculoskeletal o. Neurologic p. Hematologic q. Endocrine Palpated suprapubica the bladder is empty.
2. LABORATORY STUDIES/DIAGNOSTICS Procedure Date 20 June 2012 Indication Normal Values / Findings Actual - Findings Nursing Responsibillities/Implications (PRE, INTRA, POST)
Urine Check up : 1. Leukosit 2. Eritrosit 3. Sel e.p 4. Kristal 5. Silinder 6. Bacterium 7. Dll 1. 0-2 2. 0-1 3. + 4. Amoniumurat + 5. 6. 7.
20 June 2012
Blood Check up : 1. Urea-UV 2. Creatinine 3. Uric-acid 1. 1050m g/dl 2. 01,3m g/dl 3. 3,47mg/ dl. 1. 219mg/dl 2. 8,5mg/dl 3. 10,4mg/dl
3. OTHER ASSESMENT TOOLS Date (s) taken Comprehensive Actual Content / Legend Actual Result
J. FUNCTIONAL ASSESMENT
A. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN
CLIENTS PERCEPTION OF HEALTH :patient
life style.
medical.
B. SELF PERCEPTION / SELF CONCEPT PATTERN
CLIENTS PERCEPTION OF SELF (FEELS GOOD / BAD ABOUT SELF?) : feels LEVEL OF COMFORT WITH SELF :
good
good
PERCEPTION ON BODY IMAGE :good CHANGES IN FEELINGS ABOUT SELF SINCE ILLNESS BEGAN :he felt
slightly inferior
at garden
Requires use of equipments or device Requires assistance or supervision from another person
3 4
Requires assistance or supervision from anotherperson or device Is dependent and does not participate
SLEEPING PATTERN, STRAIGHT SLEEP OR THERE TIMES WHEN SLEEP IS DISTURBED? : Sometimes patient
FEELS GOOD UPON WAKING UP? : No USE OF SLEEPING AIDS :DAYTIME NAPS; DAILY? FROM WHAT TIME & UNTIL WHAT TIME? : yes.
I. PERSONAL HABITS
P.P.D. (PACK PER DAY) :1 P.P.D.X ALCOHOL : SOMETIMES STREET DRUGS : YR. (S) OF SMOKING TOBACCO :
J. ENVIRONMENTAL HAZARDS
NEIGHBORHOOD AIR POLLUTION : NEIGHBORHOOD WATER POLLUTION : NEIGHBORHOOD SOIL POLLUTION : NEIGHBORHOOD NOISE POLLUTION : OVERALL SAFETY OF NEIGHBORHOOD : WORK ENVIRONMENT; PRESENCE OF WORK ENVIRONMENT HAZARDS : -
II. PROBLEM LIST A. ACTUAL or Active Problem Problem No. 1. Pain associated with inflammatory processes. Data Identified DS : patient said the pain has been going on since 1 year ago. DO : the pain felt like stabbing and scale is 6. The patient seen grimacing. 2. physical mobility impaired associated with pain. DS : patient said the activity has stop and the daily activity should need the help of others. 22 june 2012 Date Resolved / Remarks 22 june 2012
DO : the daily activity like eat, bath, dressing, grooming, defecation, urination, and mobilization in bad need help by the others.
ndx 1
Patien patient t can cope the pain s showe dpainr esolve din time 3X24 hours
1.TTVobservati
1.Paincan affectTTV 2.assist indetermini ng the need forpain managemen t. 3.Bed restis necessaryto limit pain/joint injuries(up toobjective and subjectivei mprovemen
S: Patients say his legs are still aching joints O: patients seen still wince when the foot touched A: Pain is not resolved P: Intervention s continued 1. TTV observations 2. Investigate complaints of pain and
ons 2.Assesspain leveland recordthe location andintensity of pain(scale0-10) 3.Let thepatienttakea comfortable positiononabed orsittingin a chair, Boostbreaks atappropriatein dications
inflammato on since 1 year ry processes. ago. DO : the pain felt like stabbing and scale is 6. The patient seen grimacing.
record the location and intensity of pain (scale 0-10) 3. Let the patient take a comfortable position on a bed or sitting in a chair, Boost breaks at appropriate indications. 4.Pushtofreq uentlychang e positions, tomovein bed. 5.Encourage the use ofstressman agementtech niqueseg. relaxationte chniques 6.Collaborat iononanalge sicmedicatio n/therapyco ntinue.
individualsituati andincrease on. 7.Collaboration ofanalgesicdrug s. the sense ofself andfeeling healthycele brants 7.As ananalgesict o relieve pain.
Ndx 2
DS : patient said the activity has stop and the daily activity should need the help of others. DO : the daily activity like eat, bath, dressing, grooming, defecation, urination, and mobilization in bad need help by the others.
malda activiti ilyacti eswith vities again out thehel p of othersi n the 3X24 hours.
1. Maintain bed rest breaks if necessary. 2. Assist with range of motion active / passive if possible 3. Change the position of patients with frequent 4. Evaluation of monitoring the level of pain / inflammation in the joints.
S:The patientsays it is
fatigueandm stillweak aintainpowe r 2.Mengingk atkanjoint function, muscle strength andgenerals tamina. 3.Relieving pressure on thetissueand increase circulation 4.Dependin g on theactivity levelofresol ution/progre ssionof inflammator yprocesses. tomovethem selves O: patientsstill can notperform daily activitiesthe mselves A: Activity intoleranceis not resolved P: Intervention scontinued 1.maintainb ed restbreaks 2.assistivera nge of motionactiv e /passivewith therequested moving thelegsandar msslowly 3.reposition thepatient
Subject Lecturer
By group 5 Members of group : Renitha Pumadada Charly Londa Novilia P Tambajong Nelva Sagala Vica Safitri Ayu Indri H Solitan Ketut Swiranata
INTRODUCTION
Thank God we prayed to the Lord the Almighty's blessings and His grace so that we can complete the group of five papers "NURSING CARE IN PATIENTS WITH GOUT ARTHRITIS" well. We thank the subjects English lecturers in Nursing who has provided guidance and direction for us. In making this paper we realized is far from perfection, for that we are expecting criticism and constructive suggestions from readers for better preparation of the next paper to be useful for all of us. Hopefully, this paper can provide a benefit to us, especially for my friends in learning and increase student knowledge about gout arthritis.
Group V